Recurring concern

Unsafe planning and safety management of organised youth trips

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First reported 4 Feb 2014•Latest report 7 Feb 2020

Definition

What this concern includes

Includes failures in the dedicated planning and safety-management process for organised youth trips involving children or young people, including trip-plan discussion and agreement, hazard and participant risk assessment, preparation of leaders, activity-specific controls, emergency arrangements and site or route planning.

Not included

Excludes generic communication, training or leadership deficiencies that are not specifically tied to the safety planning or management of an organised youth trip.
Excludes hazards occurring during youth activities when no deficiency in trip planning or safety management is identified.
Excludes routine educational, recreational or travel planning that has no identified public-safety implication.
Excludes failures belonging to a separately named safety system or hazard where that system or hazard is the supported parent boundary.

Reports: 3
Individual concerns: 12
Date range: 2014–2020
Stated actions: 3

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department for Education2

The Scout Association1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

7 Feb2020
North Wales (East and Central)
Concerns raised4
1. Failure to provide boys with safety instruction or briefing
2. Failure of scout leaders to discuss the trip plan
3. Failure to plan the trip route
1. Unavailability of participant and emergency contact lists
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Require nights-away notifications to confirm that written risk assessments are prepared, shared with line managers, and communicated to adults and young people.
  Stated by The Scout AssociationStated completed
Respondent positions 1
1. Position
  Current guidance does not require leaders to hold participants’ contact lists, partly because communication is focused on leaders and parents and safeguarding concerns arise.
  Stated by The Scout AssociationExisting arrangements considered sufficient
AI-generated summary

Benjamin David Leonard · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Benjamin David Leonard, aged 16, died at the scene from a head injury after slipping and falling approximately 200 feet while attempting to descend a cliffside path on the Great Orme during a Scout trip on 26 August 2018. The substantive concerns included failures to follow and implement Scout safety policies, the absence of written and dynamic risk assessments, inadequate trip planning and briefing, ineffective leadership and group supervision, and insufficient organisational oversight and training.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide boys with safety instruction or briefing
Wider context from the report
“13. No instruction or briefing was given to the boys. ”
Source location
Benjamin David Leonard · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of scout leaders to discuss the trip plan
Wider context from the report
“10. There was no meaningful discussion between the scout leaders as to the plan for trip on the Orme. ”
Source location
Benjamin David Leonard · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to plan the trip route
Wider context from the report
“12. There was no route planned for the Orme trip. ”
Source location
Benjamin David Leonard · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of participant and emergency contact lists
Wider context from the report
“11. The leaders did not have a participant list nor list of phone numbers for the boys. ”
Source location
Benjamin David Leonard · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require nights-away notifications to confirm that written risk assessments are prepared, shared with line managers, and communicated to adults and young people.

Verbatim wording from the response
“Update to Nights Away Notification Form In May 2020 a new version of the Nights Away Notification Form (NAN) was circulated to volunteers. This updated NAN form includes the requirement to confirm that a written risk assessment has been prepared and shared with the respective line manager for any activities to be undertaken on the trip and is then communicated with both adults and young people involved.”

Source location
Response from Scouts
Page 8 · response
Published 26 February 2020
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Current guidance does not require leaders to hold participants’ contact lists, partly because communication is focused on leaders and parents and safeguarding concerns arise.

Verbatim wording from the response
“Our current guidance does not require a group’s leaders to have a list of participants and their telephone numbers as it is primarily focused on members maintaining communication with other leaders and parents as opposed to participants. In any event, certain safeguarding implications arise if adult leaders have the telephone numbers of young people and engage in direct communication.”

Source location
Response from Scouts
Page 16 · response
Published 26 February 2020
Open published response
18 Jan2018
Inner South London
Concerns raised6
1. Failure to assess the safest site of entry to open water
2. Inadequate risk assessment for school trips involving open-water swimming
3. Reliance on inadequate parental self-reporting of children’s swimming ability
1. Failure to assess the necessary equipment for open-water activities
2. Failure to plan how rescue would be conducted during open-water activities
3. Failure to consider the need for a lifeguard during open-water school activities
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review educational-visits guidance to strengthen advice on planning water-based activities, particularly overseas visits.
  Stated by Department for EducationStated in progress
2. Action
  Publish revised guidance for schools and colleges undertaking educational visits.
  Stated by Department for EducationStated planned
AI-generated summary

Master Abdul-Jamal Ottun · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Master Abdul-Jamal Ottun, a 17-year-old school student, drowned while swimming in Shawnigan Lake, British Columbia, during a school rugby tour on 12 July 2015. The principal concerns were the adequacy of risk assessment and supervision, including the lack of consideration of a lifeguard, the risks of cold open water, the safest entry point, necessary equipment, and rescue arrangements.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to assess the safest site of entry to open water
Wider context from the report
“He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue. ”
Source location
Master Abdul-Jamal Ottun · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate risk assessment for school trips involving open-water swimming
Wider context from the report
“He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue. ”
Source location
Master Abdul-Jamal Ottun · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Reliance on inadequate parental self-reporting of children’s swimming ability
Wider context from the report
“He said that child deaths will continue to occur unless there is a fundamental change in the curriculum and in the pre-assessment of swimming ability before school trips and occasions when swimming outdoors. In this case, parents indicated on a form the swimming ability of their children in one of three boxes (strong/ moderate/ weak) This he said was wholly inadequate, as they often have no accurate idea of the adequacy of their children’s swimming. ”
Source location
Master Abdul-Jamal Ottun · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to assess the necessary equipment for open-water activities
Wider context from the report
“He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue. ”
Source location
Master Abdul-Jamal Ottun · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to plan how rescue would be conducted during open-water activities
Wider context from the report
“He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue. ”
Source location
Master Abdul-Jamal Ottun · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to consider the need for a lifeguard during open-water school activities
Wider context from the report
“He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue. ”
Source location
Master Abdul-Jamal Ottun · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review educational-visits guidance to strengthen advice on planning water-based activities, particularly overseas visits.

