Concerns raised 3 Failure to ensure carbon monoxide poisoning risk training reaches trainers within individual troops View source Unsafe use of gas-fuelled equipment in tents by adult leaders View source Failure to provide clear, available instructions for equipment use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jack Saunders · 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
Jack Saunders was found deceased in his tent at Waddecar Scout Camp on 3 April 2017, after arriving alone on 29 March 2017. The cause of death was carbon monoxide poisoning from a Landman outdoor heater that generated high levels of carbon monoxide inside the tent. The principal concerns were the absence of available equipment instructions, inadequate delivery of carbon monoxide safety training to local trainers, and Jack’s exposure to adult leaders using fuel-burning equipment in tents.
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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carbon monoxide poisoning risk training reaches trainers within individual troops
Wider context from the report “(2) That on the finding of the jury, whilst knowledge around the risks of carbon monoxide poisoning was known and training had been prepared nationally , this had not reached the trainers within individual troops .
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Unsafe use of gas-fuelled equipment in tents by adult leaders
Wider context from the report “(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.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear, available instructions for equipment use
Wider context from the report “(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 .
” Open source report
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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 Continue strengthening targeted support and interventions so leaders understand and act on carbon monoxide risks.
Verbatim wording from the response “Continuing to strengthen how we target support and interventions, so that the CO risk is understood by leaders and acted upon.” Source location Response from the Scouts Association
Open published response
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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 Promote the safe premises audit tool, Nights Away permit review and carbon monoxide stove-safety guidance through the annual communications plan.
Verbatim wording from the response “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.” Source location Response from the Scouts Association
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 Issue a safety alert and learning notice requiring local leaders to reaffirm carbon monoxide knowledge, confirm safe practice and review displayed safety information.
Verbatim wording from the response “We will keep improving by
Issuing a specific safety alert and learning notice by 26 June 2026 to 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:” Source location Response from the Scouts Association
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 Strengthen point-of-use safety information through equipment-check guidance, warning requirements and replacement carbon monoxide labels and resources.
Verbatim wording from the response “Strengthening the visibility of safety information and instructions at the point of use by October 2026. This includes:” Source location Response from the Scouts Association
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 Update partnered carbon monoxide learning content to address dangers in tents.
Verbatim wording from the response “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.” Source location Response from the Scouts Association
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 Deliver regular, role-specific, year-round carbon monoxide safety communications supported by external partnership resources.
Verbatim wording from the response “Since 2018, our CO safety communications have moved from periodic guidance updates to regular year-round communications tailored to volunteers’ roles and responsibilities.” Source location Response from the Scouts Association
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 Maintain explicit carbon monoxide checks within safe premises audits and related safety controls.
Verbatim wording from the response “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.” Source location Response from the Scouts Association
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 District or County Lead Volunteers or nominees are responsible for approving nights away and reviewing associated risk assessments, including carbon monoxide risks.
Verbatim wording from the response “• 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.” Source location Response from the Scouts Association
Open published response
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.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 28
Action
Review and externally validate the redesigned safety training and its competency requirements.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Update safeguarding suspension systems to prevent suspended volunteers being appointed to other roles.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2024. View source
Action
Create mandatory role-specific safety training and support for senior District and County volunteers.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Designate a senior accountable staff member to lead future fatality investigations and liaise with statutory agencies.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Review safety suspension data and provide the Board with regular UK-wide compliance heat maps.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Introduce the Adult Membership System to digitise and audit Nights Away applications, permits, approvals and compliance information.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Assure that permits are appropriately issued under POR and spot-check compliance through the Audit and Assurance team.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024. View source
Action
Provide ongoing staffing and volunteer support to ensure Greater Manchester East and Stockport have sufficient training managers.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024. View source
Action
Introduce the Learner Management System with role-specific training, competency validation and training-compliance auditing.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Create and implement a Critical Incident and Investigation Policy, including prompt independent fatality investigations and transparent information sharing.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024. View source
Action
Strengthen Nights Away Notification requirements by requiring risk assessments and complete planning documentation.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2024. View source
Action
Include first-aid-kit guidance and contents in the First Aid Working Group’s annual review cycle.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Commission an external strategic safety partnership to review safety practices and provide third-party assurance.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024. View source
Action
Build and operate a permanent internal Audit and Assurance team to audit local charities, monitor compliance and report nationally.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024. View source
Action
Review and update first-aid-kit guidance, linking kit requirements to activity type, terrain and risk assessments, with example assessments.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024. View source
Action
