the Scouts Association
Other
Action Planned
The Scouts Association plans to develop a standard carbon monoxide safety statement for loaned equipment, provide additional guidance to lead volunteers, integrate CO safety into leadership briefings, and introduce a visually-led poster by September 2026. (AI summary)
View full response
[Page 1] Jack Saunders Prevention of Future Deaths Response from The Scout Association 22 May 2026
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 2] Introduction On behalf of The Scout Association (TSA) we are responding to the Prevention of Future Deaths (PFD) report dated 31 March 2026. We offer this response with deep respect and regret for the tragic death of Jack Saunders. On behalf of TSA, we express our wholehearted apology to the Saunders family, recognising the impact it has had. We recognise our responsibility to learn openly, act on what we learn, and strengthen our safety guidance, procedures and policies. We do this by practically supporting our Lead Volunteers, Trustee Boards and County Safety Advisors to challenge and influence behaviours highlighted in the PFD, making sure these are embedded in how Scouts is delivered day to day, to help reduce the risk of future harm. Following receipt of the PFD report, we have carefully considered the Coroner’s concerns. In doing so, we have:
• revisited the actions we have taken following the tragic incident in 2017
• reviewed our ongoing communications to volunteer members on Carbon monoxide (CO) safety
• reviewed our approach to safety learning and accessibility of training
• reviewed the reach and impact of our Gas Distribution Networks (GDN) partnership, specifically around their support with CO awareness
• reviewed our current practices with those of similar youth, outdoor and uniformed organisations. These reviews confirmed the controls that we already have but also identified some areas where we will strengthen our approach further. These are set out in detail against each Matter of Concern below. In our response to the PFD report, we first consider TSA's improvements regarding safety and specifically CO risks since 2017. We then address each of the Matters of Concern identified in the PFD report. We commit to reporting our progress on the actions openly through our website. As leaders of the Scout movement, we want to state our commitment to the safety of our young people and volunteers. We remain true to our values of integrity, respect, care, belief, and co-operation, and, through these values, to learning, honesty, and transparency. Chair of the Board Chief Executive UK Chief Volunteer
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 3] How The Scout Association functions TSA operates through a federated structure of over 7,000 local charities, each with its own trustees and volunteer leadership. Local Groups are supported by Districts, Districts by Counties, and Counties by the Nations and the national charity The Scout Association. This structure relies on layered controls at local and national level. Our volunteer leadership and line management have a key role in creating the local culture where safe behaviours are the norm. Nationally, TSA sets rules and expectations, and provides learning, guidance, systems and tools to support. TSA’s structure makes assurance at scale an organisational challenge that we are continuing to work on. We have yet to be satisfied that we have achieved it to the level we would like. TSA is committed to this. Since 2017, we have strengthened our approach to improving visibility of local practice and compliance with key requirements such as mandatory learning, safer recruitment and Nights Away permits. This has included introducing digital systems to support tracking and monitoring and continued development of our internal assurance approach. Overview of improvements in CO safety TSA’s CO safety management approach has changed as direct result of this incident. The initial learnings were enacted by June 2018 and further improvements have continued since then to support volunteers in using gas stoves and appliances safely while camping, highlighting CO risks. Our safe premises audit includes explicit checks on CO awareness, detection and monitoring. In 2021, TSA formed a partnership with Gas Distribution Networks (GDN), to learn from external advice and expertise to help us promote CO awareness with our membership. The comments made by the Coroner from the Inquest in 2020, and our own Fatal Accident Investigation* in 2017, have informed a programme of changes since then, including:
• Strengthened guidance
• Shared learning
• Clearer information
• Improved support
*A Fatal Accident Investigation is now described as a Fatal Incident Investigation, a TSA- commissioned review by an independent panel led by an external chair. TSA’s approach to safety risk assessment and management has developed since 2017 through both ongoing improvement work and specific projects. Current work includes a review of the Nights Away permit process, including CO safety while camping, and a separate review of wider safety risk management arrangements across the federated charity.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 4] TSA’s approach to learning and supporting young adults with additional needs We are committed to making our learning accessible, practical and relevant to real situations. Our learning is designed to support different ways of learning and is quality- assured for accessibility, including against Web Content Accessibility Guidelines (WCAG)
2.2 AA. We review feedback and how learning is applied in practice so we can continue to improve it. Communications supporting a safe culture Since 2018, our CO safety communications have moved from periodic guidance updates to regular year-round communications tailored to volunteers’ roles and responsibilities. Since 2018 this has included seasonal prompts, role-specific communications for leaders, safety advisers and trustees, and communication linked to learning and programme partnerships. In 2025 all our volunteers received CO safety communications three times which included linking to resources such as Think CO: Carbon Monoxide Awareness for Scouts, which was developed with the Gas Safe Charity. This approach has been strengthened through a partnership with Gas Distribution Networks (GDN), enabling nationally coordinated messaging that directs volunteers and young people to CO-specific resources, e-learning, activities and badge content for young people. CO safety partnership Accepting that we can learn from insight and experiences of others, since 2021 TSA has worked in partnership with GDN. GDN comprises of four operating companies: Cadent Gas, Northern Gas Networks (NGN), SGN, and Wales and West Utilities (WWU). The output of the partnership has included:
• GDN-partnered CO safety messaging is reinforced through Scouts programme planning content and targeted communications for volunteers, supporting a safety culture where learning is embedded, practical and repeatable.
