Concerns raised 17 Failure to require safety-training reference material View source Superficial and inadequate safety training View source Lack of independent periodic auditing and inspection View source Failure to impose and define effective restricted duties View source Failure to complete a timely Fatal Accident Inquiry Panel investigation View source Lack of robust training-compliance monitoring and responsibility clarity View source Delays and gaps in mandatory training completion View source Failure of central oversight of local safety execution View source Failure to ensure permit-holder competence and permit-scope clarity View source Failure to plan and provide appropriate first aid kits View source Failure to communicate death-related learning to coroners View source Lack of a culture of candour View source Failure to verify supplementary first-aid learning View source Insufficient safety-team resources and local reach View source Appointment of leaders without suitable competence or qualifications View source Insufficient Local Training Manager capacity View source Overly discretionary validation of inadequate training View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 after slipping and falling from a cliff while descending the Great Orme during an Explorer Scout trip in North Wales. The report identifies concerns about inadequate planning, risk assessment, briefing, supervision, training, safeguarding, first-aid provision, oversight and the Scouts Association’s response to the death.
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. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Failure to require safety-training reference material
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Superficial and inadequate safety training
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Lack of independent periodic auditing and inspection
Wider context from the report “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’).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Failure to impose and define effective restricted duties
Wider context from the report “14. There was a plain reluctance to prioritise the safety of young people following Ben’s death in that, the leaders ████████ 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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a timely Fatal Accident Inquiry Panel investigation
Wider context from the report “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 Scouts Association maintaining this was due to a live police investigation initially, and latterly due to this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Lack of robust training-compliance monitoring and responsibility clarity
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Delays and gaps in mandatory training completion
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Failure of central oversight of local safety execution
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure permit-holder competence and permit-scope clarity
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Failure to plan and provide appropriate first aid kits
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate death-related learning to coroners
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Lack of a culture of candour
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Failure to verify supplementary first-aid learning
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Insufficient safety-team resources and local reach
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Appointment of leaders without suitable competence or qualifications
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Insufficient Local Training Manager capacity
Wider context from the report “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” .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Overly discretionary validation of inadequate training
Wider context from the report “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 .
” 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 Call for Ofsted to take a larger role in assuring safety and safeguarding standards in youth work organisations.
Verbatim wording from the 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)).” Source location Response from Children's Commissioner
Open published response
3 Apr 2023 Name not published · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Delays in timely assessment of young people View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Name not published · 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
████████ died at home on 24 September 2022 after becoming unresponsive following a hanging incident; he could not be revived despite resuscitation efforts, and the inquest recorded misadventure. At the time of his death, he was awaiting assessment for autism after a wait of around three years. The report raised concern that delays in assessment and insufficient support placed him and other children at risk, and that earlier diagnosis and support might have avoided his death.
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. The report was sent to Office of the Children's Commissioner; that does not assign responsibility.
PFD Monitor interpretation Delays in timely assessment of young people
Wider context from the report “• With finite resources, it is acknowledged that it may not be possible for all young people to be assessed in as timely a manner as required, but there must surely come a point whereby, notwithstanding those finite resources, the wait for assessment is taking too long .
• The wait for assessment placed ████████ at risk , and other children will be similarly at risk in the absence of a timely assessment .
• It is possible that he had been diagnosed earlier, and with enough time for the relevant professionals to have been able to carry out some meaningful work with him, and had his extremely supportive Parents been given more support, ████████ death may have been avoided.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations