An official report into the deaths of at least 27 migrants using a "wholly unsuitable" boat in the English Channel has said the response team in Dover was "insufficient" to react, "foreseeable" problems were not recognised and French and British teams failed to share information properly.
The incident, in November 2021, was the deadliest involving a migrant boat trying to cross the Channel. The victims included a pregnant woman and three children.
The report, carried out by the Marine Accident Investigation Branch, says that 33 passengers had been put on a boat that was "entirely unsuitable for the intended voyage and number of people on board".
The report also says migrants phoning from boats had been told "to claim high levels of distress when in UK waters in the hope of expediting rescue" and that this "had the potential to mask genuine distress".
It also suggests that coastguard personnel may have developed a "mental threshold" of assuming that people were in "less severe peril" than they claimed.
However, relatives of those involved have criticised the report, saying it is vague, ambiguous, lacking in detail and does not hold anybody to account.
The government has announced it will hold a separate inquiry into the events surrounding the sinking of the boat, describing it as a full and independent investigation.
Transport Secretary Mark Harper said it would offer "families of the victims the clarity they deserve".
Report identifies tragic mistakes
Only two of those on the boat survived. The bodies of the other four have never been found, but they are presumed to be dead, meaning that it is almost certain that 31 people died on the night of 23-24 November, 2021.
The report is separate from France's investigation into the disaster, which has now seen preliminary charges laid against five emergency service officials for allegedly failing to assist people in danger.
This British report says that "despite extensive requests, the investigation was not granted access to any information held by French authorities".
It finds that the British response was "hampered" by a combination of poor visibility, a high number of boats that were crossing due to good weather, and the fact that there was no aircraft available to carry out a surveillance mission across the English Channel.
This meant that the search and rescue response was based on phone calls from migrants on boats, as well as information from French authorities.
Reconciling the information was "extremely challenging", the report says, due to the high number of calls, often coming from people on the same boat, and the difficulty in distinguishing one boat from another.
In the end, having established that a boat was sinking with more than 30 people on board, three migrant boats were located in UK waters during the ensuing search, leading to a wrong assumption that the people in peril had already been saved.
"The investigation found that there was an assumption that the first boat to be found was the stricken craft," the report concludes. "Events moved on and the plight of the genuinely stricken craft became masked by the increasingly busy task of dealing with crossing events."
'I am finished'
The full report is more than a hundred pages long and presents a stark account of the accident and the hectic conversations between British authorities, French counterparts and migrants.
During the night, the boat was codenamed "Charlie" by the British and Migrant8 by the French.
The report details various calls for help from passengers who call in on their phones, with one screaming down the line and saying "I am finished".
Another call is full of shouting and noise, saying that the boat has broken.
The report says call handlers seemed unsure as to whether they were dealing with another boat in peril - or simply new reports about a vessel they already knew about.
It details how a helicopter pilot had to be woken up when it was agreed that a fixed-wing aircraft couldn't fly.
The report also recounts a call received from a passenger saying that everyone is in the water and that they are "finished".
A message sent to one of the passengers at 3.33am was not delivered, leading the report to conclude that the passengers went into the water between 3.12am and 3.33am.
Other inflatable migrant boats in the area were contacted and rescued, leading to confusion as to whether these were "Charlie" or simply similar vessels.
Sister of victim 'not satisfied at all'
The report says there have been significant changes in the way authorities respond to small boat crossings since the disaster, and notes a number of reviews.
But it does call for greater coordination with the French to avoid "confusion and error" and also for UK authorities to improve surveillance.
However, relatives of those involved in the sinking have criticised the report.
Zana Mamand's brother Twana was on the boat. His body has never been recovered.
"This report is not thorough and it is very ambiguous," he told Sky News. "The French report is much better - it gave verbatim accounts of what happened, and what was said, and it has led to action.
"This one is much more vague. There is very little detail of the conversations or the decisions.
"I am not satisfied at all. The British authorities seem to have spent two years on a report that achieves very little.
"The families want answers - I want to know what effort was put into finding my brother's body.
"I have been asking this for two years and I have never received an answer."