• Children and young people learning through our programme is recognised through badges earned. In 2024-5, 14,052 Cub Scouts (8-10½-year-olds) earned their GDN-partnered Home Safety activity badge which includes gas safety. A further 8,501 badges being earned in 2025–26. Across the 2024–25 and 2025–26 reporting years, GDN-partnered CO activities available on the TSA website recorded 12,250 unique views.
• The CO Awareness blanket badge has been awarded 900 times since it launched in November 2024, indicating CO risk awareness reaches young people beyond the structured learning needed to earn activity badges.
• The GDN partnership renewed in April 2026, with plans to expand to the older youth sections, including a new activity planned for Scouts aged 14–25-years-old
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 5] that will focus on CO awareness. This activity will target known transition risks for young people leaving home for the first time. Section 1: Equipment instructions and guidance Matters of Concern 1“The equipment that had been borrowed had no instructions available as to their use, and although there were illustrations/instructions on the equipment itself warning against use in enclosed spaces, these were small and could have been clearer.” What we do today • As a result of the incident, TSA’s guidance since 2017 has explicit “don’t” statements on the use of gas, heating and cooking equipment in small spaces or areas where people sleep.
• Placing greater emphasis on practical CO safety controls, including CO alarms, ventilation, equipment condition and emergency response. This is reinforced consistently through guidance, learning and communications.
• Building CO considerations into the updates for all relevant guidance updates including food safety, fire safety, safe premises audits, camping guidance, emergency procedures and safety checklists.
• CO risk is integrated across all relevant resources to make it as easy as possible for event leaders and others to understand and mitigate the risks. This includes instructions for camping gas use, emergency procedure guidance, safe premises audits for local trustees, digital content on TSA website and email communications. In 2017 volunteers had to refer to a specific, standalone factsheet.
• CO and safe premises guidance is reviewed by our safety team on a regular basis every three years, with the next review due to publish in June and September 2026 respectively. Regular, consistent promotion of CO alarms and warning posters are shared through safety notices to volunteer leadership and digital communications. We will keep Reviewing and improving the CO information in Scout activity sites improving by by October 2026. Strengthening the visibility of safety information and instructions at the point of use by October 2026. This includes:
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 6]
• Providing stronger guidance with specific mention of safety checks for volunteers inspecting and maintaining equipment, including gifted and legacy-owned equipment held locally.
• Setting clear expectations that all shared, gifted, legacy- owned or borrowed equipment must display appropriate safety warnings.
• Making additional CO warning labels and supporting resources available where labels are missing, unclear or damaged, so volunteers can readily reinforce safety messages at the point of use. Section 2: Sharing knowledge around the risks of CO poisoning Matters of Concern 2 “That on the finding of the jury, whilst knowledge around the risks of CO poisoning was known and training had been prepared nationally, this had not reached the trainers within individual troops.” What we do today • CO knowledge is checked in the TSA assessment checklist for a Nights Away Permit AC120900 section 5: choosing, organising and maintaining the right equipment for camping, “Understand the risk of CO poisoning and its cause.”
• Since 2018, our CO safety communications have moved from periodic guidance updates to regular year-round communications tailored to volunteers’ roles and responsibilities. These include GDN-partnered and seasonal volunteer communications that reinforce key safety messages about CO risk.
• In 2020, TSA established a TSA Safety Advisor role to support with local advice and sharing awareness for County teams. In 2024 this expanded to District Safety Advisors to support District teams as well.
• CO risk is embedded and reinforced across safety training, Nights Away permits, camping and safe premises guidance, safety checklists and youth programme partnerships, rather than being isolated to one briefing.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 7]
• The relevant District or County Lead Volunteer or nominee is responsible for approving nights away for groups of adults, where each individual is aged 18 and over. This includes reviewing the risk assessment, which contributes to ensuring that CO risk knowledge is present in individual groups. This is detailed in our Policy, Organisation and Rules document (POR) - rule number 9a.1.3.2.
• Where an adult volunteer or young person may be considered to be lone working as part of their Scouts activities (i.e. where a member is operating under Policy, Organisation and Rules and seen to represent The Scout Association), the relevant District or County Lead Volunteer or nominee is responsible for approving it. A risk assessment must be completed which includes highlighting potential CO risks relevant to the overnight stay and the different types of stoves being used. An InTouch system must be in place, which is the system used to manage communications at all Scout activities and events. TSA supports volunteers to understand lone working through both the regular safety communications shared with all members and including it in briefings at inductions, workshops and webinars.
• We revised our mandatory Safety e-learning that all volunteers had to complete in 2025, to make people aware of their safety responsibilities and give them an understanding of safety risk management, including their responsibility to look for hazards and manage them. This included specific manager-level training as well. We engaged with the Royal Society for the Prevention of Accidents (RoSPA) to make sure technical accuracy and the learning was RoSPA Assured. While this does not specifically reference CO, ensuring people have access to the up-to-date national training and understand their responsibility to look for hazards contributes to our safety culture.
• Over the last couple of years, we have started to shift from just publishing guidance to also certifying local practice and compliance with key safety requirements. Self-certification took place in 2024 and in 2025 we took samples across the organisation to check how safety learning is converted into practice. This informs plans for sustained and ongoing self-
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 8] assessment against key standards in Safety, Safeguarding and Local Governance to be developed in 2026 and rolled out in 2027. Structured oversight of local practice will also be strengthened as a result.
• Incident reporting, moderation and dashboards provide visibility for volunteer and staff teams in the UK charity, nation-level and County level, confirming that reporting, learning and awareness are accessible and available locally. On 9 February 2026 TSA wrote to and asked all Trustees to confirm this reporting is being considered.
• Use of incident data and near-miss reporting to identify learning themes, shared through case studies, improved guidance, direct communication and through the County Safety Adviser network.
• At the UK level we have a trustee-chaired safety committee with independent safety professional members, an appointed senior volunteer in our TSA leadership team, regular cross- functional review of safety incidents by safety specialist staff with teams involved in implementing learning. We will keep Issuing a specific safety alert and learning notice by 26 June 2026 to improving by bring this PFD and TSA’s response to the attention of all volunteers. The notice will require lead volunteers and board members of our more than 7000 Scout charities across Groups, Districts and Counties to:
• reaffirm their knowledge around the risks of CO poisoning
• confirm that practices for CO safety are understood and applied by their volunteer teams
• review and, where needed, improve CO safety information displayed using the TSA CO-awareness poster at meeting places, campsites and activity centres (referenced in Matter of Concern 1) Promoting to volunteers our safe premises audit tool, Nights Away permit review and CO safety as part of our annual communications plan to address how stoves should be used. Implementing a new assurance framework that will require more regular self-assessment. Adding support and structure for Districts
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 9] and Counties to check self-assessments and support local charities in the improvement plans that result from the self-assessment. Strengthening our County Safety Advisor network through regular briefings. Provide a new CO safety awareness activity with the GDN partnership for Scouts aged 14–25-years-old and update the GDN- partnered learning content to include more on the danger in tents. Section 3: Learning styles and observing incorrect practice Matters of Concern 3 “That Jack, even if informed of the risks, had observed other adult leaders using gas- fuelled equipment in tents, particularly mess tents, on previous camps, and due to his visual learning style, would have placed greater reliance on the same.” What we do today TSA recognise that while national guidance and learning existed, it was not sufficiently embedded in local practice and leadership behaviours to prevent unsafe practices being seen and learned. While TSA has no evidence that gas equipment misuse is normal practice TSA recognises that the practices people see around them are what they are likely to practise regardless of learning preferences. We influence local leadership behaviour and practice by:
• ensuring access for volunteer leaders to training about inclusion and supporting young people with additional needs, contributing to our commitment to inclusion.
• continuously improving learning and training based on gathering insights from volunteers and to what extent they find the learning practical, relevant, useful and applicable to their role.
• prompting to consider the specific additional needs of individuals in a group through our risk assessments, following the Health and Safety Executive (HSE) 5 steps approach to risk assessment where in step 2 the assessor decides who might be harmed and how.
• explicitly making safety a leadership responsibility, with expectations around visibility, challenge and learning from incidents. These clear expectations for leaders about role-
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 10] modelling safe practice and challenging unsafe behaviours, are reinforced through guidance, briefings and shared learning.
• safety expectations are reinforced through role-specific safety checklists (Trustees, Lead Volunteers, Team Members).
• safety is maintained as a standing agenda item at trustee and leadership meetings.
• leadership briefings, webinars and regular volunteer communications which have been introduced since the incident, including the GDN-supported CO risk resources, materials and engagement through social media.
