Source · Prevention of Future Deaths

Benjamin Leonard

Ref: 2024-0106 Date: 22 Feb 2024 Coroner: David Pojur Area: North Wales (East and Central) Responses identified: 8 / 9 View PDF

The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical internal Fatal Accident Inquiry Panel Report was not completed in a timely manner, hindering learning.

Date 22 Feb 2024

56-day deadline 18 Apr 2024 est.

Responses identified 8 of 9

Child Death (from 2015) Other related deaths Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary

View full coroner's concerns

Public Inquiry

As part of the submission received to me from the Leonard family, it is said such are the matters of concern in the Inquest of Ben Leonard as to system issues relating to safety and safeguarding, that there is an urgent need for the establishment of a Public Inquiry under the Inquiries Act 2005 into The Scouts Association (be that statutory or non-statutory), and asking me to write to the relevant minister to request the establishment of a Public Inquiry. I have only considered the inquest relating to Ben Leonard and not wider cases. However, below, and the relevant minister is sent this report to consider the issues and the request of the family.

Tel 01824 708047 | Culture of Candour and Independent Inspection

1. I am concerned that there is not a culture of candour within The Scouts Association (‘TSA’) and the impact that this has on safety and safeguarding.

2. I am also concerned that, whilst the Charity Commission has regulatory oversight, there is no robust regulator who independently and periodically audits and inspects the systems, processes and training of The Scouts Association or the granting of permits for adventurous activities, hill walking and Nights Away permits. Further, The Scouts Association permit scheme for adventurous activities is exempt from regulation by the Health and Safety Executive (‘HSE’).

Fatal Accident Inquiry Panel Investigation Report (FAIP) now termed “Learning Review”

3. Following Ben’s death as indicated by Chapter 7 of The Scout’s Policy, Organisation and Rules, (Rule 7.2 version May 2018) at that time required the Charity and Company Secretary of the Association to establish an enquiry on behalf of the Board of Trustees. This should have detailed authorisation, training, equipment, briefing and leadership of the party involved together with their observation of the sequence of events and possible causes of the fatality.

4. As of 22.2.24, over 5 years since Ben’s death there is still no Fatal Accident Inquiry Panel Report in existence. Further still, even the prospective panel members for this investigation have not been identified. A document I have received entitled ‘BL Great Orme Learning and Actions Update’ dated 30.9.19 is inadequate when considering the root and branch type of review needed following a child fatality to identify and address issues of safety and safeguarding – particularly these having been identified as significant issues on the day of Ben’s death and despite this fact – no investigation

Tel 01824 708047 | followed -with The Scouts Association maintaining this was due to a live police investigation initially, and latterly due to this inquest.

5. Without a timely internal Fatal Accident Inquiry Panel Investigation Report (FAIP) this gives me great concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality.

6. The evidence provided by The Scouts Association has been inconsistent as to when it is said a FAIP report is commissioned and completed in circumstances where there is an inquest.

7. An FAIP investigation initiated by the Charity and Company Secretary, should have engaged with the early identification by the District Commissioner, County Commissioner, and The Scouts Association Headquarters staff who had concerns and noted failings relating to the planning, risk assessment, supervision and approval for the trip including the absence and non-attendance of the identified and necessary first aider, the presence of over 18 year olds on trip which had not been disclosed or approved by the District Commissioner and concerns around the competence of the leaders.

8. The Scouts Association reconstruction trip to the Great Orme after Ben’s death on 9.10.18 attended by The Scouts Association Senior Scouting leadership and lawyers with the actual leaders from the trip indicates a desire by the Scouts Association headquarters staff to control the narrative, especially surrounding dynamic risk assessment. Any investigation by County or District level was prevented by headquarters at Gilwell. The District and County Commissioners had identified failings and concerns relating to safety and safeguarding on the day Ben died and the extent of the failings were known and many identified further, following the trip to the Great Orme on the 9.10.2018.

9. In this investigation the evidence I have heard leads me to a concern as to a general reluctance by The Scouts Association to engage in a meaningful

Tel 01824 708047 | learning exercise to prevent a recurrence of the issues pertaining to Ben’s death. This inquest was stated as the reason preventing a FAIP report.

10. However, a FAIP relating to another death in Scouting of a 21-year-old leader was considered in evidence. This FAIP and recommendations were completed before that Inquest. However, it is not clear as to whether this report and recommendations was shared with the relevant Coroner. It is also not clear if, even when FAIP reports have been completed, whether they are provided to the relevant Coroner.

11. I therefore have concerns that not all matters regarding deaths connected with the Scouting Movement and Association are being communicated, even by provision of draft report and recommendations, to His Majesty’s Coroners of England and Wales to inform PFD issues and a Coroner’s PFD reporting duties.

Safety Training

12. Safety training is predominantly done online. Having seen and forensically within the hearing, undertaken an exercise to complete the current Safety Module, I am concerned that the course is superficial at best and fundamentally basic. It can be completed in 12 minutes. It is unsurprising that the current pass rate is now correspondingly high. This causes concern as an introductory module needed to equip thousands of leaders with an understanding of how to complete a risk assessment in order to keep Scouts safe. It does not embed the fundamental principles of safety and safe scouting.

13. Whilst reference material is available in the course, it is not mandatory reading and not required in order to complete the click through course.

Restricted Duties

14. There was a plain reluctance to prioritise the safety of young people following Ben’s death in that, the leaders

Tel 01824 708047 | were not subjected to “Restricted Duties” until 17.10.18 when Ben had died on 26.8.18 and in the time from Ben’s death, had taken part in a camp called “Deep Heat”. POR (Policy, Organisation and Rules) indicated the neutral act of suspension should have been imposed as a minimum for . Once the restricted duties were issued, there was confusion as to whether these related to individuals or specific activities and at least one of the leaders continued in their Scouting obligations with no restrictions as it related to “Scouts” rather than “Explorer Scouts” and so the restrictions were ineffective.

15. Suspension of and Group Scout Leader was only imposed in November 2022, four years after Ben’s death, following the second inquest that needed to be adjourned due to non-disclosure. Suspension exists to ensure the safety and safeguarding of children until the investigation to establish facts has been undertaken.

Absence of Safeguarding and Safety Compliance

16. The nominal Explorer Scout Leader in place when Ben Leonard died was subsequently appointed on Compass as a “District Section Leader Reddish Unit at Stockport” in November 2019. The formal interview to appoint to the role the Reddish Explorer Scout Leader took place in 2020 after his appointment on Compass. It concerns me that notwithstanding the known failures in the planning and execution of the trip, and it having been identified by the County Commissioner, the District Commissioner, the Head of Safeguarding and Head of Safety at The Scouts Association headquarters that had lied in the planning for the trip at which Ben died.

17. Over 18-year-olds were allowed on this trip, by , having not been listed on the Nights Away Notification (‘NAN’) form as adults,

Tel 01824 708047 | nor registered on the Scouts’ Compass system or having undergone Disclosure Barring Service (‘DBS’) safeguarding checks.

18. In addition, the inquest has identified the limited knowledge and understanding of of any of his training undertaken throughout his time acting as a volunteer leader for the Scouts. The lack of understanding of training was a similar picture for the other Leaders on the trip at which Ben died and for other Scouting witnesses.

19. This gives rise to a concern that there are other appointed Leaders in post who are not suitably competent or qualified in respect of the fundamental issues of safety and safeguarding.

Monitoring, Auditing and Reliance on Volunteer Line and the need for paid Trainers

20. I have heard evidence that The Scouts Association headquarters maintain that it is for the County and District as autonomous charities to monitor and audit training compliance. I am concerned that there are not robust systems of analysis, reporting and clarity as to the responsibilities of the County and District and what The Scouts Association require from the County and District in respect of:
i. Training compliance;
ii. Completion of induction training within 5 months;
iii. Completion of the full adult training scheme/ wood beads within 2 years;
iv. Appointment to roles – both pre provisional, provisional, and full appointment;
v. Granting of permits.

21. I heard evidence from the County Training Manager (‘CTM’) for Greater Manchester East-a volunteer role and he himself accepted that he had historically delivered training based on out-of-date

Tel 01824 708047 | factsheets and volunteered that he needed to update his own knowledge. I have been told that an urgent audit of the CTM occurred after his evidence to the inquest.

22. I have a concern therefore as to the general audit and inspection of County Training Managers nationally.

23. For Local Training Managers (‘LTM’) a process for validation exists whereby a training adviser interprets the Training Advisers Guide and has a broad scope within which they can validate a learner’s training. This creates a risk of the approval of superficial and inadequate learning.

24. The provision of training relies heavily on the goodwill of volunteers and is time consuming. The expert to the inquest recommended – as exists for other organisation and Charities-that there should be a paid regional individual with a responsibility for training who would serve as a point of contact for local volunteers should they require any support with their training and to ensure quality training and compliance.

25. identified that this required a paid individual that was missing in the current chain between the volunteer line and The Scouts Association necessary for training and delivery of activities.

Delays in Training

26. had not completed their mandatory training within the 5-month period: ’ training was 3 years and 9 months’ late; was 2 years and 1 month late.

27. had not completed his wood beads training within the 2-year period; it was completed 2 years and 9 months late. There was no apparent sanction for having missed deadlines for training.

Tel 01824 708047 |
28. I was then provided with the following statistics, provided by , the former UK Chief Commissioner of The Scouts Association: i) “On 7 September 2018, there were 373 open roles in Stockport District that were in scope for Getting Started and Wood Badge training. The 373 roles were held by 318 volunteers. ii) There were 180 roles (48%) overdue for completing their Getting Started training. iii) There were 94 roles (25%) overdue for their Wood Badge training. iv) There were 318 volunteers in Stockport District that were in scope for first aid training. Of those 318 people, there were 57 (18%) who were overdue their first aid training. The rules at that time did not require first aid to be up to date at all times”

29. These statistics lead to the clear conclusion that there were widespread and significant gaps in training being completed in a timely manner, with concerns surrounding the training provision in the Stockport District.

30. Whilst the training statistics have notably improved, this is based on what I have considered on superficial and basic training which raises concerns around whether the core underlying principles such as risk assessments are being adequately understood.

31. I am concerned by evidence at the inquest that, presently, Stockport only has 6 Local Training Managers in post where 9 are required. The remaining 3 are “awaiting appointment”.

First Aid Kits

32. I did not receive any evidence to suggest that, following an appropriate risk assessment for the Great Orme trip, there was a plan as to what type of first aid kit was required. None of the leaders had a

Tel 01824 708047 | first aid kit with them when they embarked on the walk up the Great Orme or on a 3-hour hike on the Saturday.

33. The Scouts Association guidance on the website about first aid kit requirements is basic and the evidence I heard from gives me a concern that more should be done to ensure on every scouting trip and at scout huts there are appropriate first aid kits and contents including tourniquets to enable, if necessary, immediate life-saving treatment to be provided.

First Aid Self Certification to meet Module 10 First Response requirement

34. There was a system in place whereby if a learner had a first aid at work certificate, they could self-certify that they had undertaken further learning, for Child CPR, hypothermia and meningitis to comply with Module 10 First Response. There were no checks to ensure that this further learning had been done, nor was it assessed.

35. I have heard evidence as to improvements that have been made to the learning gap and training to supplement a First aid at Work certificate as First Response Module 10 compliant, however, I am still concerned that the system lacks robustness.

Autonomous Charities

36. The Scouts Association is distant from its membership through its federated branches of 8000 charities and layers of hierarchy meaning that it cannot know how health and safety is executed at ground level. Training and POR are generated centrally, yet The Scouts Association defer accountability for safeguarding and safety to the individual charities.

Tel 01824 708047 |
37. The centralised safeguarding team and safety team are not on par with each other in terms of resources and reach to local level. Safety is not prioritised in the same way as safeguarding has been. Safeguarding is reacted to more quickly than safety by The Scouts Association.

Permit/ Licencing Schemes

38. The example of having been granted his Nights Away permit simply by providing a list of camps he had been on, demonstrates that there was no robust system in place to ensure that a permit holder responsible for children’s safety was suitably qualified. There is no evidence he had the necessary skills and competencies to be granted such a permit. There was also a lack of clarity on where permits would be required for activities outside of the ordinary Scouts meeting place.

39. The Scouts Association press release within moments of the jury’s conclusion demonstrates a failure of The Scouts Association to accept any accountability and understanding any proper learning from Ben’s death. The Scouts Association is institutionally defensive.

Responses

8 respondents

Charity Commission for England and Wales Central Government

22 Feb 2024 PDF

Action Planned

The Charity Commission acknowledges the report and states they are closely examining the concerns as part of their ongoing engagement with The Scout Association. They will be meeting with TSA again to discuss improvements and will take further regulatory action if needed. (AI summary)

View full response

Dear Mr Pojur Re: Regulation 28 Report to Prevent Future Deaths following inquest into the death of Benjamin Leonard

Introduction

1. I refer to your Report to Prevent Future Deaths (‘the Report’) dated 22 February 2024 concerning the death of Benjamin Leonard who died on 26 August 2018. I am replying as the Chief Executive Officer of the Charity Commission for England and Wales (‘the Commission’). Before responding to the concerns raised in the Report, I would like to express my sincere condolences to Ben’s family. The Commission is keen to assure Ben’s family and you that the concerns raised are being closely examined as part of our ongoing engagement with The Scout Association (‘TSA’), registered charity number 306101.

The role of the Charity Commission

2. The Commission is the registrar and regulator of charities in England and Wales. We are an independent, non-ministerial government department accountable to Parliament. We are also accountable for the exercise of our powers to the First-tier Tribunal and the High Court.

3. As registrar, we are responsible for maintaining an accurate and up-to-date register of charities. This includes determining whether organisations are charitable and

Mr David Pojur Assistant Coroner for North Wales (East and Central)

By email only

Charity Commission PO Box 211 Bootle L20 7YX

Date: 17 April 2024

therefore should be registered, as well as removing those that are no longer considered to be charities, have ceased to exist or do not operate.

4. As a regulator, we regulate both registered charities and charities that are not required to be registered. We operate within a clear legal framework and follow published policies and procedures, ensuring that in making regulatory decisions we are proportionate in our approach.

5. The Commission has regulatory oversight of TSA due to its status as a registered charity. The Scout Councils of Northern Ireland, Scotland and Wales along with Scout Counties, Areas, Regions (Scotland), Districts and Groups, together form the Scout movement in the United Kingdom. The majority of these bodies1 are autonomous charities affiliated to TSA and also fall under the remit of the Commission.

The Commission’s statutory objectives

6. The Commission, through the Charities Act 2011, is charged with delivering five statutory objectives. These are to:

a. increase public trust and confidence in charities.

b. promote awareness and understanding of the operation of the public benefit requirement.

c. promote compliance by charity trustees with their legal obligations in exercising control and management of the administration of their charities.

d. promote the effective use of charitable resources.

e. enhance the accountability of charities to donors, beneficiaries and the general public.
7. Although our objectives are wide-ranging, there are limitations to our role as a regulator:
• we are not a prosecuting authority but a civil regulator. The investigation of alleged criminal offences is the responsibility of law enforcement agencies.

1 There are approximately 8,000 separate local scout groups. Not all local scout groups are registered charities.

• we ordinarily cannot act as a trustee or be directly involved in the administration of a charity, unless particular circumstances apply. This means we can’t tell trustees what decisions to make, although we do seek to provide appropriate and accessible guidance to support them with their decisions to ensure they can comply with their legal duties and responsibilities.

• we also have no power to overturn trustees’ decisions if they are lawful and reasonable, even if these decisions may be unpopular. However, where trustees’ decisions could result in significant harm, for example loss or damage to a charity’s assets including its reputation, which forms part of its property, we can investigate how trustees manage their charity. Where it is necessary, for example if we identity actual or potential misconduct and/or mismanagement, we use our powers as a remedy to improve charity governance and management.

Our regulatory approach

8. We are a risk-led regulator. Being risk-led in our regulation means being proactive in identifying risks and intervening, where possible, to prevent harm before it occurs; addressing harm effectively where it occurs; and focusing our resources effectively on the highest risks. Our Regulatory and Risk Framework outlines how we operate as a risk-led regulator and, in particular, how we identify and assess risks, how we respond to risks, and how we review and adapt our approach.