Introduce automatic neutral suspension arrangements for people involved in serious safety incidents, near misses, injuries or fatalities.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2024. View source
Action
Commission and complete an independent Fatal Incident Investigation into Ben’s death, then share its findings and learning.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024. View source
Action
Publish quarterly progress against the delivery plan and provide ongoing annual Safety Report updates.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Enhance online training with guidance on first-aid-kit suitability and terrain.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Develop and approve a Duty of Candour Policy, with its principles implemented immediately.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Introduce a movement-wide assurance framework for local safety compliance monitoring and auditing.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Require face-to-face practical validation by an accredited trainer for First Response volunteers using First Aid at Work certificates.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2024. View source
Action
Publish an annual Safety Report covering learning reviews, lessons learned and actions taken.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Commission enhanced supplementary safety training and validation for all volunteers, prioritising nights-away and adventurous-activity leaders.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024. View source
Action
Engage National Governing Bodies and other expert organisations to develop stronger external oversight of Scouting.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Increase safety, adventurous-activities and training staffing capacity, including recruiting new safety roles and agreeing a permanent structure.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024. View source
Action
Commission an independent review of the permitting scheme and implement the required actions.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2024. View source
Action
Review and improve support, training, communication and accountability for County and District leadership and Trustees.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024. View source See 25 more actions
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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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 The Scout Association; 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 Review and externally validate the redesigned safety training and its competency requirements.
Verbatim wording from the response “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.” Source location Response from Scouts
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 Update safeguarding suspension systems to prevent suspended volunteers being appointed to other roles.
Verbatim wording from the response “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.” Source location Response from Scouts
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 Create mandatory role-specific safety training and support for senior District and County volunteers.
Verbatim wording from the response “6. We will create new, additional mandatory training and support that is focused for our senior leaders (District and County level) 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.” Source location Response from Scouts
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 Designate a senior accountable staff member to lead future fatality investigations and liaise with statutory agencies.
Verbatim wording from the response “• 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.” Source location Response from Scouts
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 Review safety suspension data and provide the Board with regular UK-wide compliance heat maps.
Verbatim wording from the response “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.” Source location Response from Scouts
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 Introduce the Adult Membership System to digitise and audit Nights Away applications, permits, approvals and compliance information.
Verbatim wording from the response “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:” Source location Response from Scouts
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 Assure that permits are appropriately issued under POR and spot-check compliance through the Audit and Assurance team.
Verbatim wording from the response “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).” Source location Response from Scouts
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 Provide ongoing staffing and volunteer support to ensure Greater Manchester East and Stockport have sufficient training managers.
Verbatim wording from the response “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.” Source location Response from Scouts
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 Introduce the Learner Management System with role-specific training, competency validation and training-compliance auditing.
Verbatim wording from the response “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:” Source location Response from Scouts
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 Create and implement a Critical Incident and Investigation Policy, including prompt independent fatality investigations and transparent information sharing.
Verbatim wording from the response “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.” Source location Response from Scouts
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 Strengthen Nights Away Notification requirements by requiring risk assessments and complete planning documentation.
Verbatim wording from the response “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.” Source location Response from Scouts
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 Include first-aid-kit guidance and contents in the First Aid Working Group’s annual review cycle.
Verbatim wording from the response “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).” Source location Response from Scouts
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 Commission an external strategic safety partnership to review safety practices and provide third-party assurance.
Verbatim wording from the response “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 they 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:” Source location Response from Scouts
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 Build and operate a permanent internal Audit and Assurance team to audit local charities, monitor compliance and report nationally.
Verbatim wording from the response “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.” Source location Response from Scouts
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 Review and update first-aid-kit guidance, linking kit requirements to activity type, terrain and risk assessments, with example assessments.
Verbatim wording from the response “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).” Source location Response from Scouts
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 Introduce automatic neutral suspension arrangements for people involved in serious safety incidents, near misses, injuries or fatalities.
Verbatim wording from the response “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 policies and safety suspension powers, learning from how we currently operate within our Safeguarding team.” Source location Response from Scouts
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 Commission and complete an independent Fatal Incident Investigation into Ben’s death, then share its findings and learning.