• ongoing promotion of near-miss reporting and learning reviews, and tracking that near-miss reporting is improving as part of a positive safety culture We will keep Including CO safety in the leadership briefing to County Safety improving by advisors during their next quarterly meeting. Including CO safety in the bi-monthly briefings for lead volunteers and trustees with safety and premises responsibilities. Improving education on and guidance for how volunteers enhance how reasonable adjustments are considered in activity planning. Introducing a simple visually-led poster that improves likelihood of understanding by those with visual learning styles or preferences. It will show the signs of CO poisoning and how to respond in a clear pictorial design. These will be made available as printed posters from Scout Store and downloadable from our website to be displayed in meeting places, campsites, residential buildings and activity centres. Continuing to strengthen how we target support and interventions, so that the CO risk is understood by leaders and acted upon.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 11] Sharing learning with other providers TSA’s view is that other organisations should also learn from this tragic incident and TSA will continue to share learning about CO risks with other providers over the next 12 months. TSA also continues to learn from other organisations, meeting with National Governing Bodies for outdoor activities regularly. At these meetings safety learning is discussed, including CO safety and support for volunteers to lead safely. We also meet regularly with other uniformed youth and outdoor activity organisations.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 12] Consolidated actions Action Matter of Concern Action Timing ID 1 Matter of Concern 1: Reviewing and improving the CO By October Equipment information for Scout activity sites by 2026 instructions and October 2026. guidance 2 Matter of Concern 1: Strengthening the visibility of safety By October Equipment information and instructions at the point of 2026 instructions and use by October 2026. This includes: guidance • Providing stronger guidance with specific mention of safety checks for volunteers inspecting and maintaining equipment, including gifted and legacy-owned equipment held locally.
• Setting clear expectations that all shared, gifted, legacy-owned or borrowed equipment must display appropriate safety warnings.
• Making additional CO warning labels and supporting resources available where labels are missing, unclear or damaged, so volunteers can readily reinforce safety messages at the point of use. 3 Matter of concern 2: Issuing a specific safety alert and learning By 26 June Sharing knowledge notice by 26 June 2026 to bring the PFD 2026 around the risks of CO and TSA’s response to the attention of all poisoning volunteers. The notice will require lead volunteers and board members of our more than 7000 Scout charities across Groups, Districts and Counties to
• reaffirm their knowledge around the risks of CO poisoning
• confirm that practices for CO safety are understood and applied by their volunteer teams
• review and where needed improve CO safety information displayed using the TSA CO-awareness poster at meeting places, campsites and activity centres, referenced in Matter of Concern 1.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 13] Action Matter of Concern Action Timing ID 4 Matter of Concern 2: Promoting to volunteers our safe premises July 2027 Sharing knowledge audit tool, Nights Away permit and CO around the risks of CO safety as part of our annual communications poisoning plan to address how stoves should be used. 5 Matter of Concern 2: Implementing a new assurance framework Complete Sharing knowledge that will require more regular self- pilot by around the risks of CO assessment. Adding support and structure March poisoning for Districts and Counties to check self- 2027 assessments and support local charities in the improvement plans that result from the self-assessment. 6 Matter of Concern 2: Strengthening our County Safety advisor March Sharing knowledge network through regular briefings 2027 around the risks of CO poisoning 7 Matter of Concern 2: Provide a new CO safety awareness activity By April Sharing knowledge with the GDN partnership for Scouts aged 2027 around the risks of CO 14–25 years and update the GDN- poisoning partnered learning content to include more on the danger in tents. 8 Matter of Concern 3: Including CO safety in the leadership 30 June Learning styles and briefing to County Safety advisors during 2026 observing incorrect their next quarterly meeting. practice 9 Matter of Concern 3: Including CO safety in the bi-monthly 31 July Sharing knowledge briefings for lead volunteers and trustees 2026 around the risks of CO with safety and premises responsibilities. poisoning 10 Matter of Concern 3: Improving education on and guidance for July 2027 Learning styles and how volunteers enhance how reasonable observing incorrect adjustments are considered in activity practice planning.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 14] Action Matter of Concern Action Timing ID 11 Matter of Concern 3: Introducing a simple, visually-led poster 30 Learning styles and that improves likelihood of understanding September observing incorrect by those with visual learning styles or 2026 practice preferences. It will show the signs of CO poisoning and how to respond in a clear pictorial design. These will be made available as printed posters from Scout Store and downloadable from our website to be displayed in meeting places, campsites, residential buildings and activity centres. 12 Matter of Concern 3: Continuing to strengthen how we Ongoing Learning styles and target support and interventions so that CO work, next observing incorrect risk is understood by leaders and acted on. review practice point in April 2027 13 Sharing learning with Continue to share TSA’s CO learnings with Summer other providers other providers over the next 12 months 2027
The Scout Association, May 2026 – Prevention of Future Deaths Response