9. We seek to hold charities to account to basic standards, and while we ensure concerns are investigated and intentional wrongdoing dealt with, we also focus on supporting trustees in getting things back on track, where possible when they do not go exactly as intended.

10. We put the public interest front and centre of our approach to regulating charities – making sure that the public have the information they need to make informed choices about charities and that they are confident that our approach to regulation is clear and consistent.

Trustee conduct

11. Charity trustees are the people who share ultimate responsibility for governing a charity and directing how it is managed and run. The role of the Commission, as regulator, is to ensure that trustees are actively and effectively managing risks and dealing with harm relating to their charities.

12. When we are considering regulatory action, the conduct and response of the trustees will affect our approach. We will consider whether:

• the trustees have acted honestly and reasonably.
• there are indications that they have been careless or reckless.
• there has been deliberate or wilful wrongdoing.

13. If we are satisfied that the trustees have already taken appropriate steps to address risks or harms, we may decide to take no further action depending on the specific circumstances of the case in question. However, where the nature and level of the risk demands it, we will take action in line with the statutory framework set out in the Charities Act 2011. In our regulatory work, we have a range of possible actions and powers available to us. Parliament has set clear legal tests on when and how these powers can be used.

The Commission’s role in terms of safeguarding and child safety
14. The Commission has a key regulatory role in ensuring that trustees comply with their legal duties and responsibilities in managing their charity. In the context of safeguarding and safety, the Commission has an important, but limited, role. Our role is focussed on the conduct of trustees and the steps they take to protect beneficiaries, employees, volunteers and others who come into contact with a charity through its work.
15. We have published guidance to help trustees meet their duties around safeguarding, Safeguarding for charities and trustees. Our guidance sets out that, as part of their duties, trustees must take reasonable steps to protect from harm people who come into contact with their charity – a charity should be a safe and trusted environment.
16. We expect protecting people and safeguarding responsibilities to be governance priorities for all charities and this is a fundamental part of operating as a charity for the public benefit. Any failure by trustees to manage safeguarding / safety risks adequately is a serious regulatory concern to the Commission. We may consider this to be misconduct and/or mismanagement in the administration of the charity. It may also be a breach of trustee duty.
17. The Commission does not have any prosecutorial or criminal law enforcement powers. We are not responsible for dealing with individual incidents of alleged abuse and do not administer safeguarding legislation. Where it is appropriate and necessary, we refer allegations of a criminal nature, or incidences of an individual

being at risk of harm, to the police, local authorities, DBS and other relevant safeguarding agencies.
18. We recognise that the other bodies in receipt of the Report have roles to play in helping to prevent future deaths. Where appropriate, we will liaise with them to ensure that we effectively fulfil our responsibilities to achieve a successful regulatory outcome.

The Commission’s response to the Report

19. We have been engaging with TSA on this matter since Ben’s tragic death in August
2018. Ben’s death was reported promptly to the Commission by the Charity, with TSA submitting a serious incident report on the day of his death.2 We subsequently opened a regulatory case and, since then, TSA has provided us with regular updates on significant developments. We continue to have an open case and the matter remains an ongoing, live issue for the Commission.

20. As TSA’s regulator, we take very seriously the concerns that you have raised in your Report.

21. We note the various concerns and findings identified in the Report. As set out above the Commission will focus on concerns about the charity governance issues and trustee conduct throughout TSA, in line with the Commission’s jurisdiction. Therefore, for example, the Commission can investigate the concerns in the Report about the wider structure of the Scout movement and the risk that there is no robust system in place to make sure that the divisions of the roles between TSA and the individual charities is clearly set out and understood by all concerned. The Commission can also look into past conduct by the trustees and what steps had been, and are being taken, to address all safeguarding and safety concerns set out in the Report and ensure the trustees are meeting their legal duties in governing the TSA and have suitable governance and adequate procedures, including to address your concerns as set out in the Report.

22. Following receipt of the Report, our Director of Regulatory Services requested a meeting with senior personnel at the Charity to discuss TSA’s response to the Report.

23. On 19 March 2024, the Commission met with TSA’s Chair of trustees, CEO, Executive Director of Operations and Head of Governance. It was apparent from our meeting that TSA considers the matter of Ben’s death as one of the utmost

2 This was in in line with our expectations around reporting serious incidents, set out in our guidance How to report a serious incident in your charity.

seriousness. In addition to the actions TSA confirmed to us it has already taken, TSA has made clear that it intends to make further improvements to safety and risk management in the Scout movement. Following the meeting, we have requested additional information about the actions already taken and TSA’s intended next steps, including the anticipated schedule for completion.

24. TSA has assured us it will respond fully to the Report’s findings and have committed to sharing its response with the Commission. Its response will be relevant to our decisions about any regulatory action we may consider necessary to assist, or ensure, TSA make the changes that need to be implemented to address the concerns set out in the Report. We will ensure TSA and its affiliated charities are clear on the Commission’s view about what improvements are essential and must be made and we will continue to examine the concerns identified.

25. At this stage, we cannot provide a timescale for the likely conclusion of our case. We are continuing to examine the concerns and assess whether the actions already taken by TSA have been appropriate and if the further work to be undertaken is sufficient. We will be meeting with TSA again and, in line with our role and charity law, the Commission will support TSA to continue its vital work to further strengthen safety within the Scout movement and will take further regulatory action if the need arises.

26. We are aware that, following the outcome of the Inquest, there is the possibility of a police investigation. We are in contact with the relevant police force to ensure we are clear on any actions that the police are taking, recognising that police investigations take precedence over any civil action, including our own.

27. We note Ben’s family’s request for the establishment of a public inquiry into TSA under the Inquiries Act 2005. I can confirm that, as a regulator, the Commission would always cooperate fully with any public inquiry. We also note that you highlight the absence of an external inspection regime for TSA and we would be available to support any further discussion of this by government or others, in the context of the existing charity law regime described above.

Conclusion

28. Thank you for raising these important matters with me. I hope the above response assures you that the Commission is taking appropriate steps to fulfil its regulatory role. Please do not hesitate to contact me should you require any further information about the Commission’s response to the Report.

Minister for Education Wales Devolved Administration

18 Mar 2024 PDF

Noted

The Minister for Education and Welsh Language has noted the recommendations and passed them on to Welsh Government officials, noting that the UK Government is best placed to respond to the recommendation for a Public Inquiry into the Scout Association. (AI summary)

View full response

Dear David Pojur,

Thank you for your correspondence dated 23 February providing your Prevention of Future Deaths report into the Benjamin Leonard Inquest.

I have noted the recommendations from the report and passed these on to the relevant Welsh Government officials for further consideration.

In relation to the recommendation for the establishment of a Public Inquiry under the Inquiries Act 2005 into the Scout Association, as this terrible accident took place during a trip organised by the UK Scout Association, the UK Government are best placed to respond to this recommendation.

I’ve noted you have already provided a copy of the report to the relevant Secretary of State and Minister for State within the UK Government.

Thank you once again for providing a copy of the report.

Childrens Commissioner for Wales

17 Apr 2024 PDF

Action Planned

The Children's Commissioner for Wales will seek updates from the Scouts Association and will share the PFD report with Estyn, who are expanding their inspections framework to include youth work. (AI summary)

View full response

Comisiynydd Plant Cymru Children’s Commissioner for Wales Response to the Coroner’s Prevention of Future Deaths Report No.2 in respect of Benjamin Leonard Children’s Commissioner for Wales 17th April 2024

Comisiynydd Plant Cymru Children’s Commissioner for Wales

As Children’s Commissioner for Wales, I am in receipt of the Coroner’s Prevention of Future Deaths report dated 22.2.24, in respect of Benjamin Leonard, who tragically passed away on a trip in north Wales. I wish to first extend my sincere condolences to the family and friends of Ben.

The Prevention of Future Deaths (PFD) report sets out a history of concerning events, leading up to Ben’s untimely death and since then throughout the inquest process.

My role and statutory powers do not include any regulatory or inspection functions. My remit relates to public bodies in Wales delivering statutory functions; a summary of those powers can be found here1.

I have had initial contact from the Scouts Association in respect of their actions to date but I will continue to seek updates on their actions to prevent future deaths or serious injuries in response to this report, alongside my counterpart the Children’s Commissioner for England.

In Wales, Estyn are currently expanding their inspections framework to include a bespoke approach for the youth work sector. Work is underway to develop a model that can be applied to youth work being delivered by local authorities and also voluntary sector organisations. This approach will be co-designed with the sector and through engagement with young people accessing youth work, including a pilot of the approach during this year2.

I meet regularly with Estyn and will ensure that a copy of the PFD report is shared with them for the purposes of developing and implementing their youth work inspection approach. I will also ensure that this is discussed at my next meeting with their Chief Executive.

Children’s Commissioner for Wales

1 https://www.childcomwales.org.uk/about-us/legal-powers/ 2 https://www.estyn.gov.wales/inspection/inspecting-future-2024-2030

Childrens Commissioner

18 Apr 2024 PDF

Action Planned

The Children's Commissioner will request updates from the Scouts Association by April 30th regarding actions to prevent future deaths/injuries. They have also called for Ofsted to play a larger role in assuring safety in youth work organisations. (AI summary)

View full response

Dear Mr Pojur, RE: Response to Benjamin Leonard: Prevention of future deaths report I extend my sincere condolences to the family of Ben. The circumstances set out in the prevention of future deaths report makes for sombre reading – both in the way the Scout Association has conducted itself in relation to the inquests and the extensive list of “matters of concern”. As Children’s Commissioner for England I do not have regulatory or legislative powers, however, my team will be asking the Scouts Association to provide us with updates on what, I hope will now be, a meaningful learning exercise to prevent future deaths or serious injuries. The first request will be made by 30th April 2024. I will be mindful of the Coroner’s comment that the Scout Association is “institutionally defensive” when considering their response. Organisations engaged with children need to take safety seriously so children can enjoy opportunities to explore the natural world. I have called for Ofsted to play a larger role in assuring high standards of safety and safeguarding in youth work organisations ( The Big Ambition: Ambitions, Findings and Solutions | Children's Commissioner for England (childrenscommissioner.gov.uk).

Department for Education Central Government

3 May 2024 PDF

Noted

The Department for Education acknowledges the concerns raised, expresses condolences, and references existing guidance related to safeguarding and activity licensing but commits to no specific new actions. (AI summary)

View full response

Dear Mr Pojur,

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

1. This is the Department for Education’s (DfE) response to the Regulation 28 Report to Prevent Future Deaths dated 22 February 2024. The report was issued following the third inquest into the death of Benjamin Leonard (referred to as Ben, in accordance with his family’s statements), who fell from a cliff during a Scout Association trip in 2018.

2. We want to begin by expressing our deepest condolences to Ben’s family and acknowledge the tragic nature of this incident. We appreciate that this is a serious and sensitive issue, which has been the cause of significant hurt and distress to those affected.

3. In that light, we would also like to thank you for your report, allowing us sufficient time to fully address these important issues, and your efforts to conclude the third inquest. The information provided by the report is vital in the Department’s consideration of a long-term strategy to better safeguard children.

David Johnston OBE MP Minister for Children, Families and Wellbeing Sanctuary Buildings 20 Great Smith Street Westminster London SW1P 3BT

2 DRAFT Matters of Concern

1. Your report references a request from the Leonard family for the establishment of a Public Inquiry (be it statutory under the Inquiries Act 2005, or non-statutory) into the Scout Association. In their submission to you, the family suggest that the matters of concern raised through the inquest process, point to systemic safety and safeguarding issues, warranting the urgent need for the establishment of a Public Inquiry. Your report also outlines several other matters of concern for the relevant Minister to consider.

2. The MATTERS OF CONCERN, as you outline them, are as follows:
a. The culture of candour and independent inspection – the lack of a culture of candour within the Scout Association, impacting on safety and safeguarding; and the absence of a robust regulator to independently and periodically audit and inspect the systems, processes and training of the Scout Association, including the granting of permits for activities (overnight and otherwise).
b. Fatal Accident Inquiry Panel Investigation Report (FAIP) – the timely commissioning, completion, and implementation of recommendations from this internal Scout Association process.
c. Safety Training – the quality of online training used to equip leaders with a sufficient understanding of risk assessments to keep Scouts safe.
d. Restricted Duties – that the relevant Scout leaders were not subject to restricted duties immediately following Ben’s death; and when restrictions were issued there was a lack of clarity as to whether these related to the individuals or to specific activities.
e. Absence of Safeguarding and Safety Compliance – in relation to presence of over 18s on the trip, who were not listed as adults on the Nights Away Notification, nor subject to DBS checks, and a general lack of understanding of safety and safeguarding training.
f. Monitoring, Auditing and Reliance on Volunteer Line and the need for paid trainers – regarding the quality of systems for analysis, reporting and clarity of responsibilities regarding compliance and timelines for training, inductions, appointment to roles and the granting of permits.
g. Delays in Training – a lack of sanctions for missed deadlines for mandatory Scout Association training by staff, shortages of local training managers, and statistical data showing significant numbers of roles with over-due training requirements.
h. First Aid Kits – the absence of a first aid kit, and requisite planning for one during the Great Orme trip, issues with the quality of guidance regarding first aid kits on the Scout Association website, and a need to ensure first aid kits were available on every trip and at Scout huts,

3 DRAFT including containing essential items like tourniquets, to enable immediate life-saving treatment.
i. First Aid Self-Certification – regarding learners being able to self-certify completion of further Scout Association first aid training, without checks or assessments for verification, and, despite reported improvements, prevailing concerns about the robustness of the system.
j. Autonomous Charities – the Scout Association's layers of hierarchy creating a disconnect between national staff and local clubs, as to the execution of health and safety. For example, having centralised safeguarding and safety training/policies, yet accountability for these areas being deferred to individual charities (i.e. local clubs and groups).
k. Permit / Licencing Schemes – the absence of a robust system for ensuring permit holders (granted the Nights Away Permit) responsible for children’s safety were suitably qualified, in addition to unclear permit requirements for activities outside regular Scout meeting places.

Scope of Departmental Response, Definitions and Divisions of Responsibility

3. This response sets out the Department’s current position and further steps that will be taken by Government to strengthen safeguarding of children and young people, including in Out-of-School settings and charities such as Scout clubs and activities.

4. ‘Out-of-School settings’ is a term the department uses to describe a range of organisations (both commercial and charitable) or individuals that provide tuition, training, instruction, or activities to children and young people1 in England2. They exclude activities with parental supervision, and regulated education and childcare settings (i.e. schools, colleges, alternative provision arranged by schools or local authorities, and childcare providers registered with Ofsted).

5. It is also helpful, for the purpose of this response, to clarify the divisions of responsibility, relevant powers and responsible bodies within government regarding child protection and safeguarding, in so far as they relate to the Scout Association and its Scout clubs.
a. The Department for Education (DfE) has national policy responsibility for the overarching framework for child protection and safeguarding, which is overseen by local authorities as set out in the Children Act 1989 and associated legislation. This includes the policy remit for Out-of-School Settings safeguarding, and DfE offers extensive guidance for providers and parents on these issues. DfE also has responsibility for the multi-

1 “children” and “young people” are defined in this response as “people who have not yet reached their 18th birthday”. This follows the definition in the Children Act 1989, where a child is defined as ‘a person under the age of 18’. 2 Education in the United Kingdom is devolved with each nation operating separate systems.

4 DRAFT agency guidance on safeguarding, Working Together to Safeguard Children (2023) and Keeping Children Safe in Education.
b. The Department for Culture, Media and Sport (DCMS) is responsible for ‘civil society’ policy and have specific policy responsibilities relating to young people, volunteering, social enterprises, social investment and public service mutuals in England3. It is also responsible for policy relating to charities, in relation to which the legal framework also extends to Wales. DCMS sponsors the Charity Commission for England and Wales (hereafter ‘the Charity Commission’). The Charity Commission is a non- ministerial department which registers charities in England and Wales and regulates their compliance with charity law. The Charity Commission’s independence from Ministerial or Departmental direction or control is set in statute. DCMS also leads on non-statutory youth services and positive activities for young people outside of school settings in England (such as the Scout Association). As part of these responsibilities, they have funded activity to provide safeguarding resources for all domestic charities, and improved safeguarding training for specific areas related to youth work practice. DCMS does not have responsibility for setting or monitoring standards of child protection.