Verbatim wording from the response
“We are currently reviewing the guidance we provide to schools and colleges undertaking educational visits. Our intention is to remind schools and colleges about the importance of careful planning when visits involve water based activities, especially where these are undertaken abroad. As part of our review, we have discussed with stakeholders how we can better signpost the advice and support that is available to schools and colleges on this important matter. We are due to publish revised guidance later in the year.”

Source location
2018-0020-Response-by-Department-for-Education
Page 3 · response
Published 8 March 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish revised guidance for schools and colleges undertaking educational visits.

Verbatim wording from the response
“We are currently reviewing the guidance we provide to schools and colleges undertaking educational visits. Our intention is to remind schools and colleges about the importance of careful planning when visits involve water based activities, especially where these are undertaken abroad. As part of our review, we have discussed with stakeholders how we can better signpost the advice and support that is available to schools and colleges on this important matter. We are due to publish revised guidance later in the year.”

Source location
2018-0020-Response-by-Department-for-Education
Page 3 · response
Published 8 March 2018
Open published response
4 Feb2014
South London
Concerns raised2
1. Failure to provide sufficient and accurate trip participation and preparation information
2. Failure to provide expedition and school leaders with sufficient heatstroke and hyponatremia information and training
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Samuel Boon · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Samuel Boon, aged 17, collapsed from suspected exertional heatstroke and/or hyponatremia while trekking in high temperatures on a school trip in Morocco and died during a 25-minute journey to a local medical centre. Concerns included inadequate preparation and risk assessment, insufficient assessment of participants’ fitness and medical information, inadequate training about heatstroke and hyponatremia, and evacuation arrangements that had not been adequately assessed or equipped.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide sufficient and accurate trip participation and preparation information
Wider context from the report
“(1) Preparation • The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip. Differences in ambulance and medical facilities in Morocco were not fully explained. • Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency. • Individual participants were not formally assessed as to their fitness for the activity. There was an apparent onus on the parents and participants to assess fitness, though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved. • Up to date medical information about the participants was not proactively obtained shortly before departure. Evacuation: • Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions, requiring urgent and appropriate evacuation to advanced medical facilities. In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible. • Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred. • Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited. Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny. NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely. ”
Source location
Samuel Boon · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide expedition and school leaders with sufficient heatstroke and hyponatremia information and training
Wider context from the report
“(1) Preparation • The school, parents and children were not given sufficient and accurate information to allow them to make informed choices about participation and preparation for the trip. Differences in ambulance and medical facilities in Morocco were not fully explained. • Risk assessments did not include the risks associated with insufficient fitness and preparation, acclimatisation, and evacuation in the event of a medical emergency. • Individual participants were not formally assessed as to their fitness for the activity. There was an apparent onus on the parents and participants to assess fitness, though they had no real knowledge or understanding of the environment in which the child would be staying or the activities involved. • Up to date medical information about the participants was not proactively obtained shortly before departure. Evacuation: • Exertional heatstroke and (dependent upon the cause) hyponatremia, are preventable but life-threatening conditions, requiring urgent and appropriate evacuation to advanced medical facilities. In an environment such as the foothills of the Atlas Mountains, the focus is likely be on prevention, because it is clear that urgent evacuation is not usually possible. • Expedition and school leaders were not given sufficient information and training as to the dangers of heatstroke and hyponatremia, how to recognise the risk of occurrence in a given individual, how to recognise the symptoms and how to manage them if they occurred. • Procedures and facilities for urgent evacuation were not fully and formally assessed, tested and audited. Arrangements were reliant upon local agencies and individuals and facilities which had not been subjected to adequate checking and scrutiny. NOTE: The expedition company has made a number of changes since Samuel’s death, but the purpose of this report is to raise concerns more widely. ”
Source location
Samuel Boon · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised4

Failure to provide boys with safety instruction or briefing

Failure of scout leaders to discuss the trip plan

Failure to plan the trip route

Unavailability of participant and emergency contact lists

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised6

Failure to assess the safest site of entry to open water

Inadequate risk assessment for school trips involving open-water swimming

Reliance on inadequate parental self-reporting of children’s swimming ability

Failure to assess the necessary equipment for open-water activities

Failure to plan how rescue would be conducted during open-water activities

Failure to consider the need for a lifeguard during open-water school activities

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Failure to provide sufficient and accurate trip participation and preparation information

Failure to provide expedition and school leaders with sufficient heatstroke and hyponatremia information and training

Actions described in response 1

Respondent positions 1

Actions described in response 2