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 2] Introduction On behalf of The Scout Association (TSA) we are responding to the Prevention of Future Deaths (PFD) report dated 31 March 2026. We offer this response with deep respect and regret for the tragic death of Jack Saunders. On behalf of TSA, we express our wholehearted apology to the Saunders family, recognising the impact it has had. We recognise our responsibility to learn openly, act on what we learn, and strengthen our safety guidance, procedures and policies. We do this by practically supporting our Lead Volunteers, Trustee Boards and County Safety Advisors to challenge and influence behaviours highlighted in the PFD, making sure these are embedded in how Scouts is delivered day to day, to help reduce the risk of future harm. Following receipt of the PFD report, we have carefully considered the Coroner’s concerns. In doing so, we have:
• revisited the actions we have taken following the tragic incident in 2017
• reviewed our ongoing communications to volunteer members on Carbon monoxide (CO) safety
• reviewed our approach to safety learning and accessibility of training
• reviewed the reach and impact of our Gas Distribution Networks (GDN) partnership, specifically around their support with CO awareness
• reviewed our current practices with those of similar youth, outdoor and uniformed organisations. These reviews confirmed the controls that we already have but also identified some areas where we will strengthen our approach further. These are set out in detail against each Matter of Concern below. In our response to the PFD report, we first consider TSA's improvements regarding safety and specifically CO risks since 2017. We then address each of the Matters of Concern identified in the PFD report. We commit to reporting our progress on the actions openly through our website. As leaders of the Scout movement, we want to state our commitment to the safety of our young people and volunteers. We remain true to our values of integrity, respect, care, belief, and co-operation, and, through these values, to learning, honesty, and transparency. Chair of the Board Chief Executive UK Chief Volunteer
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 3] How The Scout Association functions TSA operates through a federated structure of over 7,000 local charities, each with its own trustees and volunteer leadership. Local Groups are supported by Districts, Districts by Counties, and Counties by the Nations and the national charity The Scout Association. This structure relies on layered controls at local and national level. Our volunteer leadership and line management have a key role in creating the local culture where safe behaviours are the norm. Nationally, TSA sets rules and expectations, and provides learning, guidance, systems and tools to support. TSA’s structure makes assurance at scale an organisational challenge that we are continuing to work on. We have yet to be satisfied that we have achieved it to the level we would like. TSA is committed to this. Since 2017, we have strengthened our approach to improving visibility of local practice and compliance with key requirements such as mandatory learning, safer recruitment and Nights Away permits. This has included introducing digital systems to support tracking and monitoring and continued development of our internal assurance approach. Overview of improvements in CO safety TSA’s CO safety management approach has changed as direct result of this incident. The initial learnings were enacted by June 2018 and further improvements have continued since then to support volunteers in using gas stoves and appliances safely while camping, highlighting CO risks. Our safe premises audit includes explicit checks on CO awareness, detection and monitoring. In 2021, TSA formed a partnership with Gas Distribution Networks (GDN), to learn from external advice and expertise to help us promote CO awareness with our membership. The comments made by the Coroner from the Inquest in 2020, and our own Fatal Accident Investigation* in 2017, have informed a programme of changes since then, including:
• Strengthened guidance
• Shared learning
• Clearer information
• Improved support
*A Fatal Accident Investigation is now described as a Fatal Incident Investigation, a TSA- commissioned review by an independent panel led by an external chair. TSA’s approach to safety risk assessment and management has developed since 2017 through both ongoing improvement work and specific projects. Current work includes a review of the Nights Away permit process, including CO safety while camping, and a separate review of wider safety risk management arrangements across the federated charity.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 4] TSA’s approach to learning and supporting young adults with additional needs We are committed to making our learning accessible, practical and relevant to real situations. Our learning is designed to support different ways of learning and is quality- assured for accessibility, including against Web Content Accessibility Guidelines (WCAG)
2.2 AA. We review feedback and how learning is applied in practice so we can continue to improve it. Communications supporting a safe culture Since 2018, our CO safety communications have moved from periodic guidance updates to regular year-round communications tailored to volunteers’ roles and responsibilities. Since 2018 this has included seasonal prompts, role-specific communications for leaders, safety advisers and trustees, and communication linked to learning and programme partnerships. In 2025 all our volunteers received CO safety communications three times which included linking to resources such as Think CO: Carbon Monoxide Awareness for Scouts, which was developed with the Gas Safe Charity. This approach has been strengthened through a partnership with Gas Distribution Networks (GDN), enabling nationally coordinated messaging that directs volunteers and young people to CO-specific resources, e-learning, activities and badge content for young people. CO safety partnership Accepting that we can learn from insight and experiences of others, since 2021 TSA has worked in partnership with GDN. GDN comprises of four operating companies: Cadent Gas, Northern Gas Networks (NGN), SGN, and Wales and West Utilities (WWU). The output of the partnership has included:
• GDN-partnered CO safety messaging is reinforced through Scouts programme planning content and targeted communications for volunteers, supporting a safety culture where learning is embedded, practical and repeatable.