Verbatim wording from the response “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.” Source location Response from Scouts
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 quarterly progress against the delivery plan and provide ongoing annual Safety Report updates.
Verbatim wording from the response “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.” Source location Response from Scouts
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 Enhance online training with guidance on first-aid-kit suitability and terrain.
Verbatim wording from the response “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).” Source location Response from Scouts
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 Develop and approve a Duty of Candour Policy, with its principles implemented immediately.
Verbatim wording from the response “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).” Source location Response from Scouts
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 Introduce a movement-wide assurance framework for local safety compliance monitoring and auditing.
Verbatim wording from the response “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).” Source location Response from Scouts
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 Require face-to-face practical validation by an accredited trainer for First Response volunteers using First Aid at Work certificates.
Verbatim wording from the response “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.” Source location Response from Scouts
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 an annual Safety Report covering learning reviews, lessons learned and actions taken.
Verbatim wording from the response “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).” Source location Response from Scouts
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 Commission enhanced supplementary safety training and validation for all volunteers, prioritising nights-away and adventurous-activity leaders.
Verbatim wording from the response “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” Source location Response from Scouts
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 Engage National Governing Bodies and other expert organisations to develop stronger external oversight of Scouting.
Verbatim wording from the response “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” Source location Response from Scouts
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 Increase safety, adventurous-activities and training staffing capacity, including recruiting new safety roles and agreeing a permanent structure.
Verbatim wording from the response “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.” Source location Response from Scouts
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 Commission an independent review of the permitting scheme and implement the required actions.
Verbatim wording from the response “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).” Source location Response from Scouts
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 Review and improve support, training, communication and accountability for County and District leadership and Trustees.
Verbatim wording from the response “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.” Source location Response from Scouts
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 HM Government is responsible for determining whether regulatory oversight should be introduced.
Verbatim wording from the response “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.” Source location Response from Scouts
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 Regulatory oversight decisions are outside the respondent’s authority and are not matters for it to determine.
Verbatim wording from the response “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.” Source location Response from Scouts
Open published response
Concerns raised 14 Failure to implement the Scout Association's safety policies View source Failure to provide boys with safety instruction or briefing View source Failure to obtain required trip approval View source Failure of scout leaders to discuss the trip plan View source Inadequate understanding of risk assessment requirements View source Failure to plan the trip route View source Failure to maintain effective supervision and leadership of the group View source Inadequate understanding of safety policies at grassroots level View source Unavailability of participant and emergency contact lists View source Failure to assess leaders' health and safety competencies View source Failure to complete written or dynamic risk assessments View source Absence of permanent District Commissioner oversight View source Failure of the Scout Association to oversee health and safety execution at ground level View source Failure to recognise inadequacies in operational practice View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Issue guidance clarifying, documenting and communicating delegated activity-approval processes.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2020. View source
Action
Launch and mandate enhanced online safety training, extend it to additional roles, assess learning, and require three-yearly refreshers.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2020. View source
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 completedThe respondent said that this action was complete when they made their response on 26 February 2020. View source
Action
Improve safety-incident review processes to identify root causes and ensure local learning points are acted upon.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 February 2020. View source
Action
Appoint health and safety professionals to key committees to assess procedure efficacy and robustness.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2020. View source
Action
Conduct the Safety Incident Learning Inquiry using evidence from the Inquest and related investigations to identify further learning.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2020. View source
Action
Implement closer local scrutiny of risk assessments for events and activities.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2020. View source
Action
Introduce and circulate the Safety Advisor role to support safety-policy implementation and compliance locally.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2020. View source
Action
Update, expand and circulate written risk-assessment guidance, templates, examples and supporting resources.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2020. View source
Action
Agree six new safety staff posts, including a Head of Safety, National Headquarters Safety Manager and four Compliance Officers.
Stated plannedThe respondent said that this action was planned when they made their response on 26 February 2020. View source
Action
Update and circulate free-time and supervision guidance covering expectations, boundaries and management of associated risks.
Stated completedThe respondent said that this action was complete when they made their response on 26 February 2020. View source See 8 more actions Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 6
Position
A dynamic risk assessment was undertaken, although there was no evidence that its conclusions or controls were communicated to the group.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The volunteers’ evidence did not indicate unfamiliarity with risk assessment; they had been trained in conducting assessments appropriate to their roles.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The federated structure, central policies, local oversight, training, database and monitoring provide appropriate safety oversight despite organisational distance from local groups.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
There was no evidence that the organisation itself had failed to implement its safety policy, although procedures were not followed in this case.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Written risk assessment was not necessarily required in every situation under the applicable guidance, provided findings and controls were communicated.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
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.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source See 5 more positions
×
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. The report was sent to The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the Scout Association's safety policies
Wider context from the report “1. The arranging of the trip did not adhere to the Scout Association's own safety policies.