6. Finally, we would note that various matters identified in your report concern the internal structure and workings of the Scout Association (for example their internal FAIP process). Where feasible, we have sought to address all matters of concern, but unfortunately we cannot comment on the internal set-up and structure of individual organisations, or charities in the case of the Scout Association. We understand that the Scout Association will provide a response to your report which we expect will address these issues. Similarly, we understand that the Charity Commission will provide a response which we expect will address matters relating to charity trustees’ legal duties and responsibilities in managing their charity.

3 As the DCMS was not named in your report, DfE sought contributions where their policy remit is relevant to the matters of concern identified.

5 DRAFT Department for Education Response
1. The Government takes the safeguarding of all children very seriously. We are committed to protecting children from harm across all settings, including Out-of- School Settings and charities such as Scout Association clubs and expeditions. There are legal duties and supporting powers in place to protect children in these settings, and we expect relevant regulators (such as the Charity Commission), local authorities and police to use them as necessary when duties are not met.

2. We have set out the most relevant legal duties, guidance and best practice below, which directly address many of the coroner’s matters of concern. We strongly encourage out-of-school settings, such as The Scout Association, to follow our safeguarding guidance for providers. The DfE has also extensive wider safeguarding guidance for working with children, such as Keeping Children Safe in Education, and the Working Together to Safeguard Children, which may be useful to refer to for best practice. We expand on the full extent of existing guidance in Annex B, with specific advice addressing matters of concern on point-by-point basis in Annex C.

3. The Charity Commission is the registrar and regulator of charities in England and Wales. Elaborating on the above Division of Responsibilities, the Charity Commission are an independent, non-ministerial government department accountable to Parliament and, for the exercise of their powers, to the Tribunal and the courts.

4. Through the Charities Act 2011 (‘the 2011 Act’) – which sets out the Charity Commission’s statutory duties and functions – and relevant case law, it already has a strong regulatory framework to help ensure trustees comply with their legal duties and responsibilities in managing a charity. All charity trustees, whether for a national organisation or local clubs, have legal duties including a duty of care to safeguard those who come into contact with the charity and its work. A charity should be a safe and trusted environment.

Specific powers
5. There are a wide range of regulatory powers at the Charity Commission’s disposal. Before any use of these powers the Charity Commission assesses concerns against its Regulatory and Risk Framework, to ensure it makes proportionate and targeted use of its resources when addressing issues of concern.

6. The Charity Commission has the power to identify, investigate and take action regarding apparent misconduct or mismanagement in the administration of charities. It may also conduct inquiries with regards to charities, either generally or for particular purposes. The Charity Commission may open an inquiry at the

6 DRAFT same time as another agency or regulator. The supporting guidance states that the aim of an inquiry is to:
a. identify the extent, if any, of misconduct and/or mismanagement in the administration of the charity;
b. assess any risk to the charity and its assets;
c. and decide whether the Commission needs to act to protect the property of the charity. It further states that misconduct includes any act, or failure to act, that the person committing it knew, or ought to have known, was criminal, unlawful or improper.

7. Specifically, section 47 of the 2011 Act details some of the Charity Commission’s investigative powers available for use during a statutory inquiry. These include the power to direct any person to:
a. provide the Commission with accounts and statements in writing on the matters under investigation;
b. return to the Commission answers in writing to any questions or inquiries addressed to them, and to verify any accounts, statements or answers by statutory declaration;
c. provide copies of documents in their custody or under their control relating to the matter being investigated and to verify any copies by statutory declaration; or
d. attend at a specified time and place and give evidence or produce any documents.
e. provide evidence on oath or make a declaration of truth.

8. In practical terms, under section 47 of the 2011 Act, the Charity Commission has the power to obtain, evaluate and disseminate information in connection with the performance of any charity. In addition, with a warrant (as per sections 48 and 49 of the 2011 Act), a member of the Commission’s staff can enter and search premises, take possessions or documents, take a computer disk or other electronic storage devices, to take copies of documents. In specific circumstances (as per section 84 of the 2011 Act) the Charity Commission also has the power to close charity services, such as educational classes and recreational activities.

9. Specifically in a safeguarding context, the Charity Commission has a regulatory role focused on the conduct of trustees and steps taken to protect beneficiaries, employees, volunteers and others who come into contact with the charity through its work. As part of their legal duties, trustees of a charity must take reasonable steps to protect from harm people who come into contact with their charity.

10. As set out in the Charity Commission’s ‘How to report a serious incident in your charity guidance’, failure by charity trustees to sufficiently manage safeguarding

7 DRAFT risks or protect people adequately would be of serious regulatory concern and may be considered to be misconduct and/or mismanagement.

11. As a registered charity (no. 306101) the Scout Association must comply with charity law and regulation. As stated above in the Divisions of Responsibility, the Charity Commission is independent, including having a statutory requirement that it is not subject to Ministerial direction in the exercise of its functions. As such, we would not and could not seek to direct their ongoing engagement with the Scout Association. We also understand that the Charity Commission has been engaging with the Scout Association since Ben’s tragic death in August 2018, following the Scout’s serious incident report. As such, it is right that they will also be providing an independent response to your report and we welcome their contribution. We believe that for many of the matters of concern listed, the Scout Association’s and club trustees’ compliance with their legal duties is pivotal.

12. The Charity Commission’s Safeguarding and protecting people for charities and trustees guidance clearly sets out that it expects all charity trustees to make sure that their charity:
a. knows how to spot and handle concerns in a full and open manner
b. has a clear system of referring or reporting to relevant agencies as soon as concerns are suspected or identified
c. is quick to respond to concerns and carry out appropriate investigations
d. does not ignore harm or downplays failures
e. has a balanced trustee board and does not let one trustee dominate its work – trustees should work together
f. makes sure protecting people from harm is central to its culture

13. We know that the Charity Commission does investigate safeguarding-related matters and ensures proper compliance with charity law as needed. The Charity Commission publicly announces the opening of statutory inquiries into charities carried out under section 46 of the Charities Act 2011. We would encourage all interested parties to review their record here -

14. We would also highlight the Charity Commission’s updated strategy, published in December 2017, for dealing with safeguarding issues in charities. This further outlined its regulatory role and approach in overseeing the legal duties of trustees in relation to safeguarding. In line with this strategy, we would expect the Charity Commission to use its powers to intervene where there are serious safeguarding concerns within a charity.

8 DRAFT Other legislation and guidance relevant to settings such as the Scout Association

15. As set out above in the Divisions of Responsibility, local authorities also have legal responsibilities for safeguarding and promoting the welfare of all children in their area. These include safeguarding and promoting the welfare of children in need in their area (section 17 of the Children Act 1989) and investigating where they have reasonable cause to suspect that a child has suffered, or is likely to suffer, significant harm (section 47 of the Children Act 1989).

16. There are also several other areas of legislation which govern how the local authority should work with multi-agency partners and relevant agencies, such as charities like the Scout Association and its clubs, to ensure that children are safeguarded and protected from harm. This includes:
a. Section 10 of the Children Act 2004 which requires each local authority to make arrangements to promote cooperation between the authority and a range of other local “relevant partners” (such as the police, schools and health services) and such other persons or bodies exercising functions or engaged in activities relating to children and considered by the local authority to be appropriate with a view to improving the well-being of children in each local authority area so far as it relates to: (a) physical and mental health and emotional well-being, (b) protection from harm and neglect, (c) education, training and recreation, (d) the contribution made by them to society and (e) social and economic well-being. Such persons or bodies could conceivably include charities, such as the Scout Association and its local clubs.

17. The Children Act 2004, as amended by the Children and Social Work Act 2017 also introduced stronger multi-agency safeguarding arrangements. Local authorities, together with the local integrated care board, and local chief officer for the police – as the three statutory safeguarding partners – have a shared and equal statutory duty to make arrangements and work together to safeguard and promote the welfare of all children in their local area. The arrangements should set out how they will coordinate their safeguarding services in a local area; act as a strategic leadership group in supporting and engaging others, and implement local and national learning, including from serious child safeguarding incidents. This would include serious incidents such as the death of a child on an excursion.

18. The purpose of these local arrangements is to support and enable organisations, charities (such as the Scout Association and its clubs) and agencies to work together in a system where children are safeguarded and their welfare promoted. The arrangements should set out how partner organisations, charities and agencies collaborate, share and co-own the vision for how to achieve improved outcomes for all vulnerable children. It is for the three safeguarding partners to

9 DRAFT determine how these organisations and agencies will hold one another to account effectively and ensure that they listen and respond to the views of local children and their families. The safeguarding partners must publish a report at least once in every 12-month period which should set out how effective their arrangements have been in practice.

19. As set out in the Children Act 2004, these safeguarding arrangements also place a duty on “relevant agencies” to cooperate if asked to be part of local safeguarding arrangements; and where named they would have a statutory duty to comply with the arrangements. The Relevant Agencies are specified in the Child Safeguarding Practice Review and Relevant Agency (England) Regulations 2018 and includes charities within the meaning of Section 1 of the Charities Act 2011 – this would cover charities such as the Scout Association and its local clubs.

20. In addition to this, we also expect local authorities to work with a range of multi- agency partners (such as, but not limited to the Police, Charity Commission and the Health and Safety Executive) to intervene in settings of concern, which might be exposing children to, or placing them at risk of harm. Across these partners, there are several powers under which action can be taken, which we detail in our advice for unregistered schools and Out-of-School Settings - Collaborative working between the Department for Education, Ofsted and local authorities.

21. Beyond the role and powers of local authorities and multi-agency partners, all Out-of-School Settings also have a common law duty of care to protect the safety and welfare of children, and therefore must by law take reasonable steps to ensure the safety of children in their care and protect them from harm. It is also relevant to note that these settings are also subject to the Safeguarding Vulnerable Groups Act 2006 which makes it an offence to knowingly employ someone in 'regulated activity ' if the employer has reason to believe they are barred from working with children. We have published dedicated guidance to support them in meeting these duties.

22. Similarly, the Scout Association is part of the Youth Sector, where substantial guidance and training has been provided by the National Youth Agency (NYA), funded by the Department for Culture Media and Sport.

Further measures to strengthen safeguarding within the sector
23. The Government is committed to ensuring all settings, including Out-of-School Settings and charities such as Scout clubs, are as safe as possible and have been progressing a programme of safeguarding work with this aim in mind.

24. Recent work on Out-of-School safeguarding has included:

10 DRAFT
a. Provision of over £3 million funding to selected local authorities, between 2018 to end of 2021, to run a series of multi-agency pilots aimed at boosting local capacity to identify and intervene in settings of concern; and building the evidence based on the extent of risks in the sector, and the utility of relevant agencies’ existing legal powers to conduct safeguarding activity in these settings. Despite the pandemic disrupting many settings, the outputs from this work (an independent evaluation report published November 2022) can still be used to help inform the need for, and development of, any national approaches to further strengthen safeguarding and oversight.
b. Dedicated workstreams to support the sector’s understanding of how to run a safe setting, and their wider understanding of expected safeguarding standards (through the development of a safeguarding code of practice)
c. Development of parental safeguarding guidance on Out-of-School Settings, to help parents both make informed choices when seeking safe settings for their children, and to know what to do if they do have concerns.
d. An ongoing review of existing guidance for local authorities and multi- agency partners on safeguarding in Out-of-School Settings, to share best practice from the pilots, and to ensure local authorities are fully utilising both theirs and multi-agency partners’ powers to identify and intervene in settings of concern.

25. We have also maintained an ongoing dialogue with sector representatives and safeguarding partners on safeguarding in Out-of-School Settings using this to inform ongoing reviews and updates to existing guidance. Following the conclusion of the pilot programme and culminating evaluation report, we have also been working closely with these stakeholders on the development of potential options for further enhancing safeguarding and oversight, to help inform our upcoming Call for Evidence.

Existing Work on Regulatory Models

26. In addition, and at times as part of, the programmes above, we have continually considered and assessed the case for further regulation, and practicalities of any future system.

27. Specifically, in November 2015, we consulted on a proposed model of regulation for Out-of-School Settings, based on registration and risk-based inspection4. However, the strong negative feedback received from respondents, including that the proposed model risked placing unnecessary burdens on the many settings already providing enriching education and activities in a safe environment,

4 This was published in 2015, with a Government response in 2018.

11 DRAFT limiting parents’ choices on how they educate their children, as well as suggestions that existing legal powers were sufficient to intervene and take action in Out-of-School Settings of concern.
a. This included the wide range of legal powers held by the Charity Commission, as referenced above. In particular their powers to intervene where Trustees are not complying with their safeguarding duties.

28. The Government took the decision not to proceed with the proposed model of regulation, and to instead progress an alternative package of safeguarding measures aimed at enhancing safeguarding of children in this diverse sector.

29. While we have not ruled out further regulation of the sector, it is imperative that any system of regulation is proportionate, complements, and builds on existing legal powers.

30. As part of our ongoing work to ensure these settings are as safe as possible, we have therefore been working closely with safeguarding partners, sector representatives, and parent groups on the development of potential options for further enhancing safety of the out-of-school settings sector, with the intention of launching a call for evidence this summer.

Wider Work across Government sector

31. Government also funds the NYA to provide generic safeguarding resources available to domestic charities, and to renew the youth work curriculum and qualifications, including updated safeguarding training tailored specifically towards the youth work sector.

32. In 2018-2020 DCMS partnered with the charity sector on a Charity Safeguarding Programme to drive activity through a comprehensive cross-sector programme of projects.

33. The programme focussed on improving the generic guidance and support available to all charities whatever their size or sector of interest to ensure that basic standards were clearly set and communicated, including to:
a. Provide charities with clear, consistent and easily accessible guidance and reporting processes
b. Create the right culture in charities as the foundation for effective handling of safeguarding incidents, promoting strong leadership and challenging poor practice to change behaviour
c. Provide digital solutions giving simple and accessible ways for anyone to report a concern to the right person at the right time
d. Provide access to training, support and advice in one place that is free, accessible and sets a basic standard.

12 DRAFT

34. A fuller overview of our historical and ongoing work with the sector, and actions to improve standards, is set out in Annex A.

Request for a Public Inquiry

35. We recognise the specific call to action within the report and families’ public statements – seeking a public inquiry – and share that desire for improved standards to come from Ben’s tragic death. Whilst a public inquiry could help draw out unacceptable safeguarding practices and the impact on those affected, we believe it would not be the best route to meaningful change.

36. Our planned Call for Evidence, expected to launch this summer, would better serve any need to address systemic safeguarding or safety issues in the sector, and progress options for effective and proportionate safeguarding reform.
a. Given our commitment to ensure these settings are as safe as possible, we are keen to seek the widest possible range of views, as swiftly as possible, regarding options for strengthening safeguarding and oversight of the sector.
b. However, any inquiry would likely be of a significant length and cost, with legislative requirements (and so probable further delays) if on a statutory basis. This may also delay or place resourcing pressures on ongoing work to evaluate and take forward any policy options for longer-term safeguarding reform.

37. We will carefully consider this report as crucial to the development of our Call for Evidence, given the many helpful insights into where further measures may be needed. We strongly encourage yourself and all interested parties to contribute to this upon launch. Ben’s tragic death has redoubled the Government’s commitment to improving safeguarding standards in Out-of-School Settings.

Specific matters of concern

38. As referenced above, we cannot comment on the internal workings and structure of the Scout Association, or their implementation of internal policies and procedures. However, we have tried within Annex B and C, to address each matter of concern identified in your report. We hope this clearly sets out the current government position and guidance on these important issues. We would be very happy to discuss any particular issue further as and if needed.

39. We will also be giving consideration, as part of our regular review and refreshment of DfE guidance, to any points which could be strengthened further in light of your report, or where we could seek to further improve signposting to

13 DRAFT wider legislation or other government guidance relevant to the matters of concern identified.

40. Finally, we would again thank you for giving us the opportunity to respond and express our condolences to the family and friends of Ben Leonard.