• Children and young people learning through our programme is recognised through badges earned. In 2024-5, 14,052 Cub Scouts (8-10½-year-olds) earned their GDN-partnered Home Safety activity badge which includes gas safety. A further 8,501 badges being earned in 2025–26. Across the 2024–25 and 2025–26 reporting years, GDN-partnered CO activities available on the TSA website recorded 12,250 unique views.
• The CO Awareness blanket badge has been awarded 900 times since it launched in November 2024, indicating CO risk awareness reaches young people beyond the structured learning needed to earn activity badges.
• The GDN partnership renewed in April 2026, with plans to expand to the older youth sections, including a new activity planned for Scouts aged 14–25-years-old
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 5] that will focus on CO awareness. This activity will target known transition risks for young people leaving home for the first time. Section 1: Equipment instructions and guidance Matters of Concern 1“The equipment that had been borrowed had no instructions available as to their use, and although there were illustrations/instructions on the equipment itself warning against use in enclosed spaces, these were small and could have been clearer.” What we do today • As a result of the incident, TSA’s guidance since 2017 has explicit “don’t” statements on the use of gas, heating and cooking equipment in small spaces or areas where people sleep.
• Placing greater emphasis on practical CO safety controls, including CO alarms, ventilation, equipment condition and emergency response. This is reinforced consistently through guidance, learning and communications.
• Building CO considerations into the updates for all relevant guidance updates including food safety, fire safety, safe premises audits, camping guidance, emergency procedures and safety checklists.
• CO risk is integrated across all relevant resources to make it as easy as possible for event leaders and others to understand and mitigate the risks. This includes instructions for camping gas use, emergency procedure guidance, safe premises audits for local trustees, digital content on TSA website and email communications. In 2017 volunteers had to refer to a specific, standalone factsheet.
• CO and safe premises guidance is reviewed by our safety team on a regular basis every three years, with the next review due to publish in June and September 2026 respectively. Regular, consistent promotion of CO alarms and warning posters are shared through safety notices to volunteer leadership and digital communications. We will keep Reviewing and improving the CO information in Scout activity sites improving by by October 2026. Strengthening the visibility of safety information and instructions at the point of use by October 2026. This includes:
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 6]
• Providing stronger guidance with specific mention of safety checks for volunteers inspecting and maintaining equipment, including gifted and legacy-owned equipment held locally.
• Setting clear expectations that all shared, gifted, legacy- owned or borrowed equipment must display appropriate safety warnings.
• Making additional CO warning labels and supporting resources available where labels are missing, unclear or damaged, so volunteers can readily reinforce safety messages at the point of use. Section 2: Sharing knowledge around the risks of CO poisoning Matters of Concern 2 “That on the finding of the jury, whilst knowledge around the risks of CO poisoning was known and training had been prepared nationally, this had not reached the trainers within individual troops.” What we do today • CO knowledge is checked in the TSA assessment checklist for a Nights Away Permit AC120900 section 5: choosing, organising and maintaining the right equipment for camping, “Understand the risk of CO poisoning and its cause.”
• Since 2018, our CO safety communications have moved from periodic guidance updates to regular year-round communications tailored to volunteers’ roles and responsibilities. These include GDN-partnered and seasonal volunteer communications that reinforce key safety messages about CO risk.
• In 2020, TSA established a TSA Safety Advisor role to support with local advice and sharing awareness for County teams. In 2024 this expanded to District Safety Advisors to support District teams as well.
• CO risk is embedded and reinforced across safety training, Nights Away permits, camping and safe premises guidance, safety checklists and youth programme partnerships, rather than being isolated to one briefing.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 7]
• The relevant District or County Lead Volunteer or nominee is responsible for approving nights away for groups of adults, where each individual is aged 18 and over. This includes reviewing the risk assessment, which contributes to ensuring that CO risk knowledge is present in individual groups. This is detailed in our Policy, Organisation and Rules document (POR) - rule number 9a.1.3.2.
