This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On the 28th of August 2018 the Court commenced an investigation into the death of Benjamin David Leonard (DOR 01.11.01 DOD 26.8.18). The investigation continued with a 5 day jury inquest from 3rd to 7th February 2020. Whilst the jury were in jury retirement a matter of law arose resulting in the jury being discharged. They were discharged on 7.2.20. A new inquest will be heard.
Circumstances of the death
Ben Leonard, age 16, was on an arranged Scout trip to go up Mount Snowdon with an option to go on the Great Orme at Llandudno on 26.8.18. The Snowdon expedition had an external qualified leader in addition to the 3 scout leaders. There were 9 scouts. Snowdon was cancelled due to bad weather and so the external leader was not engaged. The group went up the Orme. Ben was with 2 other friends when they went on a different path and split off out of sight from the rest of the group. One leader was aware of this. Ben wandered around the cliff tops and thought there was an alternative path down the cliff side of the Orme, on the Marine Drive side. He followed a narrow path and moved across a ledge. He tried to climb down. He slipped and fell approximately 200 feet. He died at the scene from a head injury according to the post mortem report.
Coroner’s concerns
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. 4. There was no written risk assessment. 5. There was no dynamic risk assessment. 6. There is not a full understanding of what a risk assessment is. 7. There is not a full understanding on when to do written and or dynamic risk assessments. 8. There had been no approval sought for the trip as required from the District Commissioner. 9. There was an absence of a permanent District Commissioner to give oversight to the leadership of the group. 10. There was no meaningful discussion between the scout leaders as to the plan for trip on the Orme. 11. The leaders did not have a participant list nor list of phone numbers for the boys. 12. There was no route planned for the Orme trip. 13. No instruction or briefing was given to the boys. 14. Each of the 3 leaders assumed the 3 boys were with one of the leaders when in fact they were not. They were one their own. 15. There was no effective leadership for the group. 16. The Scout Association failed to provide the Court with full information about the action it had in fact taken concerning its leaders on the trip, post death. 17. The Scout Association created a misleading impression in the evidence concerning its actions regarding its leaders on the trip, post death. 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. 19. The health and safety training intervals for leaders are said to be every 3 years with no way of assessing their competencies. 20. The lives of young people are being put at risk by the Scout Association's failure to recognise the inadequacies of their operational practice and the part this has played in the death of Ben.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised14
Failure to implement the Scout Association's safety policies
Failure to provide boys with safety instruction or briefing
Failure to recognise inadequacies in operational practice
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.11
Action
Issue guidance clarifying, documenting and communicating delegated activity-approval processes.
Stated byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
Action
Launch and mandate enhanced online safety training, extend it to additional roles, assess learning, and require three-yearly refreshers.
Stated byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
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 byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
Action
Improve safety-incident review processes to identify root causes and ensure local learning points are acted upon.
Stated byThe Scout AssociationStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2020.
Action
Appoint health and safety professionals to key committees to assess procedure efficacy and robustness.
Stated byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
Action
Conduct the Safety Incident Learning Inquiry using evidence from the Inquest and related investigations to identify further learning.
Stated byThe Scout AssociationStated plannedThe respondent said that this action was planned when they made their response on 26 February 2020.
Action
Implement closer local scrutiny of risk assessments for events and activities.
Stated byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
Action
Introduce and circulate the Safety Advisor role to support safety-policy implementation and compliance locally.
Stated byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
Action
Update, expand and circulate written risk-assessment guidance, templates, examples and supporting resources.
Stated byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
Action
Agree six new safety staff posts, including a Head of Safety, National Headquarters Safety Manager and four Compliance Officers.
Stated byThe Scout AssociationStated plannedThe respondent said that this action was planned when they made their response on 26 February 2020.
Action
Update and circulate free-time and supervision guidance covering expectations, boundaries and management of associated risks.
Stated byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
Respondent positions A position is what a recipient says about a 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.
Stated byThe Scout AssociationDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The volunteers’ evidence did not indicate unfamiliarity with risk assessment; they had been trained in conducting assessments appropriate to their roles.
Stated byThe Scout AssociationDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The federated structure, central policies, local oversight, training, database and monitoring provide appropriate safety oversight despite organisational distance from local groups.
Stated byThe Scout AssociationExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
There was no evidence that the organisation itself had failed to implement its safety policy, although procedures were not followed in this case.
Stated byThe Scout AssociationDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Written risk assessment was not necessarily required in every situation under the applicable guidance, provided findings and controls were communicated.
Stated byThe Scout AssociationDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Current guidance does not require leaders to hold participants’ contact lists, partly because communication is focused on leaders and parents and safeguarding concerns arise.
Stated byThe Scout AssociationExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5
1
Establish a two- and three-year review schedule for safety information and resources.
Stated byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
2
Provide monthly training-compliance data and reminder emails to guide local interventions and improve compliance.
Stated byThe Scout AssociationStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2020.
3
Review guidance on communication systems for activities where young people have greater independence or remoteness from leaders.
Stated byThe Scout AssociationStated plannedThe respondent said that this action was planned when they made their response on 26 February 2020.
4
Update requirements for maintaining and refreshing volunteers’ first-aid qualifications.
Stated byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
5
Review and publish clarified terrain definitions and Terrain Zero guidance for hillwalking activities.
Stated byThe Scout AssociationStated completedThe respondent said that this action was complete when they made their response on 26 February 2020.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2
1
Financial pressures from the COVID-19 pandemic prevented full recruitment of the intended 10 to 12 additional safety staff.
Stated byThe Scout AssociationUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
2
Most trip planning and preparation, particularly the Snowdon ascent, complied with safety policies, rules and procedures.
Stated byThe Scout AssociationDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pin
Get email alerts
Request correction
Information checked against the published report and official responses