Health and Safety Executive Regulator / Inspectorate

16 May 2024 PDF

Action Planned

HSE will begin an investigation into Ben’s death and will also look at how they intervene generally with volunteering organisations that provide activities to young people such as the Scout Association to identify lessons for the future regulation of this sector. HSE will undertake a review to identify how this error occurred, and to ensure that it is not repeated and will be writing directly to Ben’s family to offer them an apology. (AI summary)

View full response

Dear Mr Pojur, Thank you for sharing a copy of your Regulation 28 report, with the Health & Safety Executive (HSE), following the inquest into the tragic death of Ben Leonard, in 2018, while on a scouting trip to North Wales. This was clearly a tragic incident and I would like to offer my condolences, and those of HSE, to Ben’s parents and family for their loss. In your report you have noted that, in your opinion, action should be taken to prevent future deaths. Whilst you have referred your report to a number of parties, you have raised two main areas of concern that appear to fall to HSE to address: that there is no independent or robust regulator who independently and proactively audits and inspects the Scout Association’s arrangements for adventurous activities and that these activities are otherwise exempt from regulation by the Health and Safety Executive (HSE). Whilst more detail is provided in this response, I would highlight here that, whilst it is true that the Scout Association is exempt from regulation by HSE’s Adventure Activities Licensing Authority, as are all voluntary associations providing services to their own members, it is not correct that this equates to a wider exemption from all HSE regulation and oversight. HSE is Britain’s national independent regulator for workplace health and safety. We work to ensure people feel safe where they live, where they work and in their environment by providing worker protection and public assurance. I can confirm that the Scout Association, as a volunteering organisation with employees, is required to comply with workplace health and safety legislation and that their scouting activities are not exempt from regulation by HSE. Under the Health and Safety at Work etc. Act 1974 (HSWA) and associated regulations the Scout Association has duties to protect their employees, and others, from risks arising from their work activities. We

have powers under HSWA to enforce those duties where necessary, including by prosecution, as do our local authority co-regulators. With regard to the provision of scouting activities, Section 3 of HSWA places a duty on the Scout Association to conduct their undertaking in such a way as to ensure, so far as reasonably practicable, that persons not in their employment are not exposed to risks to their health and safety. This duty includes protecting volunteers, scouts, and members of the public from risks that may arise from scouting activities. The Scout Association is furthermore required by the Management of Health and Safety Regulations 1999 to make a suitable and sufficient assessment of the risks to the health and safety of persons not in their employment arising out of or in connection with the conduct of their undertaking. This is for the purpose of identifying the measures they need to take to comply with their statutory duties to protect others from harm. They are also required to make appropriate arrangements for the effective planning, organisation, control, monitoring and review of the preventative and protective measures identified. As referred to above, HSE is also the licensing authority for the Adventure Activities Licensing Regulations 2004. These regulations require persons providing facilities for adventure activities, in return for payment, to hold a licence granted by HSE in accordance with the regulations. Persons are not required to hold a licence where facilities are provided by a voluntary association to its members and on this basis the provision of licensable adventure activities to scouts by the Scout Association or scout groups is exempt from the regulations. The Health and Safety (First Aid) Regulations 1981 require employers to make adequate and appropriate first aid arrangements for their employees but do not place a legal duty on employers to make first-aid provision for non-employees such as volunteers or the public. However, our guidance accompanying the regulations strongly recommends that non-employees are included in assessments of first aid needs and that provision is made for them. Enforcement of health and safety legislation is split between HSE and local authorities. Policy responsibility for health and safety regulation rests exclusively with HSE. Investigations into health and safety incidents involving scouting are allocated between HSE and local authorities according to the occupancy of a premises and the main work activity carried on there. As Ben’s death took place at the Great Orme country park and nature reserve, which is managed by Conwy Council, HSE is the enforcing authority for any investigation under the Health and Safety at Work Act. Fatal accidents arising out of or in connection with work are reportable under The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR)
2013. Where accidents involve persons not at work, the person in control of the premises where the incident took place is responsible for making the report. In the case of Ben’s death, Conwy Council would have been responsible for submitting a report

under RIDDOR as they manage the Great Orme country park. Whilst HSE has no record of a report being submitted in relation to Ben’s death, I understand that, at the time of its occurrence, your office contacted the local HSE office to inform them of the incident and was advised that Ben’s death fell to Conwy Council to investigate. This was not correct – please accept my apology for the fact that an incorrect response was given at that time. I have also been made aware that, following the conclusion of the 2020 inquest, this mistake was perpetuated as HSE colleagues, having identified Ben’s death as requiring investigation, incorrectly informed Conwy Council that they were the enforcing authority and not HSE. Our investigation Division have now begun an investigation into Ben’s death in accordance with the Work-related Death Protocol to determine the cause, identify lessons and actions needed to prevent any recurrence and take appropriate enforcement action. I have asked the team to ensure the investigation is given priority, given the unacceptable delays that have already occurred. If supported by the findings of our investigations, we will also look at how we intervene generally with volunteering organisations that provide activities to young people such as the Scout Association to identify lessons for the future regulation of this sector. In addition, I am aware that prior to the inquest North Wales Police, at your request, sought advice from HSE on the application of health and safety legislation to the circumstances of Ben’s death, and that the advice provided to North Wales Police was not consistent with the position set out above. I apologise for any misunderstanding this may have caused and assure you that it had not been our intention to mislead the inquest. The error in not identifying, repeatedly, that this was a matter for HSE to investigate was clearly unacceptable and I would like to apologise to Ben’s parents and family that an investigation has not been undertaken sooner. HSE will undertake an appropriate review to identify how this error occurred, and to ensure that it is not repeated. We also will be writing directly to Ben’s family to offer them an apology.

Scout Association Other

PDF

Action Taken

The Scouts Association details actions taken including updating POR (Policy, Organisation and Rules), developing new training modules ('Growing Roots'), creating a new safety committee, and updating risk assessment processes. They also describe planned reviews and consultations. (AI summary)

View full response

Prevention of Future Deaths Response – The Scout Association

Ben Leonard Inquest Prevention of Future Deaths Report Response from The Scout Association April 2024

Prevention of Future Deaths Response – The Scout Association

Contents

Introduction .............................................................................................................................. 3 Section 1: Culture of Candour and Independent Inspection ........................................................ 5 Section 2: Fatal Accident Inquiry Panel Investigation Report (FAIP) now termed “Learning Review” ................................................................................................................................................ 8 Section 3: Safety Training......................................................................................................... 13 Section 4: Restricted Duties .................................................................................................... 16 Section 5: Absence of Safeguarding and Safety Compliance ..................................................... 18 Section 6: Monitoring, Auditing and Reliance on Volunteer Line and the need for paid Trainers ... 21 Section 7: Delays in Training .................................................................................................... 24 Section 8: First Aid Kits ............................................................................................................ 26 Section 9: First Aid Self Certification to meet Module 10 First Response requirement. ............... 27 Section 10: Autonomous Charities .......................................................................................... 28 Section 11: Permit/ Licencing Schemes ................................................................................... 31 Appendices ............................................................................................................................ 33 Appendix A – Planned actions & delivery dates ...................................................................... 33 Appendix B – Fatal Accident Investigation Term of Reference ................................................. 36 Appendix C – Safety changes since 2018 .............................................................................. 40 Appendix D – ‘Growing Roots’ Overview ................................................................................ 42

Prevention of Future Deaths Response – The Scout Association

Introduction

On behalf of The Scout Association, we would like to express our wholehearted apology to the Leonard family – both for the death of Ben and for the anguish they have experienced over the past five and a half years. It was not the intention of anyone at Scouts to contribute towards any further pain, but we recognise that we have caused further distress and for that we are truly sorry. This inquest and HM Coroner’s Prevention of Future Deaths report has led to significant soul searching and reflection, with extensive discussions taking place within our Board and with wider stakeholders. It has rightly dominated our thinking and we pledge that it will continue to do so. As a result, we are proposing fundamental changes to our approach to safety throughout the Scout movement. Throughout this report, we have addressed the concerns of HM Coroner using the same sub- headings in his Prevention of Future Deaths notice. In each section, we outline our response to these concerns and the actions we have taken since the inquest, the actions we will take from this point forwards, as well as capturing actions that have been taken since Ben’s tragic death in
2018. This response further builds on the work we have undertaken after receiving the Prevention of Future Deaths notice in February 2020, and the further update provided in February 2021 to HM Coroner1. There are 25 key actions we will be undertaking, but we highlight the following:
1. A Fatal Accident Investigation Panel for Ben’s death with an external chair and independent panel members was initiated within 48 hours of the conclusion of the inquest and is due for completion in June.
2. A Critical Incident and Investigation Policy and a Duty of Candour Policy will be agreed by the Board in July 2024 (with these principles implemented immediately). This will provide a consistent framework in how we respond in future to serious incidents, emphasising the need for transparency and to quickly capture learning.
3. We are commissioning a new strategic partnership with a nationally recognised organisation that is a leader in safety to review our current safety practices, and this party will act as a Third-Party reviewer. We anticipate that this partnership will be in place by May, with an initial review completed by October 2024.
4. We are currently commissioning enhanced supplementary safety training and validation for all 145,000 volunteers (the new training will be available by September 2024 with a target completion within 6 months thereafter). This is designed to further support volunteers and assure us that they understand what is required of them in terms of safety, and have the required competencies and knowledge in relation to risk assessments, terrain definitions, and requirements within our Policy Organisation & Rules (POR).
5. We are investing in several new systems and resources that will transform access to information and monitoring.

1 Responses to this PFD Report were provided from The Scout Association dated 1.4.20 and then an updated response dated 12.2.21.

Prevention of Future Deaths Response – The Scout Association

These include:
• A new, movement-wide assurance framework to support local leaders, and monitor and audit compliance, including in relation to safety.
• Additional staffing resource to support areas of safety, adventurous activities, training support, and local compliance.
• The implementation of a new approach to the auditing of adult training, including the provision delivered by County Training Managers under our new Audit & Assurance approach.
• We are undertaking a full review of Permitting.
• A new Learner Management System and training packages, which will provide significantly enhanced role specific training, including compliance data for volunteers and volunteer management roles across the movement.
• A new Adult Membership System that will provide far greater access to key information and transform how we assess, approve, and audit our Nights Away Application processes. We have attached our delivery plan in Appendix A to ensure our response to Ben’s death is more than words, and that the changes already undertaken, along with those planned, will enable the thousands of volunteers who deliver Scouting to continue to do so safely. We will publish our progress against the plan on a quarterly basis in 2024 as part of our commitment to transparency and accountability. We will then include ongoing updates on progress as part of our new annual Safety Report. We understand our response must be more than simply a plan; it has to be a comprehensive response to this tragedy, and a significant moment in our history which leads to an overhaul of our culture and systems. As leaders of the Scout movement, we want to state our commitment to ensuring that this is a transformative moment for Scouting at all levels. We are committed to learning, being honest and transparent, and building the trust of parents, young people, and wider stakeholders so that we remain true to our values of integrity, respect, care, belief, and co-operation.

Chair of the Board

Chief Executive

UK Chief Volunteer

Prevention of Future Deaths Response – The Scout Association

Section 1: Culture of Candour and Independent Inspection Concerns 1–2 (and Concern 39)

1. I am concerned that there is not a culture of candour within The Scout Association (‘TSA’) and the impact that this has on safety and safeguarding.

2. I am also concerned that, whilst the Charity Commission has regulatory oversight, there is no robust regulator who independently and periodically audits and inspects the systems, processes and training of The Scout Association or the granting of permits for adventurous activities, hill walking and Nights Away permits. Further, The Scout Association permit scheme for adventurous activities is exempt from regulation by the Health and Safety Executive (‘HSE’).

39. The Scout Association press release within moments of the jury’s conclusion demonstrates a failure of The Scout Association to accept any accountability and understanding any proper learning from Ben’s death. The Scout Association is institutionally defensive.

Culture of Candour The Scout Association is committed to learning from Ben’s tragic death. We know we can and must do better. We have carefully considered the Coroner’s concerns in detail and will act with greater openness and transparency. We agree with the Coroner that a culture of candour is essential in relation to safety and safeguarding, and we recognise there is more we must do in this respect. We have therefore agreed to put in place concrete measures to adopt an enhanced culture of candour. These include new policies and training in respect of how we respond to critical incidents. This will ensure we are clear with parents when things go wrong, we work with them, so they know the actions we are taking, and publish learning to ensure transparency and accountability. We wholeheartedly apologise for any lack of candour in the past. Across Scouts, we strive to have an open and transparent culture and we accept improvement is needed. Regulation & Audit We are mindful that any decision on regulatory oversight is not a matter for The Scout Association but is for HM Government to determine. We will abide by their decision and stand ready to actively participate in any such discussions and/or proposals. There are a number of regulatory frameworks which we now work within, including the Charity Commission, Office of the Scottish Charity Regulator, Health & Safety Executive, ICO, DBS, AccessNI & PVG and our Primary Authority relationship. We have significantly reflected on the Coroner’s concerns and, irrespective of any government proposals, we are going further in terms of seeking Third Party external review, inspection, advice,

Prevention of Future Deaths Response – The Scout Association

and assurance. In the actions section below, we outline the work we are now undertaking to engage in external strategic reviews and identify learning from National Governing Bodies (NGBs) that would enable a strengthened model for Scouting. Finally, with regards to Concern 39 specifically, we wholeheartedly apologise to the Leonard family for the timing of our press release. While we stand by the commitment that we made to learning in the statement, we accept that it was released too soon. We hope the details in this response demonstrate our commitment to ensuring clear accountability. Actions Culture of Candour
1. To underpin our commitment to transparency, the Board have agreed to develop and adopt a new Duty of Candour Policy to be approved in our July Board 2024 (with these principles implemented immediately).

2. Starting in 2025, each year we will publish a new annual Safety Report that outlines our in-year learning reviews, lessons learned, and actions taken, further building a culture of candour in relation to Safety & Safeguarding (first publication April 2025).

Audit & Inspection

3. We are in discussions to commission a new strategic partnership with a nationally recognised organisation that is a leader in safety to review our current safety practices, and this party will act as a Third-Party reviewer2. We anticipate this partnership will be in place by May 2024 and will initially cover four core areas:
• A comprehensive independent review of our current safety practices (including the risk assessment process – identification, mitigation, change, review and sign- off) to assess if learning is successfully delivered, appropriate and effective.
• A review of the required competencies and skills to inform our syllabus and approach to safety training and best practice.
• The development of a revised safety framework and associated standards.
• A yearly independent review of all safety policies and processes, along with review of these safety practices to align to internal and external learning and best practices. This is similar to the work already undertaken by the NSPCC on our safeguarding policies and procedures. (first review September 2024) The Board has agreed to invest in the required resources, including additional staffing, based on the findings of this review. This initial strategic review will report within six months (October 2024) with planned recommendations and proposed action.

4. Learning from external expert bodies is central to how The Scout Association operates. We already have membership and relationships with several National Governing Bodies (NGBs) within adventurous activities and sport. We will focus our engagement on relevant areas, such as hillwalking and adventurous activities permitting, and to understand how

2 Third Party Reviewer – an independent organisation or body providing services in areas such as inspection, investigation, audit, and assurance.

Prevention of Future Deaths Response – The Scout Association

better external scrutiny and oversight can address the concerns raised by the Coroner and support the external review outlined above. This will be initiated by June 2024.

Other key areas of work
5. In October 2023, The Scout Association agreed to make a significant investment into a new and permanent internal Audit & Assurance staff team which we are currently building. This new team, working in partnership with volunteer leadership, will look to audit and monitor all of our 8,000 charities at local level and provide reporting nationally to the Board. The new Audit & Assurance team will initially look at training compliance, permitting compliance, the quality and effectiveness of risk assessment against proposed activities, implementation, and management of the Nights Away Permit approval process and wider permitting. Furthermore, it will ensure that robust action plans are built, any issues are addressed, and if required, stop an activity from happening in partnership with local volunteer leadership. It will also support local Scouts charity Trustees in their responsibilities.

6. We are also investing significantly in a new Adult Membership System (AMS), due to be rolled out from December 2024, which will provide the following benefits:
i. Enable volunteers to undertake key safety tasks more efficiently (including suspensions, permitting, Nights Away applications and approvals). In particular, it will transform how we approve and monitor Nights Away and Permitting by moving all applications and approvals online with a mandated requirement to upload all required paperwork, including risk assessments. The approver (Senior Volunteer) will be able to see all volunteers attending the trip, their training and disclosure status and assess all documentation when deciding whether to approve or decline the trip. The system will enable a full audit trail of all processes.
ii. It will allow the integrated production and visibility of real time reporting at local and national levels for all training and wider compliance data.
iii. It will integrate with our recruitment, onboarding and learning tools, as well as existing tools including disclosure checking, so local managers have access to all volunteer automated data and can validate compliance and safety vetting.