2. Such policies were not adequately understood at grass roots level.
3. Safety policies exist but are not implemented.
” 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 The Scout Association; that does not assign responsibility.
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.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain required trip approval
Wider context from the report “8. There had been no approval sought for the trip as required from the District Commissioner.
” 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 The Scout Association; that does not assign responsibility.
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.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Inadequate understanding of risk assessment requirements
Wider context from the report “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.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Failure to plan the trip route
Wider context from the report “12. There was no route planned for the Orme trip.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective supervision and leadership of the group
Wider context from the report “14. Each of the 3 leaders assumed the 3 boys were with one of the leaders when in fact they were not. They were one their own.
15. There was no effective leadership for the group.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Inadequate understanding of safety policies at grassroots level
Wider context from the report “1. The arranging of the trip did not adhere to the Scout Association's own safety policies.
2. Such policies were not adequately understood at grass roots level.
3. Safety policies exist but are not implemented.
” 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 The Scout Association; that does not assign responsibility.
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.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Failure to assess leaders' health and safety competencies
Wider context from the report “19. The health and safety training intervals for leaders are said to be every 3 years with no way of assessing their competencies.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Failure to complete written or dynamic risk assessments
Wider context from the report “4. There was no written risk assessment.
5. There was no dynamic risk assessment.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Absence of permanent District Commissioner oversight
Wider context from the report “9. There was an absence of a permanent District Commissioner to give oversight to the leadership of the group.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Failure of the Scout Association to oversee health and safety execution at ground level
Wider context from the report “18. 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.
” 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 The Scout Association; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise inadequacies in operational practice
Wider context from the report “20. The lives of young people are being put at risk by the Scout Association's failure to recognise the inadequacies of their operational practice and the part this has played in the death of Ben.
” 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 Issue guidance clarifying, documenting and communicating delegated activity-approval processes.
Verbatim wording from the response “• Approval process: the rules governing the process by which District and County Commissioners approve activities is the subject of review by the Safety Committee. In particular, clarity is required around the informal system of delegation of approval that is described in the current rule 9.1(b) and work is being undertaken to provide more guidance for Commissioners in this regard. This guidance will clarify the options available to Commissioners in respect of activity approval and how that process should be documented and communicated to volunteers. The current aim is for this work to be delivered in April 2020.” Source location Response from Scouts
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 Launch and mandate enhanced online safety training, extend it to additional roles, assess learning, and require three-yearly refreshers.
Verbatim wording from the response “Update to safety training
In September 2020 the enhanced safety training module was launched to volunteers. This module is an online course that includes questions to validate learning and then issues a certificate of completion. It is mandatory for all volunteers fulfilling a role that requires safety training to complete this online module, to ensure consistency of training across all volunteers. Face to face training can be added at a local level to complement this training but all volunteers that are required to do safety training must complete the online module. A workbook has been created which must be completed by all those undertaking safety training who are unable to access the online training and it must then be validated by a local line manager as part of certification for that training.” Source location Response from Scouts
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 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
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 Improve safety-incident review processes to identify root causes and ensure local learning points are acted upon.
Verbatim wording from the response “The specific responses to this tragedy have been implemented alongside other improvements to safety management that were being undertaken in any event in accordance with the Safety Committee’s current programme of work. These steps included:” Source location Response from Scouts
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 Appoint health and safety professionals to key committees to assess procedure efficacy and robustness.
Verbatim wording from the response “• appointment of health and safety professionals to key committees to assist in the review of the efficacy and robustness of the procedures that are intended to fulfil our commitment to keep our members safe from harm.” Source location Response from Scouts
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 Conduct the Safety Incident Learning Inquiry using evidence from the Inquest and related investigations to identify further learning.
Verbatim wording from the response “In the days that followed, the Safety Committee was engaged. The need for a Safety Incident Learning Inquiry was recognised and approved in principle but given the ongoing investigation by the police and the Coroner, this Learning Review was paused pending the outcome of the Inquest.” Source location Response from Scouts
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 Implement closer local scrutiny of risk assessments for events and activities.