• Where an adult volunteer or young person may be considered to be lone working as part of their Scouts activities (i.e. where a member is operating under Policy, Organisation and Rules and seen to represent The Scout Association), the relevant District or County Lead Volunteer or nominee is responsible for approving it. A risk assessment must be completed which includes highlighting potential CO risks relevant to the overnight stay and the different types of stoves being used. An InTouch system must be in place, which is the system used to manage communications at all Scout activities and events. TSA supports volunteers to understand lone working through both the regular safety communications shared with all members and including it in briefings at inductions, workshops and webinars.
• We revised our mandatory Safety e-learning that all volunteers had to complete in 2025, to make people aware of their safety responsibilities and give them an understanding of safety risk management, including their responsibility to look for hazards and manage them. This included specific manager-level training as well. We engaged with the Royal Society for the Prevention of Accidents (RoSPA) to make sure technical accuracy and the learning was RoSPA Assured. While this does not specifically reference CO, ensuring people have access to the up-to-date national training and understand their responsibility to look for hazards contributes to our safety culture.
• Over the last couple of years, we have started to shift from just publishing guidance to also certifying local practice and compliance with key safety requirements. Self-certification took place in 2024 and in 2025 we took samples across the organisation to check how safety learning is converted into practice. This informs plans for sustained and ongoing self-
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 8] assessment against key standards in Safety, Safeguarding and Local Governance to be developed in 2026 and rolled out in 2027. Structured oversight of local practice will also be strengthened as a result.
• Incident reporting, moderation and dashboards provide visibility for volunteer and staff teams in the UK charity, nation-level and County level, confirming that reporting, learning and awareness are accessible and available locally. On 9 February 2026 TSA wrote to and asked all Trustees to confirm this reporting is being considered.
• Use of incident data and near-miss reporting to identify learning themes, shared through case studies, improved guidance, direct communication and through the County Safety Adviser network.
• At the UK level we have a trustee-chaired safety committee with independent safety professional members, an appointed senior volunteer in our TSA leadership team, regular cross- functional review of safety incidents by safety specialist staff with teams involved in implementing learning. We will keep Issuing a specific safety alert and learning notice by 26 June 2026 to improving by bring this PFD and TSA’s response to the attention of all volunteers. The notice will require lead volunteers and board members of our more than 7000 Scout charities across Groups, Districts and Counties to:
• reaffirm their knowledge around the risks of CO poisoning
• confirm that practices for CO safety are understood and applied by their volunteer teams
• review and, where needed, improve CO safety information displayed using the TSA CO-awareness poster at meeting places, campsites and activity centres (referenced in Matter of Concern 1) Promoting to volunteers our safe premises audit tool, Nights Away permit review and CO safety as part of our annual communications plan to address how stoves should be used. Implementing a new assurance framework that will require more regular self-assessment. Adding support and structure for Districts
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 9] and Counties to check self-assessments and support local charities in the improvement plans that result from the self-assessment. Strengthening our County Safety Advisor network through regular briefings. Provide a new CO safety awareness activity with the GDN partnership for Scouts aged 14–25-years-old and update the GDN- partnered learning content to include more on the danger in tents. Section 3: Learning styles and observing incorrect practice Matters of Concern 3 “That Jack, even if informed of the risks, had observed other adult leaders using gas- fuelled equipment in tents, particularly mess tents, on previous camps, and due to his visual learning style, would have placed greater reliance on the same.” What we do today TSA recognise that while national guidance and learning existed, it was not sufficiently embedded in local practice and leadership behaviours to prevent unsafe practices being seen and learned. While TSA has no evidence that gas equipment misuse is normal practice TSA recognises that the practices people see around them are what they are likely to practise regardless of learning preferences. We influence local leadership behaviour and practice by:
• ensuring access for volunteer leaders to training about inclusion and supporting young people with additional needs, contributing to our commitment to inclusion.
• continuously improving learning and training based on gathering insights from volunteers and to what extent they find the learning practical, relevant, useful and applicable to their role.
• prompting to consider the specific additional needs of individuals in a group through our risk assessments, following the Health and Safety Executive (HSE) 5 steps approach to risk assessment where in step 2 the assessor decides who might be harmed and how.
• explicitly making safety a leadership responsibility, with expectations around visibility, challenge and learning from incidents. These clear expectations for leaders about role-
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 10] modelling safe practice and challenging unsafe behaviours, are reinforced through guidance, briefings and shared learning.
• safety expectations are reinforced through role-specific safety checklists (Trustees, Lead Volunteers, Team Members).
• safety is maintained as a standing agenda item at trustee and leadership meetings.
• leadership briefings, webinars and regular volunteer communications which have been introduced since the incident, including the GDN-supported CO risk resources, materials and engagement through social media.
• ongoing promotion of near-miss reporting and learning reviews, and tracking that near-miss reporting is improving as part of a positive safety culture We will keep Including CO safety in the leadership briefing to County Safety improving by advisors during their next quarterly meeting. Including CO safety in the bi-monthly briefings for lead volunteers and trustees with safety and premises responsibilities. Improving education on and guidance for how volunteers enhance how reasonable adjustments are considered in activity planning. Introducing a simple visually-led poster that improves likelihood of understanding by those with visual learning styles or preferences. It will show the signs of CO poisoning and how to respond in a clear pictorial design. These will be made available as printed posters from Scout Store and downloadable from our website to be displayed in meeting places, campsites, residential buildings and activity centres. Continuing to strengthen how we target support and interventions, so that the CO risk is understood by leaders and acted upon.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 11] Sharing learning with other providers TSA’s view is that other organisations should also learn from this tragic incident and TSA will continue to share learning about CO risks with other providers over the next 12 months. TSA also continues to learn from other organisations, meeting with National Governing Bodies for outdoor activities regularly. At these meetings safety learning is discussed, including CO safety and support for volunteers to lead safely. We also meet regularly with other uniformed youth and outdoor activity organisations.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 12] Consolidated actions Action Matter of Concern Action Timing ID 1 Matter of Concern 1: Reviewing and improving the CO By October Equipment information for Scout activity sites by 2026 instructions and October 2026. guidance 2 Matter of Concern 1: Strengthening the visibility of safety By October Equipment information and instructions at the point of 2026 instructions and use by October 2026. This includes: guidance • Providing stronger guidance with specific mention of safety checks for volunteers inspecting and maintaining equipment, including gifted and legacy-owned equipment held locally.
• Setting clear expectations that all shared, gifted, legacy-owned or borrowed equipment must display appropriate safety warnings.
• Making additional CO warning labels and supporting resources available where labels are missing, unclear or damaged, so volunteers can readily reinforce safety messages at the point of use. 3 Matter of concern 2: Issuing a specific safety alert and learning By 26 June Sharing knowledge notice by 26 June 2026 to bring the PFD 2026 around the risks of CO and TSA’s response to the attention of all poisoning volunteers. The notice will require lead volunteers and board members of our more than 7000 Scout charities across Groups, Districts and Counties to
• reaffirm their knowledge around the risks of CO poisoning
• confirm that practices for CO safety are understood and applied by their volunteer teams
• review and where needed improve CO safety information displayed using the TSA CO-awareness poster at meeting places, campsites and activity centres, referenced in Matter of Concern 1.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 13] Action Matter of Concern Action Timing ID 4 Matter of Concern 2: Promoting to volunteers our safe premises July 2027 Sharing knowledge audit tool, Nights Away permit and CO around the risks of CO safety as part of our annual communications poisoning plan to address how stoves should be used. 5 Matter of Concern 2: Implementing a new assurance framework Complete Sharing knowledge that will require more regular self- pilot by around the risks of CO assessment. Adding support and structure March poisoning for Districts and Counties to check self- 2027 assessments and support local charities in the improvement plans that result from the self-assessment. 6 Matter of Concern 2: Strengthening our County Safety advisor March Sharing knowledge network through regular briefings 2027 around the risks of CO poisoning 7 Matter of Concern 2: Provide a new CO safety awareness activity By April Sharing knowledge with the GDN partnership for Scouts aged 2027 around the risks of CO 14–25 years and update the GDN- poisoning partnered learning content to include more on the danger in tents. 8 Matter of Concern 3: Including CO safety in the leadership 30 June Learning styles and briefing to County Safety advisors during 2026 observing incorrect their next quarterly meeting. practice 9 Matter of Concern 3: Including CO safety in the bi-monthly 31 July Sharing knowledge briefings for lead volunteers and trustees 2026 around the risks of CO with safety and premises responsibilities. poisoning 10 Matter of Concern 3: Improving education on and guidance for July 2027 Learning styles and how volunteers enhance how reasonable observing incorrect adjustments are considered in activity practice planning.
The Scout Association, May 2026 – Prevention of Future Deaths Response
[Page 14] Action Matter of Concern Action Timing ID 11 Matter of Concern 3: Introducing a simple, visually-led poster 30 Learning styles and that improves likelihood of understanding September observing incorrect by those with visual learning styles or 2026 practice preferences. It will show the signs of CO poisoning and how to respond in a clear pictorial design. These will be made available as printed posters from Scout Store and downloadable from our website to be displayed in meeting places, campsites, residential buildings and activity centres. 12 Matter of Concern 3: Continuing to strengthen how we Ongoing Learning styles and target support and interventions so that CO work, next observing incorrect risk is understood by leaders and acted on. review practice point in April 2027 13 Sharing learning with Continue to share TSA’s CO learnings with Summer other providers other providers over the next 12 months 2027
The Scout Association, May 2026 – Prevention of Future Deaths Response