Prevention of Future Deaths Response – The Scout Association

Section 2: Fatal Accident Inquiry Panel Investigation Report (FAIP) now termed “Learning Review” Concerns 3–11

3. Following Ben’s death, as indicated by Chapter 7 of The Scouts’ Policy, Organisation and Rules (Rule 7.2 version May 2018), at that time required the Charity and Company Secretary of the Association to establish an enquiry on behalf of the Board of Trustees. This should have detailed authorisation, training, equipment, briefing and leadership of the party involved together with their observation of the sequence of events and possible causes of the fatality.

4. As of 22.2.24, over 5 years since Ben’s death, there is still no Fatal Accident Inquiry Panel Report in existence. Further still, even the prospective panel members for this investigation have not been identified. A document I have received entitled ‘BL Great Orme Learning and Actions Update’ dated 30.9.19 is inadequate when considering the root and branch type of review needed following a child fatality to identify and address issues of safety and safeguarding – particularly these having been identified as significant issues on the day of Ben’s death and despite this fact – no investigation followed - with The Scout Association maintaining this was due to a live police investigation initially, and latterly due to this inquest.

5. Without a timely internal Fatal Accident Inquiry Panel Investigation Report (FAIP), this gives me great concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality.

6. The evidence provided by The Scout Association has been inconsistent as to when it is said a FAIP report is commissioned and completed in circumstances where there is an inquest.

7. An FAIP investigation initiated by the Charity and Company Secretary, should have engaged with the early identification by the District Commissioner, County Commissioner, and The Scout Association Headquarters staff who had concerns and noted failings relating to the planning, risk assessment, supervision and approval for the trip including the absence and non-attendance of the identified and necessary first aider, the presence of over 18 year olds on trip which had not been disclosed or approved by the District Commissioner and concerns around the competence of the leaders.

8. The Scout Association reconstruction trip to the Great Orme after Ben’s death on 9.10.18 attended by The Scout Association Senior Scouting leadership and lawyers with the actual leaders from the trip indicates a desire by The Scout Association headquarters staff to control the narrative, especially surrounding dynamic risk assessment. Any investigation by County or District level was prevented by headquarters at Gilwell. The District and County Commissioners had identified failings and concerns relating to safety

Prevention of Future Deaths Response – The Scout Association

and safeguarding on the day Ben died and the extent of the failings were known and many identified further, following the trip to the Great Orme on the 9.10.2018.

9. In this investigation, the evidence I have heard leads me to a concern as to a general reluctance by The Scout Association to engage in a meaningful learning exercise to prevent a recurrence of the issues pertaining to Ben’s death. This inquest was stated as the reason preventing a FAIP report.

10. However, a FAIP relating to another death in Scouting of a 21-year-old leader was considered in evidence. This FAIP and recommendations were completed before that Inquest. However, it is not clear as to whether this report and recommendations was shared with the relevant Coroner. It is also not clear if, even when FAIP reports have been completed, whether they are provided to the relevant Coroner.

11. I therefore have concerns that not all matters regarding deaths connected with the Scouting Movement and Association are being communicated, even by provision of draft report and recommendations, to His Majesty’s Coroners of England and Wales to inform PFD issues and a Coroner’s PFD reporting duties.

Fatal Accident Investigation We wholeheartedly apologise for not completing a Fatal Accident Investigation (FAI) prior to this inquest and accept that our decision to not do so was wrong. This will not happen again. We recognise that the lack of a FAI report into Ben’s death has added to the distress experienced by the Leonard family and to the challenges within the inquest process. While we followed legal advice regarding the timing of the FAI after Ben’s death, we accept it was wrong not to initiate a FAI in advance of the inquest. We recognise that undertaking an FAI would have allowed greater information to be available earlier in relation to Safety and Safeguarding matters and would have prompted quicker action in key areas. Critical Incident Response & Learning Learning from any incident is central to our commitment to continuous and cultural improvement. As such, we are fully reviewing our approach to Critical Incidents. This will now include a new approach that we will call a Fatal Incident Investigation3. We are reviewing current policies and creating a new Critical Incident & Investigation Policy and procedure, which will form part of our wider learning review process for any incidents. This will make sure any future critical incidents are immediately and robustly investigated, and learning is gathered quickly. Should a fatality occur again, all investigation findings will be provided to His Majesty’s Coroners of England and Wales (and devolved nation equivalents) ahead of any inquest proceedings. We acknowledge the concerns raised by HM Coroner with regard to the perception that members of The Scout Association tried to control the narrative. To the best of our knowledge, it was not the

3 Moving forwards, and after discussion with external experts, we have agreed to remove the term ‘accident’ from Fatal Accident Investigation and use the term ‘Incident’ instead. This recognises that using the term ‘accident’ may reduce the importance of how an incident is seen and hinder the ability to identify the root causes.

Prevention of Future Deaths Response – The Scout Association

intent of any individual within The Scout Association to attempt to do so, however we have learned from this. As detailed in point 2 below, we will now appoint a member of the Executive Leadership Team, who will report into the Board to ensure full transparency and accountability. Our new Critical Incident & Investigation Policy will also set clear rules regarding site visits and how information is gathered. The policy will include a commitment to share all relevant information with statutory agencies in a fully transparent manner. We recognise the concerns raised about poor communication with local leadership. We are committed to changing and learning from this. In future, we will ensure there is greater clarity about the roles and responsibilities of different parties, especially where any fatality has occurred. We will ensure that guidance is clear and update POR where a national policy, such as the new Critical Incident & Investigation policy, is implemented. With regards to Concern 10 specifically, we would like to add some information regarding the tragic death in Scouting of a 21-year-old leader that was considered in evidence. We would like to clarify that The Scout Association did provide a copy of the fatal accident inquiry panel report to inquest investigators before the inquest commenced. Specifically, the report was shared with the Senior Environmental Health Officer (EHO) at Preston City Council, who the Coroner had instructed to provide a report to the inquest. Learning from this and in future, the new Critical Incident & Investigation Policy will ensure we have a consistent approach to the provision of such information. Actions Learning from Ben’s Tragic Death

1. The Scout Association has now commissioned the Fatal Accident Investigation (FAI) into Ben’s death with Terms of Reference, completed within 48 hours of the inquest concluding. Please see TORs attached for reference at Appendix B. As we highlight, we apologise for not doing this sooner. The initial FAI report is due to be completed by June 2024 and its findings and actions will be shared with the Leonard family and HM Coroner in accordance with our commitment at the inquest. We have also asked the FAI panel to undertake a detailed review into actions by The Scout Association after Ben’s death and our response. This is to ensure learning and to better understand the changes we need to make. This will also be shared with the Leonard family and as part of our annual Safety Report. As part of our commitment to transparency, the findings will also:
• Be shared across the wider charitable and youth sector to enable wider learning. This will form part of our new Safety Report.
• Be provided to the organisation we appoint to undertake our external strategic safety review to ensure that the learnings from this FAI are embedded in future ways of working. To lead the FAI panel, we have appointed an independent Chair with a robust senior health care background in the NHS and two independent panel members with significant safety expertise, along with two internal senior volunteers who are unconnected to any matters relating to this tragedy (see Appendix B)

Prevention of Future Deaths Response – The Scout Association

Future Critical Incidents & Learning
2. The Scout Association is creating a new Critical Incident & Investigation Policy (using a root cause analysis approach) which will be formally approved by the Board in July 2024 (with the principles of the policy being implemented immediately). While the Board approval process is in train, the Board has agreed that the key requirements within this new policy are implemented immediately.

The new policy will ensure a consistent approach that is founded in learning and the need to robustly investigate, act on, and learn from critical Incidents, including fatalities.

Specifically, in relation to fatalities, it will include the requirement to initiate a Fatal Incident Investigation (FII) as soon as practically possible after a fatality has occurred, the need for independence within the process and, where appropriate, use external experts and chairs. The Critical Incident and Investigation Policy will set out in detail how any process is to be conducted. When this policy is produced and shared publicly, we would welcome feedback from any interested party.

In terms of the governance of the Critical Incident process:
• As is the current procedure, any Critical Incident is overseen by the Safety Committee (a sub-committee of the Board of Trustees, which includes additional expert and external members). The full report is presented to the Board with a list of recommended actions.
• In the event of a fatality, a senior level staff member (Executive Director level) will be designated as the senior accountable person for leading the process and for collating information and liaising with relevant statutory agencies. That staff member will report directly to the Board.
• The Critical Incident & Investigation process will be commissioned by Safety Committee on behalf of the Board within 72 hours of any future incidents, which will ensure the timely capture of all required information in one central location, and its findings will be presented to any statutory agencies on an open disclosure basis. This will be accompanied by an overall learning review for all critical incidents. Other key areas of work
3. We will be developing bespoke training packages to support our new approach to Critical Incidents to build competency and ensure this approach is clearly understood by all key stakeholders.

4. We will conduct an annual Critical Incident scenario exercise to ensure the policy remains live and institutional knowledge is not lost. This will be independently reviewed and assessed to ensure learning is objectively identified and applied. (first scenario exercise December 2024)

5. Since Ben’s tragic death in 2018, Scouts have made over 50 changes to our policies, systems, processes, and ways of working. These include changes to our Policy Organisation and Rules (POR), updated guidance and policy on risk assessments, Terrain

Prevention of Future Deaths Response – The Scout Association

definitions, improvements in training and auditing compliance (see appendix C for a full list of these changes).

6. Over the past five years, we have undertaken five key learning reviews for critical incidents and a range of reviews for other accidents. We will now review our approaches aligned to the new Critical Incident and Investigation policy to ensure we capture learning for any incident.

7. Safety & Safeguarding reports have been reviewed by the Board of Trustees at each of their quarterly meetings since 2020. There are Safety & Safeguarding Committees in place, as sub-committees of the Trustee Board, with independent chairs (who are Trustees with professional roles external to Scouting, meaning they have relevant expertise) and additional expert members to contribute knowledge of outside trends and learning.

Prevention of Future Deaths Response – The Scout Association

Section 3: Safety Training Concerns 12–13

12. Safety training is predominantly done online. Having seen and forensically within the hearing, undertaken an exercise to complete the current Safety Module, I am concerned that the course is superficial at best and fundamentally basic. It can be completed in 12 minutes. It is unsurprising that the current pass rate is now correspondingly high. This causes concern as an introductory module needed to equip thousands of leaders with an understanding of how to complete a risk assessment in order to keep Scouts safe. It does not embed the fundamental principles of safety and safe Scouting.

13. While reference material is available in the course, it is not mandatory reading and not required in order to complete the click through course.

Online Safety Training The Scout Association made the decision to bring its safety training exclusively online in 2020. This was to ensure volunteers were appropriately trained and there was consistency, including in terms of validation. In light of the concerns expressed by HM Coroner in the PFD report, we are now reviewing the balance of online training versus face-to-face training, and this will form part of our external strategic safety review (Section 1, point 3). This will ensure we are focusing even more on assessing competence, suitability and building a prevailing culture of safety. We think it is important to highlight that safety training is just one component of our initial training suite, which also includes Safeguarding and First Response training, with the latter including an in-person practical component. We also provide clear guidance, further resources, and tools on our website which are available at all times and updated regularly. However, we recognise we must do more to support volunteers, so we can assure they have the right capabilities and better validate, evidence and audit delivery. We accept the HM Coroner’s concern that, if individuals chose to do so, they could complete our current training in 12 minutes. We have now acted on this, so the course cannot be undertaken in such a manner, which is explained below in point 1. As before these changes, at the end of the training module, the person being trained also needs to answer all safety questions to the pass mark of 100% to achieve completion and certification. Actions
1. The Scout Association has urgently reviewed the safety training provided online, so a candidate cannot simply ‘click through’ the material and made the reading of the materials mandatory. Individuals are required to complete a self-declaration stating they have read all required materials, and they still need to achieve 100% in the final test.

2. We are currently commissioning enhanced supplementary safety training and validation for all 145,000 volunteers. The new training will be available by September 2024 with a target completion within 6 months thereafter. We will focus initially on

Prevention of Future Deaths Response – The Scout Association

volunteers who will be delivering nights away or adventurous activities as our priority. For any volunteer who does not complete the training in the agreed time frames we will introduce agreed restrictions or suspension in line with the detail provided within Section 7 (Compliance & Suspensions). This new training is designed to further support volunteers, assuring us that they understand what is required of them in terms of safety, and they have the required competencies in the following four core areas:
• How to conduct and complete risk assessments (written and dynamic)
• Terrain definitions
• The related requirements within our Policy Organisation & Rules (POR)
• Permitting

3. As detailed in Section 1, point 3, we are commissioning an independent strategic review of all new proposed safety training as part of our strategic partnership. This will specifically address the issues and concerns identified by HM Coroner with the intention that all future training is fit for purpose. It will provide volunteers at every level, including our managers and senior volunteers, with the required competencies and skills suited to their role, including ongoing learning and development. Where possible, we will be seeking external accreditation for this training. Other key areas of work
4. The Scout Association is also investing in a new Learner Management System (LMS) which will be rolled out to all 145,000 volunteers in late 2024. The LMS will enable the delivery of new, redesigned and enhanced safety training. It will enable all volunteers to easily access training that suits their role and builds their individual competency throughout the year, instead of being trained every three years. The system will:
i. Mitigate the risk that only individuals with the correct access can undertake specific training programmes (lessening the risk of training being undertaken by one person on behalf of another).
ii. Validate and assess volunteers for competency after undertaking relevant courses.
iii. Enable full auditing of training compliance and check training is undertaken in a timely manner. It will drive greater consistency and will ensure that only nationally endorsed and up-to-date materials are being used.

5. As outlined in Section 1(point 6), we have significantly invested in a new Adult Membership System (AMS).

6. The new AMS will also enable all Nights Away Applications and associated Permitting to be done online, including the submission and verification of all required paperwork in line with POR. There will be the ability to approve or decline any application by the relevant line manager or approver and to check for appropriate training and disclosures, as well as a full audit capability that will form part of our new national Audit & Assurance framework.

Prevention of Future Deaths Response – The Scout Association

7. As part of our volunteer transformation programme which started the design work in 2018 and launched at the start of 2023, we are developing a new approach to how we manage and equip volunteers. We have devised a completely new approach to training across the UK, replacing the requirement to undertake Wood Badge training. Instead, the most important elements from the Wood Badge training will now form part of our mandatory training to be completed within six months of becoming a volunteer. This includes a requirement to undertake Safeguarding and Safety training within the first month of becoming a volunteer. Without up-to-date Safeguarding or Safety training, volunteers will not be allowed to lead or plan activities and will be supervised at all times. If a volunteer has not undertaken their training (within a one- month window), they will be suspended until this has occurred. (For a full overview of all training areas above, please refer to Appendix D).

Prevention of Future Deaths Response – The Scout Association

Section 4: Restricted Duties Concerns 14–15

14. There was a plain reluctance to prioritise the safety of young people following Ben’s death in that, the leaders Sean Glaister, Mary Carr and Gareth Williams were not subjected to “Restricted Duties” until 17.10.18 when Ben had died on 26.8.18 and in the time from Ben’s death, Sean Glaister and Gareth Williams had taken part in a camp called “Deep Heat”. POR (Policy, Organisation and Rules) indicated the neutral act of suspension should have been imposed as a minimum for Sean Glaister. Once the restricted duties were issued, there was confusion as to whether these related to individuals or specific activities and at least one of the leaders continued in their Scouting obligations with no restrictions as it related to “Scouts” rather than “Explorer Scouts” and so the restrictions were ineffective.

15. Suspension of Sean Glaister and Group Scout Leader Brian Garraway was only imposed in November 2022, four years after Ben’s death, following the second inquest that needed to be adjourned due to non-disclosure. Suspension exists to ensure the safety and safeguarding of children until the investigation to establish facts has been undertaken.

Compliance & Suspensions We acknowledge that Ben’s death was initially treated as a tragic accident. In hindsight, we were wrong to take that approach and we apologise for it. We also recognise than a timely FAI would have identified concerns. We followed legal advice at the time that informed our approach to implementing restricted duties on the leaders. Again, we made the wrong decision and should have suspended those involved. We have now changed our practices to underpin a culture of transparency and learning, making several immediate changes to ensure this will not happen again. Actions
1. For any future incidents where there are significant near misses, injuries and/or a fatality, all relevant individuals will be automatically suspended (as a neutral act) to enable a full and frank investigation. This will be supported by changes in our polices and safety suspension powers, learning from how we currently operate within our Safeguarding team.

2. As set out in Section 2, we have agreed a new approach to Critical Incident Investigation. While the full policy is being finalised, the Board has agreed to enact the key requirements immediately. The new process will identify the key facts and enable robust and swift action where issues are identified within a framework of Root Cause Analysis to capture learning promptly.

3. In the event of a fatality, a senior level staff member (Executive Director level) will be designated as the senior accountable person for collating information and liaising

Prevention of Future Deaths Response – The Scout Association

with relevant statutory agencies. They will report directly to the Board, ensuring clarity and communication at all levels.

4. We will review our assessment criteria for Safeguarding to ensure that any future critical incidents are automatically seen within a Safeguarding framework and can be assessed as such; by identifying any safeguarding concerns, and putting appropriate actions in place.

Prevention of Future Deaths Response – The Scout Association

Section 5: Absence of Safeguarding and Safety Compliance Concerns 16–19

16. The nominal Explorer Scout Leader Sean Glaister in place when Ben Leonard died was subsequently appointed on Compass as a “District Section Leader Reddish Unit at Stockport” in November 2019. The formal interview to appoint Sean Glaister to the role the Reddish Explorer Scout Leader took place in 2020 after his appointment on Compass. It concerns me that notwithstanding the known failures in the planning and execution of the trip, and it having been identified by the County Commissioner, the District Commissioner, the Head of Safeguarding and Head of Safety at The Scout Association headquarters that Sean Glaister had lied in the planning for the trip at which Ben died.

17. Over 18-year-olds were allowed on this trip, by Sean Glaister, having not been listed on the Nights Away Notification (‘NAN’) form as adults, nor registered on the Scouts’ Compass system or having undergone Disclosure Barring Service (‘DBS’) safeguarding checks.

18. In addition, the inquest has identified the limited knowledge and understanding of Sean Glaister of any of his training undertaken throughout his time acting as a volunteer leader for the Scouts. The lack of understanding of training was a similar picture for the other Leaders on the trip at which Ben died and for other Scouting witnesses.

19. This gives rise to a concern that there are other appointed Leaders in post who are not suitably competent or qualified in respect of the fundamental issues of safety and safeguarding.

Competent and trained volunteers Competent and effectively trained volunteers are vitally important to ensure the safety of all children and young people. We understand this must be underpinned by an effective culture of safety and prevention, and we recognise we have more to do to further improve both areas to enable consistency. We accept the concerns raised by the Coroner. There was clearly a breakdown in our internal systems that enabled Sean Glaister to be fully appointed to a role supervising young people, for which we take full accountability and have acted to prevent a similar situation being repeated. As part of our volunteer transformation programme (highlighted in section 3, point 7), we have also introduced key changes and new ways of working. We are continuing to invest in new approaches so that we can make sure everyone is fit and proper to undertake their roles with a culture of safety at the foundation. When volunteers apply for any role within Scouts, there is a local appointment process to assess suitability for each role including full references and appropriate disclosure and vetting checks conducted nationally. The recruitment process is overseen by our Regional and County Commissioners (senior volunteers). In addition, our strategic portfolio includes significant investment in a new adult membership system (AMS),

Prevention of Future Deaths Response – The Scout Association

learning management system (LMS), and associated processes that will make appointing, tracking, and monitoring the competency of our volunteers more effective (detailed in Section 1, point 6, and Section 3 point 4). To assure ourselves that all our individual volunteers have the skills and knowledge to keep young people safe, we are urgently undertaking a process to provide enhanced supplementary training and validation to support and ensure the competency of our 145,000 volunteers. Furthermore, we are working alongside the volunteer leadership to assure ourselves that other local appointments have been made in line with our policies and rules. It was wrong for Sean Glaister to be appointed to the role of Explorer Leader in 2020, and we accept that anyone over the age of 18 should not have been on this trip without the correct planning and permissions. We accept that Sean Glaister and others said they had limited knowledge of our training. In Section 3 (points 2 and 3), we have described the movement-wide review we are undertaking of our training to ensure these issues are robustly addressed. As highlighted during this inquest, we are continuing to build robust approaches to Safeguarding practices and culture. We are committed to doing all that is practical to ensure all young people are always safe, and building a clear and ever-present safety culture. In response to this inquest and the concerns expressed by HM Coroner, we are now making a further investment to increase the size of our safety staff team and building a volunteer pool of experts to respond to and support the issues identified. This will increase capacity and offer additional support to our volunteers, including training support. Actions
1. The Scout Association Board have agreed to invest in and recruit sufficient safety and training focused staff to deliver the commitments within this document, which will be informed by the external strategic safety review. However, we are already taking action. The Scout Association has already started to recruit to new roles into our safety team, and we are currently designing a new structure. A permanent structure with additional staff in the areas of safety and training support will be agreed at the October 2024 Board meeting.

2. The Scout Association are currently commissioning enhanced supplementary safety training and validation for all 145,000 volunteers with the new course available by September 2024 (detailed in Section 3, point 2).

3. We have updated our safeguarding suspension system to include safety cases. This will ensure any individuals who are appointed to volunteer roles during a safety suspension period are automatically flagged in our centralised case management system, which will prevent them from being appointed to another role while the suspension is active. This follows what we are doing in Safeguarding.

4. We have agreed to fully review our new approach to training delivery and training content in light of the findings from this inquest. This will be undertaken as part of our external strategic partnership. As in point 1 above, the Board have agreed to invest in and recruit the required staffing levels to support this commitment.

Prevention of Future Deaths Response – The Scout Association

5. As set out in Sections 4 (point 1), we have made changes to our systems and approach to enable suspensions for serious safety matters. This will include the flagging and pausing of any changes to appointment for a volunteer role during any suspension and thorough investigation.

6. We will create new, additional mandatory training and support that is focused for our senior leaders (District and County levels) so they are clear on their safety responsibilities. This will further support the skills for their roles and will be underpinned by ongoing learning. We are planning this training to be externally validated and we are currently discussing this with potential providers. Learning from the inquest initial learning will be delivered by July 2024, then full ongoing training will roll out by October 2024 with completion within 6 months.

7. We will provide further training to all District and County Commissioners on the issues of over 18-year-olds and update the relevant guidance. This will be cascaded to all our volunteer leaders. Other key areas of work
8. We have made changes to our systems for those who turn 18, so they do not automatically become Network Members. This addresses the safeguarding concern raised by HM Coroner in Concern 17 above.
a. This will safeguard that:
i. If anyone wishes to attend camp and they are over 18, they will need to have the correct membership level within our systems.
ii. If they are assisting in the running of the camp, the relevant disclosure check has occurred prior to camp.
iii. If they wish to participate in a camp with under 18s present, then the correct applications, staffing ratios, supervision and camp set up has been agreed prior with the District Commissioner (or approver) as part of the Nights Away Notification process. (This will also form part of our new Audit & Assurance review process (as detailed in Section 1, point 5).

9. We have substantially changed our approach to Nights Away Notification to ensure there is clarity on all documentation required, including the submission of risk assessments and all related planning documentation. As detailed in Section 1 (point 6), we are making further changes to this as we fully digitise the process within the new Adult Membership System. A recent staff supported review of Nights Away applications within the Greater Manchester East area found the correct paperwork to be in order, although we provided guidance on areas of improvement and offered best practice guidance on collating medical information.

Prevention of Future Deaths Response – The Scout Association

Section 6: Monitoring, Auditing and Reliance on Volunteer Line and the need for paid Trainers Concerns 20–25

20. I have heard evidence that The Scout Association headquarters maintain that it is for the County and District as autonomous charities to monitor and audit training compliance. I am concerned that there are not robust systems of analysis, reporting and clarity as to the responsibilities of the County and District and what The Scout Association require from the County and District in respect of:

i. Training compliance;
ii. Completion of induction training within 5 months;
iii. Completion of the full adult training scheme/ wood beads within 2 years;
iv. Appointment to roles – both pre provisional, provisional, and full appointment;
v. Granting of permits.

21. I heard evidence from the County Training Manager (‘CTM’) for Greater Manchester East- a volunteer role and he himself accepted that he had historically delivered training based on out-of-date factsheets and volunteered that he needed to update his own knowledge. I have been told that an urgent audit of the CTM occurred after his evidence to the inquest.

22. I have a concern therefore as to the general audit and inspection of County Training Managers nationally.

23. For Local Training Managers (‘LTM’) a process for validation exists whereby a training adviser interprets the Training Advisers Guide and has a broad scope within which they can validate a learner’s training. This creates a risk of the approval of superficial and inadequate learning.

24. The provision of training relies heavily on the goodwill of volunteers and is time consuming. The expert to the inquest Mr Rosser recommended – as exists for other organisation and Charities – that there should be a paid regional individual with a responsibility for training who would serve as a point of contact for local volunteers should they require any support with their training and to ensure quality training and compliance.

25. Mr Rosser identified that this required a paid individual that was missing in the current chain between the volunteer line and The Scout Association necessary for training and delivery of activities.

Monitoring, auditing, and supporting the volunteer line management We agree with HM Coroner that we need to do more to ensure that, across Scouts, there is absolute clarity for Counties and Districts on the areas identified. This includes providing more support to local volunteers and to volunteer leadership.

Prevention of Future Deaths Response – The Scout Association

We have already changed our approach:
• In 2023, we launched a new volunteer transformation programme, which has introduced changes to volunteer roles and leadership, training, systems and provided far greater clarity on expectations, including guidance and responsibilities.
• We changed existing Executive Committees (those running the 8,000 charities) to Trustee Boards, with greater clarity on expectations and their responsibilities.
• Since 2020, training compliance is monitored at local (89 counties), regional and national levels, including by The Scout Association Board.
• Local compliance data is produced monthly with swift action, including in relation to those not compliant (detailed Section 7 – Compliance & Suspensions). Additionally, as highlighted in Section 5, point 1, The Scout Association Board have agreed to invest in further staff resources to support our safety work, adventurous activities, and training support, which responds to the recommendations made by Mr Rosser in concerns 24 and 25. We accept that the County Training Manager for Greater Manchester East was using an out-of- date fact sheet in 2014, and that he needed to update his knowledge. We have undertaken an independent local review to provide assurance and to implement swift corrective actions. Finally, as we outline below, we will keep investing in many areas to ensure we continue to build a culture that has safety, assurance, and accountability at its core. Actions
1. In response to concerns 20–23, we are investing in key new systems and resources that will transform access to information and monitoring these including. These include:
a. A new Learner Management System, which will provide significantly enhanced information and data for volunteers and volunteer management roles across the movement (detailed in Section 3, point 4).
b. A new Adult Membership System, that will provide far great access to key information (detailed in Section 1, point 6).
c. A new movement-wide assurance framework to support local leaders, monitor and audit compliance, including in relation to safety (detailed in Section 1, point 5).
d. Additional staffing resource to support areas of safety, adventurous activities, training support, and local compliance (detailed in Section 5, point
1).
e. A strategic partnership that will review future safety training and ensure we have identified the correct competencies and skills required to inform future training design, delivery, and validation (detailed in Section,1 point 3).
f. The implementation of a new approach to the auditing of adult training including the provision delivered by County Training Managers under our new Audit & Assurance approach (detailed in Section 1, point 5).
g. As we detail in Section 11 below, we are undertaking a full review of permitting.

Prevention of Future Deaths Response – The Scout Association

Other key areas of work
2. While training non-compliance is already monitored at The Scout Association Board level, we will now also review safety suspension data to assure ourselves that preventative and corrective action is being embedded.

3. The Scout Association Board will receive regular UK-wide heat mapping4, showing data in relation to training, safety, suspensions, and complaints.

4. In Greater Manchester East, we have undertaken a full review of training provision and put in place a volunteer and staff supported robust plan to enable the ongoing consistency and quality of provision. The plan includes changes to support, peer review, moderation, and leadership.

5. Since 2020, we have implemented new suspension protocols for any volunteer who has not completed their training. This includes notification at 60 and 30 days prior to the expiry of any certification (usually three years), as highlighted in Section 7 (Suspensions & Compliance).

6. All training guidance, fact sheets and materials are available from our website. We have removed the ability to download fact sheets, so individuals must access the most up-to-date versions. We will continue to make sure our communications are clear on all relevant updates and changes.

4 Heat Mapping uses data from various agreed sources to provide a coloured visual map. The colours, usually red, amber, and green, highlight where there may be issues or concerns within a specific geographic location after analysing all available data and identifying trends for further investigation.

Prevention of Future Deaths Response – The Scout Association

Section 7: Delays in Training Concerns 26–31

26. Gareth Williams and Mary Carr had not completed their mandatory training within the 5-month period: Gareth Williams’ training was 3 years and 9 months’ late; Mary Carr’s was 2 years and 1 month late.

27. Sean Glaister had not completed his wood beads training within the 2-year period; it was completed 2 years and 9 months late. There was no apparent sanction for having missed deadlines for training.

28. I was then provided with the following statistics, provided by Mr Kidd, the former UK Chief Commissioner of The Scout Association:

i. “On 7 September 2018, there were 373 open roles in Stockport District that were in scope for Getting Started and Wood Badge training. The 373 roles were held by 318 volunteers.
ii. There were 180 roles (48%) overdue for completing their Getting Started training.
iii. There were 94 roles (25%) overdue for their Wood Badge training.
iv. There were 318 volunteers in Stockport District that were in scope for first aid training. Of those 318 people, there were 57 (18%) who were overdue their first aid training. The rules at that time did not require first aid to be up to date at all times”

29. These statistics lead to the clear conclusion that there were widespread and significant gaps in training being completed in a timely manner, with concerns surrounding the training provision in the Stockport District.

30. Whilst the training statistics have notably improved, this is based on what I have considered on superficial and basic training which raises concerns around whether the core underlying principles such as risk assessments are being adequately understood.

31. I am concerned by evidence at the inquest that, presently, Stockport only has 6 Local Training Managers in post where 9 are required. The remaining 3 are “awaiting appointment”.

Training delays (please also see Section 3 – Safety Training) We accept the above concerns expressed by HM Coroner, regarding delays in training and wider compliance issues across the movement in 2018. We have made significant progress since then, and there is now 98% compliance for Safety and Safeguarding training. However, we acknowledge the concerns raised by HM Coroner with regards to the training compliance statistics today, and as detailed in Section 3 (point 2), we are currently commissioning enhanced supplementary safety training and validation for all 145,000 volunteers to make certain that key issues, such as risk assessments and underlying principles, are understood.

Prevention of Future Deaths Response – The Scout Association

We recognise that the effective delivery, quality, and governance of training is vital, and as detailed in Section 5, point 1, we are investing in additional paid training staff to ensure we respond to the concerns raised and issues identified. Compliance & Suspensions Since 2020, we have monitored training compliance at local and national levels across the movement. We have introduced new local powers to suspend volunteers significantly reducing non-compliance across Scouting. We are now going further and introducing a system whereby any volunteer who is not compliant with our mandatory Safeguarding and/or Safety training requirement will not be allowed to lead or plan activities and will be supervised at all times (to not be alone with children or young people). We accept it was wrong that the three volunteer leaders had not completed the requisite training in the correct time. It was a failing in our systems to adequately identify this. We accept the concerns of the HM Coroner with regards to the local training manager and have taken prompt action. This includes a full review into local practices and ways of working in relation to training. The result of this process is a bespoke action plan for Greater Manchester East to respond to the issues identified. Actions
1. As outlined in Section 5, point 1, The Scout Association Board have agreed to invest the necessary staff resources in order to ensure effective oversight of local delivery. This will include a team of both new staff and senior volunteers. We are currently reviewing the requirements and future structure, which will be informed by our external strategic review, but will require significant investment into additional staffing.

2. Since 2020, we have implemented new suspension protocols for any volunteer who has not completed their training. This includes notification at 60 and 30 days prior to the expiry of any certification (usually three years).

3. As we highlight in Section 6 (but detail here for ease of reference), we are also investing in:
a. A new Learner Management System, which will provide significantly enhanced information and data for volunteers and volunteer management roles across the movement as highlighted in Section 3, point 4.
b. A new Adult Membership System, that will provide far great access to key information as highlighted in Section 1, point 6.
c. A new movement wide assurance framework to support local leaders, monitor and audit compliance as highlighted in Section 1, point 5.

4. We would like to confirm we are actively working with Greater Manchester East and Stockport to ensure they have sufficient training managers. We are also providing additional staffing and volunteer support to make sure all issues are responded to.

Prevention of Future Deaths Response – The Scout Association

Section 8: First Aid Kits Findings 32–33

32. I did not receive any evidence to suggest that, following an appropriate risk assessment for the Great Orme trip, there was a plan as to what type of first aid kit was required. None of the leaders had a first aid kit with them when they embarked on the walk up the Great Orme or on a 3-hour hike on the Saturday.

33. The Scout Association guidance on the website about first aid kit requirements is basic and the evidence I heard from Mr Killick gives me a concern that more should be done to ensure on every scouting trip and at scout huts there are appropriate first aid kits and contents including tourniquets to enable, if necessary, immediate life-saving treatment to be provided.

First Aid Kits We accept the concerns raised by HM Coroner. All leaders should have had a first aid kit suitable for the nature of the activity they were undertaking. As a result of the Coroner’s concern, we have now reviewed this approach and our guidance. Actions
1. We have confirmed that the current information is fully in line with current Health & Safety Executive advice and updated our guidance in line with industry standards (action completed).

2. We are revising our guidance to make clear to all volunteers that first aid kit requirements are directly linked to the type of activity (including terrain) and that they must also be informed by risk assessments. We will also provide example risk assessment to support this (to be completed by May 2024).

3. We will enhance our online training to provide specific guidance on first aid kit suitability and specifically to support the issues identified around terrain guidance (to be completed by September 2024).

4. We will review our governance approach and ensure that our First Aid Working Group has a review of the guidance relating to first aid kits as part of its annual review cycle. Our First Aid Working Group has a remit to provide a single focal point for all national level first aid decisions and actions, and to seek ways to improve the relevance and quality of first aid support and training across Scouts (to be completed by May 2024).

Prevention of Future Deaths Response – The Scout Association

Section 9: First Aid Self Certification to meet Module 10 First Response requirement.

Findings 34–35

34. There was a system in place whereby if a learner had a first aid at work certificate, they could self-certify that they had undertaken further learning, for Child CPR, hypothermia and meningitis to comply with Module 10 First Response. There were no checks to ensure that this further learning had been done, nor was it assessed.

35. I have heard evidence as to improvements that have been made to the learning gap and training to supplement a First aid at Work certificate as First Response Module 10 compliant, however, I am still concerned that the system lacks robustness.

First Aid certification to meet module 10 requirement We accept that the system in place at the time was not suitable and our guidance was not clear. At the time, we also acknowledge that our Policy, Organisation and Rules (POR) was not explicit on the nature of additional validation for child-specific elements that were not within most First Aid at Work qualifications (FAW), such as hypothermia, meningitis and child CPR. Over the past five years, we have made several changes to our approach to our First Response training, and this is overseen by our First Aid Working Group. In order to address HM Coroner’s concerns, we have taken action to provide consistency across the movement and enable the robustness required. Actions
1. All volunteers who use FAW as a basis for First Response must subsequently meet with a First Aid Accredited trainer to demonstrate the specific child elements as part of a face-to-face practical element. Only on passing this validation process will their accreditation be added to our training system.

2. Any volunteer who has already used a FAW as the basis for First Response within the past two years is now required to undertake a validation meeting with a First Aid accredited trainer if they have not already done so. (to be completed by November 2024)

3. Moving forwards, we will monitor and track at Safety Committee (a sub-committee of the Board) all First Aid at Work conversion within The Scout Association and ensure, as part of our ongoing audit cycle, that conversions and associated requirements are monitored and assessed through the appropriate audit process.

Prevention of Future Deaths Response – The Scout Association

Section 10: Autonomous Charities Findings 36–37

36. The Scout Association is distant from its membership through its federated branches of 8000 charities and layers of hierarchy meaning that it cannot know how health and safety is executed at ground level. Training and POR are generated centrally, yet The Scout Association defer accountability for safeguarding and safety to the individual charities.

37. The centralised safeguarding team and safety team are not on par with each other in terms of resources and reach to local level. Safety is not prioritised in the same way as safeguarding has been. Safeguarding is reacted to more quickly than safety by The Scout Association.

Federated model of the Scout movement The issues identified by HM Coroner in concern 36 of the PFD notice have caused us to reflect hard on our structures and the challenges inherent in the scale of our activity. In particular, we have reflected on how we can strengthen relationships, support, communication and accountability, and introduce Third Party inspection and assurance within the movement. We recognise that, in some cases, local charity governance has not been consistently well delivered and in some instances we have not provided sufficient support to local Scout Trustees. We are taking steps to address this as part of our transformation work that commenced at the start of 2023, which includes additional support and training to local Trustees, with support on safety responsibilities, good governance and building local accountability. We know good governance underpins a culture of safety and accountability, rather than hindering it. However, if our federated structure presents barriers to the future safety of young people as we make the changes set out in this response, we are prepared to act and will propose to our Council (our most senior governing body) any changes we think are needed. We accept that The Scout Association has a clear responsibility to ensure that it is not distant from its membership and that we learn from the issues and concerns raised during the inquest and by HM Coroner. We have outlined a number of steps in this response which underpin our commitment to ensuring health and safety is consistently and reliably executed at ground level. This includes new systems for auditing and support of training, additional staff resources from working in partnership with our volunteer leadership, and clear powers for both staff and volunteer senior leaders so that volunteers do not supervise activities unless they have received the relevant training and/or Permits. During the inquest, it became clear that knowledge at certain levels of our Policy, Organisation and Rules (POR) was not robust or clear. It is incumbent on us to change our systems and communication, so everyone in Scouts knows what is required of them and they have the

Prevention of Future Deaths Response – The Scout Association

information they need. We will now review our approach and improve the clarity we provide to the charities within our federation and all our volunteers. While local Scouts charities are responsible for the governance and decisions within their own separate charity, we take overall responsibility and accountability for safeguarding and safety within The Scout Association. Our central Safeguarding staff team and central Safety staff team, accountable to the Executive Director of Operations, hold the responsibility that all safeguarding and safety concerns are investigated and supported. Everyone in Scouting has a personal responsibility and accountability to ensure they uphold our safeguarding and safety requirements as outlined in our Yellow and Purple Cards. We would not expect this responsibility to be abdicated to local groups (even though they clearly do have a responsibility for safety within their group). We also acknowledge the observation by HM Coroner that our Safeguarding team and Safety team in terms of resource and reach are not on par with each other, and that safety has a different structure and approach. While there are historical reasons for this, we have listened carefully to the concerns raised. As outlined in Section 5, point 1, we are investing in and designing a new structure with significantly increased staff resources. This new staff team will work in partnership with a team of senior volunteers with appropriate skills and experience. Actions
1. As outlined within previous sections of our response, we are:
a. Further reviewing the support we need to provide to County and District leadership, including Trustees, so they have the right tools and support in place to deliver the safest of provision. This is part of our volunteer transformation work.
b. Investing in new staffing resources to significantly bolster our safety, adventurous activities, and training teams to work in partnership with our volunteer leadership. The new structure is to be agreed by the October 2024 Board meeting (with additional resources being recruited now).
c. Creating new safety suspension powers as part of how we operate.
d. Reviewing our approach to training at all levels, so we provide the right competencies, access to information and are clear on our rules with particular focus on safety requirements (linked to our external safety review)
e. The Scout Association Board have invested in a new Assurance & Audit staff team that is already starting to be built.

2. Additionally, to underpin our approach moving forwards, we are in the process of commissioning a new external strategic safety review. As outlined in Section 1 (point
3), this will lead to:
a. A comprehensive independent review of our current safety practices (including the risk assessment process – identification, mitigation, change, review and sign- off) to assess if learning is successfully delivered, appropriate and effective.
b. A review of our safety training and required competencies and skills and future approaches and syllabus.
c. The development of a revised safety framework and associated standards.
d. A yearly independent review of all safety policies and processes, similar to the work already undertaken by NSPCC on our safeguarding policies and procedures.

Prevention of Future Deaths Response – The Scout Association

3. Since 2018, we have held all-member calls, open to all volunteers with attendance of the entire volunteer leadership Team and Executive (staff) Leadership Team. We have a range of other communication methods so we can provide relevant and accurate information, and open communication.

Prevention of Future Deaths Response – The Scout Association

Section 11: Permit/ Licencing Schemes Finding 38

The example of Sean Glaister having been granted his Nights Away permit simply by providing a list of camps he had been on, demonstrates that there was no robust system in place to ensure that a permit holder responsible for children’s safety was suitably qualified. There is no evidence he had the necessary skills and competencies to be granted such a permit. There was also a lack of clarity on where permits would be required for activities outside of the ordinary Scouts meeting place.

Permit Scheme We accept that Sean Glaister should not have been granted a Nights Away permit based on the information he provided. Permitting is a fundamental component to how Scouting operates and has a vital part to play in keeping people safe, especially in higher risk activities. To provide further assurance, many permit holders hold an externally recognised accreditation, which is used to assist with permit granting. This includes an external validation in areas such as mountaineering, water sports and adventurous activities. We accept the Coroner’s concerns regarding the Nights Away permit system and the circumstances when a permit is required. We will address them through the improvements in our permitting system outlined in detail in Section 3, point 6, as part of our new Adult Membership System. This will include the ability for all permitting to be fully digitised and auditable through the new online system. The new system will improve oversight, evidence, and approvals, so we have a consistent approach across Scouting. As we have detailed in Section 1, point 5, our new Audit & Assurance work has Permitting as one of the initial areas of focus. It will continue to make sure we deliver the safest of provision and that it is effectively monitored at UK, County and District level. However, we have taken immediate steps to undertake a full UK-wide review of permit holders to confirm they have been issued in line with our policies and rules. Finally, we are committed to externally reviewing our permitting scheme, working both with other NGBs and as part of our externally led strategic safety review. This will identify key issues and we will commit to any required changes. Actions
1. We have in train a process whereby counties are assuring us that permits have been issued appropriately in line with our Policy, Organisation and Rules (POR), and we are taking action where there are concerns or gaps. The Assurance and Audit team will subsequently spot check adherence (due for completion by August 2024, then ongoing).

Prevention of Future Deaths Response – The Scout Association

2. Our planned strategic partnership with an external expert body will include a full review of our permitting system. We are also identifying other organisations who can add relevant expertise, such as NGOs and subject matter experts, to support this focused work. This will be completed within six months and the required actions implemented (due for completion by October 2024).

Prevention of Future Deaths Response – The Scout Association

Appendices Appendix A – Planned actions & delivery dates As detailed within Section 2, page 10, we are currently undertaking a Fatal Accident Investigation into the Bens death. This will provide clear learning and recommendations shared with the family and HM Coroner including other relevant internal and external stakeholders. The main report is due in June 2024 Below are the other key actions we are undertaking. No. Action Delivery date Page
1. Develop and adopt a new Duty of Candour Policy which will be published by July 2024. July 2024 6
2. Publish a new annual Safety Report that outlines our in-year learning reviews, lessons learnt, and actions taken. Annual – intended first report April 2025 6
3. Commission a new strategic partnership with a nationally recognised organisation that is a leader in safety to review our current safety practices, and act as a Third Party reviewer. May 2024 6
4. Working with our strategic partner, we have undertaken a comprehensive independent review of our current safety practices with clear recommendations for action.
- Review all existing and proposed safety training and seek external accreditation. Initial review by October 2024

6
5. Working with our strategic partner to undertake a yearly review and audit of all safety policies and processes at The Scouts, similar to the work already undertaken by the NSPCC on our safeguarding policies and procedures. For 2024, this review will form part of the comprehensive independent review above and be repeated annually. Annually – first review September 2024 6
6. We will engage with National Governing Bodies (NGBs) and other relevant partner organisations to understand how they exercise external oversight and apply standards to their subject areas. We will use this research to develop an improved approach to external oversight in Scouting.

Initiated by June 2024 6
7. Introduce a new internal assurance function consisting of staff and volunteers, to monitor and audit at local level all our 8,000 charities and provide reporting nationally to the Board. April to November 2024 7

Prevention of Future Deaths Response – The Scout Association

8. Introduce the new Adult Membership System and associated improvements to managing safety compliance. December 2024 to April 2025 7
9. Introduce a new Critical Incident & Investigation Policy, that includes
- Automatic neutral suspensions
- Viewing incidents through the safeguarding framework July 2024 11
10. Develop training packages to support our new approach to Critical Incidents. July 2024 11
11. Conduct a yearly Critical Incident scenario exercise (independently reviewed and assessed). December 2024 11
12. Commission enhanced supplementary training and validation process for all 145,000 volunteers. Training programme available by September 2024, and target completion of all volunteers within 6 months 13
13. Introduce new Learning Management System to improve management and oversight of safety training. December 2024 14
14. Create new automatic suspension powers for those involved in Critical Incidents or significant near misses. April 2024 16
15. Increase the capacity of the safety team immediately and propose a new permanent structure to introduce additional staff in the areas of safety and training support. April to October 2024 19
16. Create new additional mandatory safety training and support that is level/role specific and appropriate for our senior District and County volunteer levels. Urgent inquest learning by July 2024 – full training programme by October 2024 (completion within 6 months thereafter) 20

17. The Board of Trustees will receive the first of regular reports on safety suspension data alongside heat maps of UK-wide compliance data relating to training completion, safety and safeguarding suspensions and complaints.

July 2024 meeting 23
18. Ongoing support to ensure Greater Manchester East has the correct volunteers and support in place to deliver effective training. Ongoing, target completion September 2024 24
19. We will enhance our online training for volunteers to provide specific guidance on first aid kit suitability and terrain guidance. September 2024 26

Prevention of Future Deaths Response – The Scout Association

20. Ensure that the reviewing of first aid kit guidance & contents is part of the annual review cycle for The First Aid Working Group. May 2024 26
21. Change our processes so volunteers who use a First Aid at Work certificate as the basis for their First Response accreditation must meet with a qualified trainer and demonstrate practical skills face-to-face.

June 2024 27
22. Ask any volunteer who has already used a First Aid at Work certificate as the basis for their First Response accreditation to undertake a face-to- face re-validation meeting with a qualified First Aid Trainer. Process starting May 2024 27
23. County assurance process confirming that that permits have been issued appropriately in line with our Policy, Organisation and Rules (POR), August 2024 (ongoing as part of new Audit & Assurance process) 31
24. Undertake a full independent led review of our Permit Scheme. October 2024 32

Prevention of Future Deaths Response – The Scout Association

Appendix B – Fatal Accident Investigation Term of Reference

Purpose of the FAI The Scouts Safety Committee has commissioned a Safe Scouting FAI into the circumstances relating to the incident where Ben Leonard, an Explorer Scout, suffered fatal injuries following a fall from the Great Orme in North Wales on 26th August 2018 and following the coroner inquest conclusion. Owing to the nature of two previous failed inquests, significant document disclosure, and two Prevention of Future Death reports by HM Coroner, the FAIP must look at all available information, and only where absolutely necessary (to allow the FAIP to achieve its aims and objectives) speak to those relevant individuals. However, the FAIP must also be mindful of the ongoing and/or potential Police investigation(s) and the limitations that this may present on the ability to meet with those directly involved. It is envisaged that the considerable witness statements, evidence, and testimony should enable most areas to be robustly explored.

This FAI seeks to: a) Undertake a systems-based investigation that explores the circumstances that led to the incident (what?), the contributing factor(s) to such circumstances (how?), and the root cause(s)/fundamental issues (why?) b) Understand the risk control measures that should or could have avoided the incident. Understand the role, organisational and human factors that may have resulted in, or contributed to, actions and the underlying reasons for those actions and decisions that may have caused or contributed to this incident. c) Make use of relevant research/previous Learning Review recommendations or FAIP reports to inform findings. d) The FAIP and recommendations should be delivered by describing the outcome of what needs to be achieved rather than the output of what needs to happen in order to get to the outcome. This will allow for the Safety Committee to link with any previous learning and ensure the report truly reflects on any learning rather than a task list.

Aims and Objectives of the FAI This FAI seeks to fully understand the factors that lead to Ben’s death, including the following objectives, to: a) Assess the circumstances surrounding the incident, taking into account any external reports (such as police and coronial investigations) to establish the nature of the incident; b) Assess the systems, processes and governance associated with the incident; c) Identify any procedures adopted locally (including in respect of safeguarding and safety) at the time of the incident; d) Assess the basis on which the Policy, Organisation and Rules (POR) of The Scout Association and associated guidance were followed and/or assisted or detracted from any

Prevention of Future Deaths Response – The Scout Association

decision making process; e) Understanding actions, the role and organisational factors and/or conditions, including the contribution of historic organisational changes, that led to a person(s) to act in the way they did; f) Assess and understand the decisions and reasons why actions were taken by local Scouting members in the management of the activity/incident; g) Assess adequacy and robustness of relevant assurance processes and whether those processes are sufficiently independent; h) Understand the rationale for the decisions relating to suspension of leaders as opposed to placing them on restricted duties and the factors that led to this decision, including making future recommendations; i) Assess why an FAIP was not undertaken directly after Ben’s death; and j) Assess the effectiveness of changes in risk control measures that have been implemented since the incident in 2018, in mitigating or preventing the system failures which contributed to or caused the incident.

Learning Points The FAI will identify learning points for action that the Association, at any level, should undertake/implement to assure the future safety of young people, the effective response to such incidents and to maintain the confidence in Scouting’s safety arrangements. These should include;
• culture,
• the impact, if any, of the Federated Structure,
• reporting issues,
• system and process changes,
• learning, changes to POR and guidance,
• training requirements,
• developments in good practice and
• any other learning points deemed relevant in the circumstances.

Learning points must focus on the outcome (and not the deliverables) which will be needed to achieve this outcome. The review group must indicate priorities where they feel there is significant importance, including the time scales appropriate for such recommendations. However, the responsibility for agreeing timescales and resource to achieve the approved learnings/requirements shall be a matter for the Safety Committee and be approved by the Board of The Scout Association.

Prevention of Future Deaths Response – The Scout Association

Membership
• The review group will be made up of a minimum of five people.
• It will have an independent Chair to Scouting.
• The review group will consist of members of the Safe Scouting FAI Group, but may also seek membership from those with specific expertise relating to the incident or case.
• Members of the commissioning committee may not participate in a FAI.
• All those appointed to undertake a learning review must sign Scouts’ confidentiality agreement and return to headquarters ahead of the review commencing. FAI Members:
• Chair – Karen Thomas
•
– External consultant
•
– External consultant
•
– Scout Volunteer Berkshire
•
– consulting as required to panel on Youth Scouting experience Safe Scouting Support:
•
– Safe Scouting Programme Sponsor Senior Staff Support:
• (Executive Director for Operations)
• (legal support)
• (Interim Head of Safety)

Timescales Date FAI approved:

28th February 2024 Date ToR approved:
• Chair of Safety Committee
• UK Chief Commissioner Executive Director of Operations 27th February 2024

• Safety Committee 28th February 2024 Formally commissioned:

28th February 2024 Target date for report submission:
• TSA Safety Committee June 2024 Report received:

Prevention of Future Deaths Response – The Scout Association

Generic ways of working/requirements a) The FAIP should produce a clear, actionable report to be presented to the Safety Committee for review and agreement prior to being presented to the Board of Trustees. b) Initial meeting to be set up within two weeks of identifying the FAIP membership to fully understand Terms of Reference (ToR) and internal support needed. This will be attended by a member of the Safe Scouting Management Team. c) If during the FAIP there is information that indicates a child may be at risk of non- compliance with safety processes, procedures and rules, it must be flagged immediately with a member of the Safe Scouting Management Team (preferably on the day or as soon as is practically possible). d) The FAIP will seek to conclude all interviews within six weeks from the date of the initial set up meeting (as per point 1). It is important to ensure the quality of the review, so extensions will be considered in the learning review keeping in touch meetings. e) The Executive Director will set up a meeting within ten days of receipt of the report to be briefed and consider the learning points to be recommended to the Safety Committee. The report will be considered at the next face-to-face meeting of the Safety Committee. f) The FAIP group should explore the existing information and research the evidence or statements provided as part of the inquest hearings. It should also include the impact on the other young people in the group and the volunteers. For clarity, this does not mean interviewing, but asking the group to keep the young person and their family at the centre of the review. This information can come from records. g) It is recognised that the impact of the past five and a half years and recent inquest has impacted on individuals in different ways. An ongoing check by line managers of their staff members should be undertaken to ensure their welfare is of paramount focus. The UK Chief Commissioner will also work within the volunteer line to ensure the same approach. Should any individual need additional support, this will be provided as far as practically possible.

Version: 6.3

Prevention of Future Deaths Response – The Scout Association

Appendix C – Safety changes since 2018 Area Change Date Policy POR Approval of activities 9.1. POR updated to be clear on the documenting of risk assessments. February 2021 Safety Policy now reviewed annually. May 2021 Change to approval processes for activities. January 2022 Documented risk assessment required as mandatory. December 2022 Activity and Nights Away Permit holders have to evidence their competency in risk assessment with 100% compliance rate. Assessors all have to have external accreditation (National Governing Body for XX) for chosen activity. 2020 Guidance Change to Approval processes for Commissioners. April 2020 Terrain Definitions updated and clarified (Terrain zero specific). April 2020 Terrain Definition – review 2020, resources launched. 2021 New safety checklists. August 2020 Approving activities guidance updated. May 2020 Revised January 2022 Risk assessment guidance updated. August 2020 Risk assessment examples launched and constantly expanded on Socuts.org.uk. August 2020 Review and update of website guidance on premises safety and web pages covering types of asbestos updated. 2021 Guidance on talking to young people about safety. July 2021 Updates to risk assessment guidance – focus on reshaping narrative to look at safety to enable safe and enjoyable programmes. February 2022 Additional guidance for local managers, Group Scout Leaders and other local volunteers – how you make sure things are happening locally, including risk assessments. February 2022 Risk assessment guidance update – specific focus on contingency planning and ongoing dynamic decision making. February 2023 Processes:

Mandate risk assessment being provided with Nights Away Notifications (NAN) form. April 2020 and June 2020 Review and improvement of HQ (The Scout Association) Safety Management System, The Scout Association Health and Safety website launched. 2021 Launch new safety incident reporting tool (Eclipse). 2020–22 NAN process and form updated to including contingency planning. February 2023 Training Mandatory Safety training changed and updated with learnings from 2018 and Inquest 1. 2020 updated 2024 Launch of the updated first response training programme in partnership with Girlguiding. November 2020 First Aid compliance – significant programme to drive first aid training compliance (as of March 2024 – 97%). 2020 onwards First Aid – who needs it guidance amended. 2024 Line manager safety induction workshops updated. September 2022 Safety role specific induction content is being pulled into role specific training and mandated from the start of transformation.

Prevention of Future Deaths Response – The Scout Association

Area Change Date safety and safeguarding training modules – Module 1 (Essential Information) and Module 1E (trustee induction) rolled out. September 2020 Risk assessment videos launched. 2020 Managers and Trustees committee training updated and mandated. September 2020 Safety training 100% pass mark required and taken fully online and managed by The Scout Association central, clarified assessment and learning relating to the safety policy. August 2020 Launch of two new webinars – one including premises safety and one on asbestos management underpinning focus on risk and risk management. 2021 Governance webinars on supporting Trustees on managing and supporting risk. July 2021 Support for World Scouting Jamboree on using dynamic risk assessment processes. April/May 2023 Communications to members – informing of all changes. Ongoing Comms

Local Trustees – Health & Safety focus. Yearly update Board meetings – Nations Boards. Yearly update Hill walking resources. 2022 Resources DC confidence survey. 2022 Assurance Bank of risk assessment guidance and support videos. 2021 COVID-19 restart risk assessment – good data and evidence provided, including dip sampling. 2020–21 RAAC – underpinning needs for risk assessment processes. 2023 Adult membership– NAN & NAP processes – new multi-million pound membership system, bringing key processes fully online for approval and audit. Build through 2023, fully rolled out by November 24 New Assurance framework investment agreed at Board Level. October 2023 Ongoing updates to Data & Insights focusing on Training Compliance and suspensions for non-compliance. 2021 Assurance policy. May 2022 Central safety function established and Head of Safety role created with associated investment. April 2021 Safety team enlarged with additional movement facing Safety and Compliance Officers Allows for more:
• Planned site visits across UK
• Reactive visits
• Requests for visits
• Post incident reviews and active visits to concerns sites
• Face to face County and District Commissioner support January/ February 2022 Safety team KPIs. 2023 Central safety team has done 100% sample activity Permit moderation (annually, every County is required to do a self-assessment). 2022

Prevention of Future Deaths Response – The Scout Association

Appendix D – ‘Growing Roots’ Overview The modules outlined below are part of our upcoming changes to training.
a. Safe Scouting (including)
i. Understanding safety
ii. Assessing and managing risk
iii. Managing and reporting incidents
iv. Safeguarding – why it is important
v. Recognising concerns
b. Creating Inclusion – how we make Scouts a welcoming space for everybody.
i. How to challenge assumptions
ii. Practical ways to be more inclusive in everything we do
iii. How to respond when people need reasonable adjustments
iv. How to challenge discrimination
c. Data Protection – how we take care of people's personal data.
i. What data protection and personal data is
ii. How to gather personal data in Scouts
iii. How to use, share and store personal data in Scouts
iv. How to delete or archive personal data securely
v. How to respond in case of a data breach or subject access request
d. Who we are and what we do – what Scouts is and how we help young people develop skills for life.
i. Our purpose, Promise and values as Scouts
ii. The support that’s available to you
iii. How our different teams work together
iv. How Scouts create impact

Volunteers leading and running youth sections will also be required to complete:
e. Delivering a great programme – an introduction to how to run and deliver safe programmes.
i. The Scout Method and how we create impact
ii. How to involve young people and be youth led
iii. How to promote positive behaviour when working with young people
iv. How to plan and run our programmes, so young people can achieve their top awards
v. How to work with parents and carers of our young people
f. First Response
i. Managing a first aid incident
ii. Offering emergency life support such as CPR
iii. Helping in situations where a person is unconscious
iv. Dealing with common Scouting injuries, including bleeding, sprains and head injuries
v. A basic understanding of some of the major illnesses: asthma, stoke, diabetes, and so on

Unity

PDF

Noted

Unity Insurance Services acknowledges receipt of the report and expresses sympathy, noting they are working with insurers and The Scout Association to support customers, and clarifying a factual inaccuracy regarding the chair in 2018. (AI summary)

View full response

David Pojur Assistant Coroner for North Wales (East and Central Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN

Scout Insurance Services Limited trading as Unity Insurance Services has received a copy of the prevention of future death and acknowledges receipt. As a subsidiary of The Scout Association, and with nearly 100 years of Scouting insurance experience, keeping young people safe from harm remains our priority, and we are working with the insurers and the Scout Association to support our customers.

I believe, I was incorrectly named in the inquest as the Chair of Unity in 2018, however, the Chair at that time was Michael Trip.

We take the conclusion of the inquest extremely seriously. We want to restate our wholehearted apology to Ben Leonard’s family and our deepest sympathies continue to be with his family and friends.”

Kind Regards

Chair of the Board Unity Insurance Services

Report sections

Investigation and inquest

On the 28.8.18 the Court commenced an investigation into the death of Benjamin David Leonard (DOB 01.11.01). Ben died on 26.8.18.

Tel 01824 708047 | The investigation continued with a 5-day jury inquest from 3.2.20-7.2.20. Whilst the jury were in jury retirement, on hearing the PFD evidence it became apparent that the Court had been misled, resulting in the jury being discharged on 7.2.20. On 7.2.20, I issued a Report to Prevent Future Deaths (‘PFD’) with the following 20 points:
1. The arranging of the trip did not adhere to the Scouts Association's own safety policies.
2. Such policies were not adequately understood at grass roots level.
3. Safety policies exist but are not implemented.
4. There was no written risk assessment.
5. There was no dynamic risk assessment.
6. There is not a full understanding of what a risk assessment is.
7. There is not a full understanding on when to do written and/or dynamic risk assessments.
8. There had been no approval sought for the trip as required from the District Commissioner.
9. There was an absence of a permanent District Commissioner to give oversight to the leadership of the group.
10. There was no meaningful discussion between the scout leaders as to the plan for trip on the Great Orme.
11. The leaders did not have a participant list nor list of phone numbers for the boys.
12. There was no route planned for the Great Orme trip.
13. No instruction or briefing was given to the boys.
14. Each of the 3 leaders assumed the 3 boys were with one of the leaders when in fact they were not. They were on their own.
15. There was no effective leadership for the group.
16. The Scouts Association failed to provide the Court with full information about the action it had in fact taken concerning its leaders on the trip, post death.
17. The Scouts Association created a misleading impression in the evidence concerning its actions regarding its leaders on the trip post death.

Tel 01824 708047 |
18. The Scouts Association is distant from its membership through its federated branches of 8,000 charities and layers of hierarchy meaning that it cannot know how health and safety is executed at ground level.
19. The health and safety training intervals for leaders are said to be every 3 years with no way of assessing their competencies.
20. The lives of young people are being put at risk by The Scouts Association's failure to recognise the inadequacies of their operational practice and the part this has played in the death of Ben.

Responses to this PFD Report were provided from The Scouts Association dated 1.4.20 and then an updated response dated 12.2.21.

The Second jury inquest was fixed for 4 weeks and was due to proceed on 2.11.22 but had to be aborted due to material non-disclosure to the court. The Third jury inquest began on 4.1.24 and concluded on 22.2.24. The Jury recorded their ultimate Conclusion in Section 4 was:

Unlawful killing by the Explorer Scout Leader and Assistant Explorer Scout Leader contributed to by the Neglect of the Scouts Association.

Circumstances of the death

Ben (aged 16) was on a 3-day Explorer Scout trip in North Wales with 3 leaders and 8 other Explorer Scouts. Prior to the trip, Ben had undergone a circumcision. On the day of arrival, the Assistant Explorer Scout Leader took all the Explorer Scouts on a 3-hour unplanned hike without the other leaders. The next day’s plan of going up Snowdon was rearranged due to poor weather conditions. They instead went to Llandudno. After breakfast, the Explorer Scout Leader and his son left to move his car. The two other leaders and remaining Scouts walked through the town towards the Great Orme. There was no brief, instructions or written risk assessment was done. The group then proceeded up the Orme led by the Assistant Explorer Scout Leader, with the Assistant Scout Leader at the rear.

Tel 01824 708047 | Ben and two of the other Explorer Scouts split off from the main group, taking a different path up the Orme. Part way up the Orme, the Assistant Scout Leader paused and broke away from the group. Near the top of the Orme, the Assistant Explorer Scout Leader saw Ben and the two other Scouts on the grassy tops. The Assistant Explorer Scout Leader did not give any instructions to regroup, or to stay on the safe path. Ben and the two other Scouts were left unsupervised and proceeded to walk to the cliff edge. Ben complained of discomfort due to circumcision. Ben thought he could see a quicker way down the Orme and attempted to follow animal tracks down the cliff edge. During his descent, Ben slipped and fell from the cliff. Paramedics attended the scene and performed medical interventions and CPR. Ben was pronounced dead at 14:45 on the 26th August 2018 due to head injury.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2024-0106
Date of report: 22 February 2024
Coroner: David Pojur
Coroner area: North Wales (East and Central)

Responses identified

Responses identified 8 of 9

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 Apr 2024 (estimated).

Sent to

Charity Commission for England and Wales

Children’s Commissioner for England

Children’s Commissioner for Wales

Department for Education

Health and Safety Executive

Minister for Education, Wales

Minister of State for Children and Families

Scouts Association

Unity Insurance Services: Scouting and Scout Groups Insurance

Part of a series

2 reports

2020-0032 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.