Verbatim wording from the response “At a local level, the County Commissioner has implemented a system to provide closer scrutiny on risk assessments produced for events and activities as is provided for in TSA’s rules relating to the approval of activities.” Source location Response from Scouts
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 Introduce and circulate the Safety Advisor role to support safety-policy implementation and compliance locally.
Verbatim wording from the response “The role of Safety Coordinators (a volunteer role at County level) was reviewed and a new role description and role title of Safety Advisor was circulated to volunteer line managers in November 2020. The role of the new Safety Advisor is:” Source location Response from Scouts
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 Update, expand and circulate written risk-assessment guidance, templates, examples and supporting resources.
Verbatim wording from the response “Update on risk assessments
The working group (mentioned above) completed its work and made recommendations in respect of Factsheet FS120000 and guidance on written risk assessments. These were approved by the Safety Committee and then circulated to volunteers in the movement for consultation.” Source location Response from Scouts
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 Agree six new safety staff posts, including a Head of Safety, National Headquarters Safety Manager and four Compliance Officers.
Verbatim wording from the response “Update on the additional staff with expertise in safety management
The financial pressures created by the COVID-19 pandemic has meant that at this stage we are unable to fully recruit the intended 10 to 12 additional staff members as originally stated in this response. Due to the financial implications of the pandemic, TSA has gone through a redundancy programme during 2020 and reduced staff headcount by 29%. However, despite this the number of staff in the Safe Scouting department focussing on safety will increase as detailed below.” Source location Response from Scouts
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 Update and circulate free-time and supervision guidance covering expectations, boundaries and management of associated risks.
Verbatim wording from the response “Update on free time guidance
The Safety Committee reviewed and updated the free time guidance with revisions published in August 2020. This guidance expanded on how to set expectations and boundaries on free time and how to communicate these with young people.” Source location Response from Scouts
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 A dynamic risk assessment was undertaken, although there was no evidence that its conclusions or controls were communicated to the group.
Verbatim wording from the response “There was evidence that a dynamic risk assessment was undertaken. However, we cannot identify any evidence that its conclusions or controls were communicated to the group.” Source location Response from Scouts
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 The volunteers’ evidence did not indicate unfamiliarity with risk assessment; they had been trained in conducting assessments appropriate to their roles.
Verbatim wording from the response “The volunteers confirmed that they had been trained in conducting risk assessments commensurate with their different roles. Their evidence did not suggest that they were unfamiliar with risk assessment. On the contrary, they understood what a risk assessment was.” Source location Response from Scouts
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 The federated structure, central policies, local oversight, training, database and monitoring provide appropriate safety oversight despite organisational distance from local groups.
Verbatim wording from the response “In particular, the role of TSA is to produce policies, rules and procedures for those volunteers who deliver scouting in the community; to ensure that those policies, rules and procedures are made available to local Scout Groups to assist them in providing Scouting activities to our young people; to provide an organisational framework for volunteers that ensures that there is oversight by volunteer line managers at District, County and country level; to provide resources to enable training for its volunteer leaders; to maintain a national membership database that records their various qualifications and certifications (as outlined above); and to monitor the efficacy and continuing suitability of these rules and processes by analyzing various sources of data - whether data on training compliance, incident reports, or by commissioning external studies - and to take any necessary action as” Source location Response from Scouts
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 There was no evidence that the organisation itself had failed to implement its safety policy, although procedures were not followed in this case.
Verbatim wording from the response “As far as we are aware, there was no evidence that TSA itself had failed to implement its own policy.” Source location Response from Scouts
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 Written risk assessment was not necessarily required in every situation under the applicable guidance, provided findings and controls were communicated.
Verbatim wording from the response “The evidence was that rules 4.7(k) and 9.4 of POR required risk assessments to be carried out before and during every activity; and that the relevant guidance on such risk assessments was contained in our Factsheet FS120000 (Activities – Risk Assessment). This guidance did not stipulate that such a risk assessment should necessarily be written in every situation but indicated it should be recorded and also said that one was particularly useful for a trip away. That Factsheet also emphasises under the heading “Record your Findings” that “you will always need to tell those involved in the activity what action they should take – and what action they must not take”.” Source location Response from Scouts
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
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations