Benjamin Leonard

Mr David Pojur 
Assistant Coroner for North Wales (East and Central) 
HM Coroner's Office 
County Hall 
Wynnstay Road 
Ruthin   
LL15 1YN 

Dear Mr Pojur 

Inquest touching upon the death of Ben Leonard 

12 February 2021 

Updated version of Regulation 28: Response to Prevention of Future Death Report sent on 1 April 2020 

On 1 April 2020 we sent you our response to the Regulation 28 Report dated 7 February 2020. Since then 

we have  made  further  changes  and  improvements  to  the  guidance,  rules  and  systems  described  in  that 

response  as  a  result  of  our  continuing  commitment  to  an  ongoing  review  of  keeping  everyone  safe  in 

Scouting. We  therefore thought it  may  be  of  assistance to  you  if we  outlined  where matters  mentioned 

within the original response have progressed further than as described. This letter therefore contains the 

same wording as the original response, dated 1 April 2020, but with added updates detailed in red text.  

Thank you for writing to The Scout Association (“TSA”) and bringing our attention to the various Matters of 

Concern that were prompted by your recent investigations into the tragic death  of Ben Leonard.   Those 

concerns  have  been  shared  with,  and  considered  carefully  by,  our  Board  of  Trustees  and  its  Safety 

Committee, as well as the appropriate senior volunteers and staff representatives of TSA.  Although signed 

by our Chair of Trustees, this letter is our collective response on behalf of the organisation to your Report to 
Prevent  Future Deaths  dated  7th  February  2020  (“the  Report”)  in  accordance  with  the provisions  of  the 

Coroners and Justice Act 2009.  In this regard, TSA would like to take this opportunity to assure you that 

there will be senior representatives of TSA providing witness evidence at the resumed Inquest in respect of 

the matters discussed below. 

Registered Charity Numbers 306101 (England and Wales) and SC038437 (Scotland) Incorporated by Royal Charter. 

The Scout Association 
Gilwell Park 
Chingford 
London E4 7QW 

0345 300 1818 (UK) 
+44 (0)20 8433 7100 
scout.association@scouts.org.uk 
scouts.org.uk 

/scoutassociation 
@UKScouting 

 
 
 
 
 
 
 
 
 
 
 
 
 Please may we start by restating TSA’s commitment to the safety of young people and volunteers.  It is our 

number one priority.  As is explained in more detail later, we have worked hard over many years to develop 

and  maintain  policies  and  procedures  that  are  intended  to  minimise  the  risks  that  inevitably  occur  from 

Scouting  activities.    We  recognise  the  importance  of  training  volunteers  to  follow  those  policies  and 

procedures.  We encourage and support their familiarity with relevant policies and procedures through a 

rolling programme of such training and compliance with such training is monitored at a local and national 

level. Incident data is collected and analysed in order to measure safety performance.  

We  also  recognise  the  importance  of  learning  from  experience.    This  is  embedded  in  our  culture  and 

systems.  We have processes and procedures in place to ensure that we gather data about incidents.  We 

consider that data carefully and make improvements when appropriate. 

In so doing, we hope to honour the safety commitment that we have made, and will continue to make, to 

our young people, our volunteers and families; and to live up to the ideal, defined by our founder in the 

Fundamentals of Scouting, to seek improvement through “learning by doing”.  This approach has guided 

the way in which TSA responds in this letter to the Matters of Concern raised in your Report to Prevent 

Future Deaths. 

Before  addressing  those  Matters  individually,  we  provide  some  further  information  about  the  Scout 

movement’s  history,  ethos,  organisational  structure  and  the  steps  that  have  already  been  taken  to  learn 

lessons from this tragedy.  As these matters are relevant to a number of the specific concerns that you have 

raised, we hope that it is helpful to address them at the outset in order to avoid repetition.  We are sorry 

that this information was not provided to you at or before the recent hearings.  Please may we assure you 

that this information, and more, will be contained in the written statements that are being prepared in order 

to assist you at the resumed Inquest. 

History and ethos 

The Scout movement has been in existence for more than a hundred years.  Since its inception, it has been 

a voluntary, non-political, educational movement for young people that is open to all regardless of gender, 

race or creed, in accordance with the purpose, principles and method conceived by its founder, Lord Baden-

Powell.  It  is  one  of  a  very  few  worldwide  youth  organisations  with  over  50  million  members  across  the 

world. 

Our aim is to actively engage and support young people in their personal development, empowering them 

to make a positive contribution to society.  In partnership with adults, young people take part in fun indoor 

and outdoor activities.  They learn by doing, by sharing in spiritual reflection and by taking responsibility. 

They make choices, undertake new and challenging activities, and they live the Scout Promise and through 

social action, Scouts make a real difference to the communities in which we live. 

Page 2 of 19 

 
 
 
 
 
 
 
 
 
 Organisational structure of the Scout Movement 

Local Scout Groups 

The Scout movement in the UK is made up of c460,000 young people aged between 6 and 25 and c160,000 

adult volunteer leaders.  In England and Wales, Scouting itself takes place in the c.7,000 local Scout Groups 

and c.1,000 other charitable bodies.  Each usually meets once a week to carry out Scouting activities at a 

local venue or further afield and is operated by adult volunteers (often parents and/or former Scouts).  Each 

is  therefore  its  own  entity,  usually  its  own  charity.    Such  Groups  are  the  heartbeat  of  Scouting  and  the 

purpose of all of the other Scout charitable bodies is to support and enhance the quality of the provision by 

these volunteers at the local level. 

District, County and National Commissioners 

Above an individual Scout Group is a hierarchy of volunteer Commissioners – at District, County and Country 

level.  Each Commissioner has oversight for the Scouting that goes on in their geographical area and each 

District, County etc. is its own charitable body.  These Commissioners are the managers of the volunteer 

network.    Their  roles  include  arranging  training  for  volunteers,  maintaining  records  of  the  qualifications 

gained by the adult volunteers, and providing approval for activities.  The volunteers are led by the UK Chief 

Commissioner (Tim Kidd OBE).  Their figure-head is the Chief Scout (Bear Grylls OBE). 

The Scout Association 

TSA was incorporated by Royal Charter in 1912 to sit at the heart of this federation of voluntary bodies (the 

Scout Groups, Districts, Counties etc).  It is a registered charity.  It is governed by a Council of members 

comprising  nominated  volunteers  from  each  Scout  County  and  overseas  Branch,  elected  members  and 

members of the Board of Trustees.   

The Board of Trustees exists to manage the business of TSA.  It comprises 20 members: most are elected 

volunteers from local Scouting, some are appointed by dint of their role, some are external appointees with 

particular skills-sets.  In accordance with our bye-laws, this is the body which makes the policy and rules 

for those volunteers who undertake Scouting locally.  These are published in a compendium named Policy, 

Organisations and Rules (“POR”) and the various factsheets and other literature. 

The Board delegates responsibility for key areas to sub-Committees.  One such is the Safety Committee.  It 

has delegated responsibility to provide leadership and oversight of safety policies and procedures that are 

provided to our volunteers.  Its purpose is to ensure that our young people and volunteers are protected.  It 

is  chaired  by  an  external  appointee  with  significant  professional  experience  of  health  and  safety 

management in civil engineering and infrastructure projects.  Its other members include two independent 

professionals including the Head of Safety and Risk Management at a County Fire and Rescue Service and 

a  Health  and  Safety  Change  Specialist  who  specialises  in  safety  culture  and  behavioural  change 

management.  Its meetings are attended by representatives from TSA’s volunteer leadership and by staff 

from the Safe Scouting department at headquarters. 

Page 3 of 19 

 
 
 
 
 
 
 
 
 
 
 Although the Scout movement is volunteer-led, the Board’s work is supported by a small staff employed at 

headquarters at Gilwell Park in Chingford, London.  This staff team has a departmental structure in order to 

implement  its  policy  and  to  provide  services  and  materials  necessary  for  the  proper  conduct  and 

development of Scouting locally.  Led by a Chief Executive 

 and a Chief Operating Officer 

 their job is to ensure that the policies and rules made by the Board are made available to 

the  local  volunteers  with  a  framework  for  their  effective  implementation  at  local  level.    These  rules  and 

guidance  are  provided  online.    TSA  also  provides  training  and  advice  that  is  to  be  delivered  locally  plus 

support for volunteer leaders and their volunteer line managers.  And, as explained below, it has appropriate 

reporting  systems  in  place  to  be  able  to  monitor  such  things  as  compliance  with  training  and  incident 

statistics. 

Safety policies and rules 

As  stated  above,  one  way  in  which  the  Board  supports  volunteers  is  by  publishing  policies,  rules  and 

guidance for those leading such activities.  One of the Key Policies – which underpins all of our work – is the 

Safety Policy set out in Chapter Two of POR.  This is to “provide Scouting in a safe manner without risk to 

health so far as is reasonably practicable”.   This is because, although a sense of adventure lies at the heart 

of good Scouting, doing things safely is fundamental to everything we do.  Given its importance, this policy 

is reviewed annually. 

The rules in POR, and the various guidance that sits alongside them, reflect this priority.  They provide rules 

and procedures for the way that volunteers plan, prepare and engage in Scouting activities.  All volunteers 

are  required  to  undertake  relevant  training  at  a  local  level.    Certain  activities  must  be  approved  by  local 

Commissioners.    There  are  extensive  permitting  and  certification  arrangements.    There  is  a  national 

membership  database  that  includes  both  training  records  and  internal  qualifications  (permits)  called 

Compass. POR includes a universal requirement that each activity for our young people is planned and is 

the subject of risk assessment, which is repeated in a number of factsheets and other literature. 

Safety leadership 

TSA recognises that safety leadership is vital to an effective and thriving safety culture. 

The Board takes safety matters extremely seriously.  Safety is the first agenda point of each of its quarterly 

meetings as part of which it receives an update on safety matters (including incident statistics, training and 

compliance reports and the minutes of every Safety Committee meeting).  It is also notified of any critical 

incident that may have occurred in that quarter.  Annually, the Board receive a full report of the activities of 

the Safety Committee and a detailed overview of trends and statistics, and in addition one of the quarterly 

Board development sessions is focussed on safety on a rolling annual cycle. 

Given  the  importance  of  such  matters,  as  explained  above,  in  July  2018  the  Board  created  the  Safety 

Committee  (a  dedicated  sub-committee)  that  has  oversight  of  safety  and  provides  leadership  on  such 

matters. It has the following functions: 

Page 4 of 19 

 
 
 
 
 
 
 
 
 
 
  

 

 

 

 

It reviews on a rolling basis all of the safety rules and processes, including its adventurous activity rules 

and guidance. 

It collates and analyses data on training compliance from local volunteers and produces a safety training 

compliance report to help volunteer line managers to improve local safety training compliance.  

It analyses the near-miss data and accident reports made by local volunteers in order to identify trends, 

identify actions and share lessons-learned in order to inform changes to TSA’s rules, training, processes 

and procedures.  

It commissions studies by external bodies to analyse the efficacy of its systems (including a recent study 

by MBA students at the University of Westminster on incident reporting).   

It considers whether, and if so how, the TSA’s rules, procedures and guidance should be updated in the 

light of past experience and lessons learned; and how any such changes should be implemented – both 

by updating TSA’s information resources and volunteer training modules. 

Response to this incident 

TSA has a Critical Incident Procedure Response which was triggered on the day of this tragedy.  Amongst 

other things this resulted in: 

 

The  incident  was  reported  to  TSA’s  Duty  Critical  Incident  Manager  (a  staff  member)  which  in  turn 

triggered notifications to other staff at headquarters (including the Chief Operating Officer and Safety 

Manager), the UK Chief Commissioner and other members of volunteer line management and Trustees. 

  Both the Acting District Commissioner and the County Commissioner were contacted immediately by 

telephone  by  TSA’s  Duty  Critical  Incident  Manager.    The  Acting  District  Commissioner  travelled  to 

Llandudno  that  afternoon  and  arranged  for  the  volunteers  and  young  people  to  travel  back  to 

Manchester. 

 

In  the  immediate  aftermath,  and  in  accordance  with  TSA’s  Critical  Incident  Procedure,  the  Chief 

Operating Officer at headquarters established the initial facts.  An incident log was opened by TSA’s 

Duty Incident Manager to record all actions.  There was liaison with the necessary statutory agencies. 

A Serious Incident Report was prepared and submitted to the Charity Commission.  A support plan was 

agreed  for  those  involved  in  the  incident.  Senior  leaders  wrote  to  Ben’s  family  to  express  their 

condolence and support. 

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. 

 

There was regular contact through a number of different sources with Ben’s family, primarily with his 

father 

.  

Page 5 of 19 

 
 
 
 
 
 
 
 
 
 
 
 
  

Following  that,  the  local  volunteer  line  management  took  various  precautionary  steps  taking  a  risk 

based,  pragmatic  approach.    The  volunteers  on  the  trip  had  restrictions  placed  upon  their  Scouting 

operations  by  the  Acting  District  Commissioner  and  County  Commissioner  pending  the  outcome  of 

investigations  by  the  statutory  agencies  and  the  internal  Safety  Incident  Learning  Inquiry.    This 

prevented  them  from  leading  any  adventurous  activities,  undertaking  activities  away  from  the usual 

meeting place without additional support and required the approval of risk assessments by their Acting 

District Commissioner for any outdoor activities they wished to lead.   

Even though our Safety Incident Learning Inquiry has not yet concluded, a number of changes have already 

been prompted by this tragedy. 

Local learning 

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.  

National learning 

At national level, a number of changes have been implemented by the Safety Committee since the incident.  

They included the following:  

  Risk assessments:  work has been undertaken to strengthen the advice and guidance to volunteers in 

respect of  undertaking suitable and sufficient risk assessments:   

o 

In December 2018 volunteers were reminded by email of the various guidance on risk assessment 

that was available online (including a factsheet, a template and a safety checklist) and were asked 

to review all their current risk assessments and ensure they were up to date.   Volunteers were 

also  asked  to  review  their  InTouch  communication  systems  and  ensure  they  remained  fit  for 

purpose.   

o  As  part  of  TSA’s  ongoing  review,  in  February  2019  Factsheet  FS120000  (Activities  –  Risk 
Assessment) was amended to be made more concise and the risk assessment template was also 

updated.  These amended and updated documents were made available online and sent to all 

volunteers by email with a reminder of how essential risk assessment is to ensuring the provision 

of safe Scouting.  Volunteer line managers also received a separate email reminding them of the 

importance  of  risk  assessment,  providing  a  link  to  the  safety  checklist  on  TSA’s  website  and 

asking them to support leaders to use the new risk assessment template.  

o 

In April 2019 volunteers were reminded by email of the necessity of risk assessment for summer 

activities and sent links to the revised risk assessment guidance and template. 

Page 6 of 19 

 
 
 
 
 
 
 
 
 
 
 
 
 
 o 

o 

o 

o 

o 

o 

In May 2019 all volunteer line managers received a safety message reminding them to keep a 

copy of the Safety Checklist for Managers handy as a reference and to guide all volunteers to the 

new risk assessment guidance and templates available. 

In June 2019, and as a result of feedback from volunteers, further minor amendments were made 

to Factsheet FS120000. Again, a copy of this revised guidance was sent to volunteers by email 

along with information about supervision, leader/young person ratios, the role of the Leader in 

Charge, risk assessment and free time. 

In June 2019, all Scouting centres/campsites were reminded by email of the importance of safety 

for staff, volunteers and visitors.  The importance of having clear risk assessments and operating 

procedures was emphasised, as was the need to manage activities in accordance with Chapter 9 

of the POR and to report any incidents as soon as possible. 

In  October  2019  all  volunteer  line  managers  received  an  email  with  a  reiteration  of  guidance 

relating to the management of events with a specific focus on Remembrance Day events. 

In  December  2019  further  reminders  of  the  importance  of  reviewing  and  updating  risk 

assessments were circulated. 

In the light of further review and recommendations by a specially constituted working group of 

experts (including a former Health and Safety Executive Inspector), Factsheet FS120000 will be 

updated again in the coming months.  The importance of initial written risk assessments is to be 

re-emphasised;  and  the  difference  between  an  initial  risk  assessment  and  a  dynamic  risk 

assessment to be set out.  As well as the existing safety checklist and risk assessment template, 

a  range  of  methods  are  being  explored  for  recording  the  risk  assessments,  including  tools 

available through digital methods (such as recording on mobile phones), the ability to annotate 

existing assessments and template forms.  This new guidance will be reinforced through updated 

safety training.  

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. 

In  August  2020,  following  the  consultation,  an  updated  Factsheet  FS120000  was  launched  along  with 

guidance on carrying out written risk assessments and circulated to volunteers. The guidance also included 

examples of methods to record risk assessments such as using Online Scout Manager (a digital tool) or using 

the notes feature on a mobile phone to annotate changes as part of a dynamic risk assessment. 

Since August 2020 the supporting information relating to risk assessment has been further developed and 

the guidance includes a bank of example risk assessments for a variety of activities and settings, a series of 

videos explaining how to do the five steps of risk assessment and examples of where a risk assessment could 

be improved. 

Page 7 of 19 

 
 
 
 
 
 
 
 
 In October 2020 the Factsheet FS120000 was again updated clarifying specific wording in step three – how 

risks are controlled.  

This updated guidance on written risk assessments has been included in the revised Safety training module 

which was launched in September 2020 (see further below).  

  Nights Away Permit Scheme:  Amendments have been made to the Nights Away Permit Scheme as a 

result of some of the challenges highlighted by this incident as follows: 

o 

o 

o 

In September 2018, and in order to simplify procedure and make compliance easier, the Nights 

Away Notification Form was combined with the Activity Information Form. 

In January 2019 POR was updated requiring parents to be aware of the supervision plans for a 

nights away activity. 

A  new  version  of  the  Nights  Away  Notification  Form  is  being  developed  which  requires  the 

Leader in Charge to certify that a written risk assessment has been prepared and communicated. 

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.  

  Safety training:  in the light of an internal review commissioned by the Safety Committee in September 

2019, which recommended more safety training for volunteers, POR is to be amended to enhance the 

nature and extent of the initial safety training given to volunteers on their appointment.  The work to 

strengthen the quality and reach of safety training has been accelerated and will ultimately deliver an 

enhanced online safety training package for volunteers.  This online training will also be replicated in 

face-to-face training and more support will be provided to those volunteers delivering safety training 

locally  by  the  appointment  of  additional  volunteer  Safety  Co-ordinators  in  counties.    Further,  the 

requirement for volunteers to refresh safety training will now be every three years.  

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. 

Page 8 of 19 

 
 
 
 
 
 
 
 
 
 
 In September 2020 there were changes to POR that mandated the following: 
  Whilst safety training has always been mandatory for new volunteers, that training has been enhanced 

by  making  the  revised  online  safety  training  module  part  of  the  induction  package  ‘Getting  Started’ 

which needs to be completed within the first five months of starting a role. 

  A wider range of roles, including all line managers and Trustee positions, are required to complete the 

enhanced safety  training module  as part of their induction (which needs to be completed within  five 

months of starting the role). 

  The requirement to undertake the safety training module as an update and refresher was reduced from 

every five years to every three years.  

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: 

“To  provide  support  to  members  and  processes  in  the  area  of  safety,  promoting  and  supporting 

compliance with The Scouts’ Safety Policy within the County/Area/Region (Scotland). To advise the 

County/Area/Regional (Scotland) Commissioner and Executive Committee on the implementation of 

The  Scouts’  Safety  Policy  within  the  County/Area/Region  (Scotland)  and  to  assist  District 

Commissioners in operating the policy.” 

  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.  

Update on approval process  

The guidance described above was issued to volunteer line managers in April 2020 which gave examples 

of  an  approval  process  system  that  must  be  documented  and  communicated  to  provide  clarity  on  any 

delegation of approval as described in rule 9.1(b). The Safety Committee will continue to monitor this issue 

as part of TSA’s ongoing review process. 

 

 

First aid training:  in January 2019 requirements for first aid training for volunteers were updated in 

POR. Volunteers were required to maintain a first aid qualification at all times and such first aid training 

has to be refreshed every three years.  

Free -time guidance:  guidance supporting members with the understanding and management of free 

time activities was developed and launched just before this tragedy.  In the light of events on the Great 

Orme, this guidance was recirculated and reinforced in the months following.  

Page 9 of 19 

 
 
 
 
  
 
 
 
 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. 

The  Committee  also  created  separate  supervision  guidance  to  support  leaders  with  identifying  how  to 

manage the risks associated with free time activities and the parts of the programme (particularly for older 

age ranges) where greater independence is given to young people. This was published in August 2020 and 

circulated to volunteers in September 2020.  

 

Terrain definitions:  in 2020 a specifically constituted review group of volunteers and TSA staff (that 

includes  highly  qualified  hill  walking  specialists)  has  been  identified  to  review  the  various  terrain 

definitions, and the rules and guidance relating to all hillwalking activities.  For information, the terrain 

definitions were last reviewed by a similar group between May 2017 and January 2018. 

Update on Terrain definitions 

The  review  (outlined  above)  has  been completed  and  updates  to  the  Terrain definitions  (changes  to  the 

language to provide clarity) and Terrain Zero guidance were approved by both the Safety Committee and 

Operations Committee (the latter now known as the Strategy and Delivery Committee following changes 

to TSA’s governance). The proposed changes were circulated to the movement for pre-launch checks in 

November 2020 and then published in February 2021. 

Ongoing safety reviews and enhancements 

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: 

 

 

 

reviewing  the  improvement  of  the  process  for  reviewing  safety  incidents,  with  a  focus  on  a  greater 

depth of understanding of root cause and ensuring local learning points identified and acted upon as a 

result of any incidents; 

a  schedule  of  review  of  safety  information  and  resources  established  to  ensure  that  everything  is 

reviewed regularly using a two and three year cycle; and 

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.  

Finally, the Safety Committee has endorsed and recommended the recruitment of 10 to 12 additional staff 

members (with expertise in safety management) to the Board.  Their role would be to support volunteer line 

managers and leaders in complying with their safety obligations.  It is currently envisaged that they would 

be deployed around the country to provide specialist advice, guidance and training on safety matters, and 

to assist local line management  in driving mandatory training compliance through local monitoring.   The 

Page 10 of 19 

 
 
 
 
 
 
 
 
 
 
 significant additional staff costs will be met by an increase in the national membership fee. 

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.  

Six  new  staff  posts  have  been  agreed;  including  introducing  a  Head  of  Safety,  a  National  Headquarters 

Safety Manager and four Compliance Officers. This means the staff team for safety will be a total of seven 

staff members and their primary role will be addressing the challenge of supporting safety compliance and 

quality assurance throughout the movement. 

In  the  meantime  senior  volunteer  line  managers  and  staff  have  assisted  the  local  line  management  in 

monitoring and improving training compliance by providing monthly data on compliance in order to guide 

and prompt the necessary local interventions, in addition to sending training reminder emails to ensure that 

this important matter remains a priority locally for volunteers.  

Specific responses to Matters of Concern 

We have considered carefully the transcripts of the recent hearing in order to understand the evidence that 

gave rise to your various Matters of Concern.  At the outset, may we apologise for the fact that we had not 

previously provided you with sufficient evidence to allay your concerns about the risk of future deaths.  We 

respond as follows to the specific numbered Matters of Concern in the Report: 

We do not propose to repeat the further actions and improvements made by the TSA and detailed above in 

reference  to  each  specific  Matter  of  Concern  raised  in  the  Report  to  avoid  unnecessary  duplication.  We 

would,  however,  request  that  the  above  further  details  be  considered  in  conjunction  with  the  specific 

responses  below.  If  it  would  be  of  assistance,  however,  TSA  can  of  course  provide  a  further  document 

setting  out  the  further  actions  and  improvements  made  that  are  relevant  to  each  individual  Matter  of 

Concern. 

1. 

The arranging of the trip did not adhere to the Scout Association’s own safety policies.  

We understand from the transcript of the hearing that the Explorer Leader was suitably qualified as a 

Leader-in-Charge for this overnight activity.  He had obtained the required approval from the Acting 

District Commissioner for the nights away activity as per the Nights Away Permit Scheme.  He had 

obtained parental consent and had organised a safety briefing for the young people in the week before 

the trip.  He had engaged suitable specialist mountain guides for the planned ascent of Snowdon and 

had ensured that leader/young person ratios were appropriate.  It therefore seems that the planning 

and preparation for most of the aspects of the trip, and in particular the ascent of Snowdon, complied 

with TSA’s safety policies, rules and procedures.  

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 However, we agree that the evidence was also that specific approval had not been obtained, given 

this  was  a  free  time  activity  and  in  Terrain  Zero,  from  the  Acting  District  Commissioner  for  the 

proposed  walk  on  the  Great  Orme  because  such  approval  was  considered  unnecessary;  and  that, 

although one of the volunteers had a valid first aid certificate, her qualification was not recorded on 

the national membership database Compass and the volunteer who been added to the Nights Away 

paperwork with the necessary first aid qualification did not attend the trip. 

As explained above, since this incident TSA has taken various steps to reinforce the importance of 

volunteers (a) obtaining prior approval from their District or County Commissioners in accordance with 

rule 9.1(b) of the POR; (b) ensuring that first aid qualifications are properly recorded on the national 

membership  database  Compass;  and  (c)  ensuring  that  all  volunteers  receive  regular  and  repeated 

safety training. 

2. 

Such policies were not adequately understood at grass roots level. 

The evidence suggested that the Explorer Leader was aware of the relevant policies.  He was aware 

of the need to obtain prior approval and the need for relevant qualifications to be recorded accurately. 

His evidence was that he had been kept up to date with safety information, policies, etc. produced by 

TSA. 

He told you, however, that he did not think that it was necessary to seek approval from the Acting 

District Commissioner in relation to the walk on the Great Orme because it was an activity in Terrain 

Zero.  In fact, such approval was required by Rule 9.1(b) and 9.2(a) and the Terrain Zero Activities 

Factsheet which also required a risk assessment to be undertaken. 

As  explained  above, the  local  volunteer  line management  has  taken  steps  to  monitor  the activities 

organised by these leaders and others in the relevant District and County.  

At a national level, as set out above, the rules and guidance governing the approval process is currently 

the subject of review by the Safety Committee.  

We understand the concern from the evidence and are committed to the principle that our procedures 

should  be  clear,  that  they  are  available,  that  volunteer  leaders  receive  initial  and  refresher  safety 

training and that we monitor non-compliance of that training and take action upon non-compliance.  

Finally, the anticipated deployment of dedicated staff to support local Scout Groups will assist local 

volunteer line managers to understand and implement our safety policies, rules and procedures and 

to ensure that they are understood and implemented at a local grass roots level.  

3. 

Safety policies exist but are not implemented. 

As far as we are aware, there was no evidence that TSA itself had failed to implement its own policy.  

Although aspects of the procedure were not followed in this specific case, you received evidence that 

Page 12 of 19 

 
 
 
 
 
 
  
 
 
 
 
 
 there were written rules and procedures that applied to all Scouting activities at the local level; that 

volunteers were trained on these rules and procedures as part of their own certification process; and 

that leaders received updates on any improvements to these procedures. 

In the light of your concern, we have explained above how our safety policy and procedures have been 

(and  are)  implemented  through  written  procedures  and  training;  how  we  monitor  our  volunteers’ 

compliance; and the steps that the Safety Committee has taken to review these procedures, guidance 

and monitoring.  

4. 

There was no written risk assessment. 

There was no written risk assessment in relation to the proposed walk on the Great Orme.   

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 actions they must not take”. 

We believe that the key was to ensure that those involved were told what action they should take – 

and what actions they must not take. 

We  have  explained  above,  however,  that  the  Factsheet  has  been  updated  since  this  tragedy  and 

various steps have been taken to reinforce the importance of risk assessment in activity planning; and 

that, in the light of a review by a dedicated working group (which includes a former Health and Safety 

Executive Inspector), the Factsheet will be revised again in the coming months.  The importance of 

initial written risk assessments is re-emphasised; the difference between an initial risk assessment 

and  a  dynamic  risk  assessment  will  be  clarified  to  avoid  any  confusion;  and  volunteers  will  be 

encouraged  to  use  a  new  digital  tool  –  available  on  smartphones  -  to  assist  in  carrying  out  and 

recording risk assessments. 

5. 

There was no dynamic risk assessment. 

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.  

Nonetheless, and as explained above, we have already clarified and simplified the written guidance 

offered to our volunteers on risk assessment; and, following further review by the dedicated working 

group, a further update is about to be published.  This revised factsheet makes it plain, as before, that 

risks  should  be  properly  assessed,  considered  and  controlled  at  the  outset;  that  a  dynamic  risk 

assessment  is  only  used  for  assessing  risks  during  an  activity  if  things  change;  and  that  any  such 

dynamic risk assessment should be recorded.  

Page 13 of 19 

 
 
 
 
 
 
 
 
 
 
 6. 

There is not a full understanding of what a risk assessment is. 

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.   

As  explained  in  detail  previously,  a  number  of  steps  have  been  taken  to  ensure  that  all  of  our 

volunteers have access to our various risk assessment resources; that they have regular safety training 

that re-emphasises the importance of risk assessments and teaches them how to carry them out; and 

that non-compliance with safety training is monitored locally and nationally.    

7. 

There is not a full understanding on when to do written and or dynamic risk assessments. 

Please see our responses to points 4, 5 and 6 above.   

8. 

There had been no approval sought for the trip as required from the District Commissioner. 

Although there had been discussions with volunteer line managers about the ascent of Snowdon, and 

the  Nights  Away  Notification  Form  had  been  approved  by  the  acting  District  Commissioner,  no 

specific approval had been sought for the walk on the Great Orme.  It was not considered that this 

activity required such approval because it was to be conducted in Terrain Zero.  Such approval was 

required by Rule 9.1(b) and 9.2(a) and Factsheet FS120426 (Terrain Zero Activities). 

As  explained  in  detail  above,  since  this  tragedy  we  have  taken  various  steps  to  reinforce  the 

importance  of  volunteers  obtaining  prior  approval  from  their  District  or  County  Commissioners  in 

accordance with rule 9.1(b) of POR; to ensure that all volunteers receive regular and repeated safety 

training; and to monitor non-compliance.    

9. 

There was an absence of permanent District Commissioner to give oversight to the leadership of 

the group. 

There was a permanent District Commissioner in position until the beginning of August 2018.  At the 

beginning of August 2018, 

 (Deputy County Commissioner) was appointed as acting 

District  Commissioner  by  the  County  Commissioner  and  assumed  all  District  Commissioner 

responsibilities immediately. 

 remains the acting District Commissioner to date. 

In addition to this, there was a permanent District Explorer Scout Commissioner (“DESC”) in post until 

March 2018. In March 2018 the incumbent DESC left her post and the Deputy District Commissioner 

assumed those responsibilities pending appointment of a new DESC.  For the avoidance of doubt, a 

DESC line manages the Explorer Scout Leader within the relevant district and reports directly to the 

District  Commissioner.    A  DESC  is  responsible  for  assisting  the  District  Commissioner  with  the 

provision of the Explorer Scout section within the District and (amongst other things) must ensure 

Explorer Scout Leaders’ meetings are held within the district.  Upon assuming the responsibilities of 

Page 14 of 19 

 
 
 
 
 
 
 
 
 
 
 
 
 DESC, the Deputy District Commissioner continued to hold those meetings. 

10.  There was no meaningful discussion between the scout leaders as to the plan for the trip on the 

Orme.  

We understand that there were informal discussions about the walk but insufficient planning by the 

volunteers leading this activity. 

The local volunteer line management has, as explained above, taken steps to monitor the activities 

organised by these volunteers and others in the relevant District and County. 

We have also explained above how, at a national level, we have taken steps to review our procedures 

to  assure  ourselves  that  they  are  clear,  that  they  are  available,  that  volunteers  receive  initial  and 

refresher safety training and that we monitor training non-compliance locally and nationally and take 

action upon that non-compliance.  

However, we note that the POR has always emphasised the importance of communication between 

leaders and participants, for example Rule 9.2(a) of the POR states that in preparing for an activity 

each leader must: 

- 

- 

ensure that each participant has appropriate training; and 

ensure that a risk assessment is carried out in accordance with Rule 9.4 and safety instructions 

are communicated to all supervising adults and participants. 

Further,  factsheet  FS120000  by  way  of  example  states  that    “  you  will  always  need  to  tell  those 

involved in the activity what action they should take – and what action they must not take!”. 

In addition, the enhancements we have made to guidance on risk assessments and safety training are 

outlined  above  in  the  section  entitled  “National  Learning”  and  within  those  enhancements,  further 

emphasis has been placed on the importance of leaders clearly communicating planned activities and 

risk assessments to participants. 

Finally, the anticipated deployment of dedicated staff to support Scout Groups locally will assist local 

volunteer line managers to understand and implement our safety policies, rules and procedures and 

ensure that they are understood and implemented at a local grass roots level.  

11.  The leaders did not have a participant list nor list of phone numbers for the boys. 

We have been unable to identify any conclusive evidence from the transcript regarding whether the 

volunteers had a participant list or not.  The volunteers did confirm, however, that they had access to 

all  relevant  mobile  numbers.    Any  problems  in  communication  arose,  however,  from  the  limited 

network coverage on the Great Orme. 

Page 15 of 19 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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. 

This guidance is, however, being reviewed to reinforce the importance of suitable systems being in 

place where young people are given a greater degree of independence and are allowed to be more 

remote from their leader.  The guidance will not prescribe the suitable method of communication nor 

system  that  should  be  adopted  as  it  recognises  that  this  will vary  depending  on  the  age  of  young 

people and the location of the activity (amongst other factors).  

12.  There was no route planned for the Orme trip. 

No specific route had been planned and agreed. Our response to point 10 is repeated.   

13.  No instruction or briefing was given to the boys. 

We understand that there was a brief discussion about the proposed walk with one of the Assistant 

Leaders,  but  that  there  were  no  specific  instructions  or  briefing  given  to  the  young  people.    Our 

Factsheet FS120426 (Terrain Zero Activities) advised that all participants should be briefed and this 

advice is also contained in Rule 9.2 and FS120000.  Further, both our previous training and our revised 

training  emphasise  the  importance  of  discussing  the  risk  assessment  with  those  involved.    Our 

response to point 10 is repeated. 

14.  Each of the 3 leaders assumed the 3 boys were with one of the leaders when in fact they were not. 

They were on their own. 

Our response to point 10 is repeated.    

15.  There was no effective leadership for the group. 

Our response to point 10 is repeated.   

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. 

We  are  very  sorry  that  you  have  reached  this  conclusion.   We  understand  that  on  day  two  of  the 

Inquest you heard that an initial review was carried out soon after this tragedy, and that a more formal 

and detailed review (i.e. an internal Safety Incident Learning Inquiry) would be carried out following 

the conclusion of the police investigation and Inquest.  Although this evidence was consistent with 

the detailed summary that we have set out above, you were not told at that stage in the Inquest about 

all of the post-incident actions.   

Page 16 of 19 

 
 
 
 
 
 
   
 
 
 
 
 
 
 
 We understand from the transcript, however, that this line of questioning was not pursued further at 

that time because, in discussion with the advocates, it was decided that evidence about post-incident 

learning relevant to any Prevention of Future Deaths Report would be taken after the jury had retired. 

For that reason, it appears that the Safety Manager’s evidence on such matters was limited at  that 

stage. 

We also understand, however, that you and the jury subsequently received evidence about the police’s 

response  to  the  incident  which  gave  the  impression  that  no  restrictions  had  been  placed  on  the 

volunteers’ activities after the tragedy.  And we understand, therefore, your concern when you heard 

(after the jury had retired and in the context of considerations relating to the issuing of a Prevention 

of Future Deaths Report) that the County Commissioner had placed post-incident restrictions on the 

volunteers and therefore the activities of the Explorer Scout Unit pending further investigations.  You 

felt  that  this  evidence  should  have  been  given  to  the  jury  at  an  earlier  stage;  and  that  you  were 

concerned that this omission compromised the process. 

Those representing TSA at the Inquest in February have assured us that there was no intention to 

withhold this information about TSA’s post-incident response from the jury.  We are mortified that, 

as  a  result  of  this  misunderstanding,  they  gave  such  an  impression.    We  are  very  sorry  that  this 

unfortunate impression has been created.  We wish to apologise unreservedly for this to you and to 

the  members  of  Ben’s  family  and  we  assure  you  that  TSA  will  play  a  full  role  in  your  continuing 

investigation. 

17.  The  Scout  Association  created  a  misleading  impression  in  the  evidence  concerning  its  actions 

regarding its leaders on the trip, post death. 

Again, we are very sorry that you have been given this impression.  Please may we repeat our previous 

response  and  our  previous  apology.   We  hope  that  the  information  that  has  been  provided  in  this 

letter, and the further evidence that will be contained in witness statements from senior leaders, will 

provide you with full particulars of the post-incident actions. 

18.  The  Scout  Association  is  distant  from  its  membership  through  its  federated  branches  of  8,000 

charities and layers of hierarchy meaning that it cannot know how health and safety is executed 

at a ground level. 

Scouting delivers everyday adventure for young people which helps them to develop skills for life.  We 

recognise that Scouting activities inevitably bear an element of risk.  We are not complacent as to 

such risk: quite the opposite.  The safety of the young people and volunteers involved in Scouting is 

our number one priority.  This explains why the Scout movement has developed, over many years, 

systems and procedures to manage risk.  

Scouting is a grass-roots movement that is led by volunteers.  By intention and design, it is delivered 

through Scout Groups locally.  This model enables us to make a real difference to our young people 

and  to  their  local  communities.    And  the  purpose  of  all  of  the  other  charitable  bodies  in  the  Scout 

movement is to support and enhance the quality of the provision by these volunteers at the local Group 

Page 17 of 19 

 
 
 
 
 
 
 
 
 level. 

Earlier  in  this  letter,  we  have  explained  how  the  various  elements  of  the  Scout  movement  work 

together to honour our common commitment to safety through safety leadership, policies, procedures, 

training and monitoring.  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 a result of that analysis.  In this way, TSA provides oversight of safety and provides leadership on 

safety matters in an appropriate way given the federated nature of the Scout movement.  

Although these structures are kept under constant review, we believe that this federated structure 

strikes  the  appropriate  balance  between  localism  and  centralism  and  is  the  most  effective  way  of 

ensuring that society continues to benefit from Scouting.  We hope that the further information and 

explanation provided in this letter allays your concern. 

19.  The  health  and  safety  training  intervals  of  leaders  are  said  to  be  every  3  years  with  no  way  of 

assessing their competencies. 

The  Inquest  heard  evidence  that  safety  training  is  moving  from  a  five-year  period  to  a  three-year 

period and will include an assessment of competence.  As explained above, work to undertake this 

change  has  been  accelerated  in  recent  months.    It  had  been  hoped  to  roll  this  out  in  June  2020, 

although this may be delayed by the current Covid-19 situation.  

The online safety training module will check competence through a question and answer process that 

issues  a  certificate  of  completion  and  will  be  recorded  on  TSA’s  national  membership  database 

Compass.  Safety training is also provided face-to-face and a competence assessment will be included 

following the same questions as the online training. 

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 played in the death of Ben. 

Please  may  we  reassure  you  and  Ben’s  family  that  all  of  us,  whether  senior  leaders  of  the  Scout 

movement, TSA staff members and/or Trustees, are committed to understanding, and learning from, 

the tragic events of August 2018.   

This commitment is reflected in the procedures and rules that have been developed over a number of 

years to meet our number one priority – which is to keep people safe. 

Page 18 of 19 

 
 
 
 
 
 
 
 
 
 
 We set out earlier in this letter the various steps that TSA has already taken to improve and enhance 

its operational practice since this tragedy so as to ensure that young people and volunteers are kept 

safe from harm.  And we have also referred to the steps that we continue to take in the light of the 

concerns that we had identified and you have raised.  Please may we assure you and Ben’s family that 

TSA will consider all of the evidence that has been (and will be) given at the Inquest, the content of 

your Report dated 7 February, any conclusions reached by your jury in July and any further Matters of 

Concern that are brought to our attention by you.  This evidence will be considered in the first instance 

by the Safety Committee as part of its own forthcoming Safety Incident Learning Inquiry.  And we will 

do all that we can to continue to learn from this tragedy. 

Conclusion 

We are grateful to you for raising the various concerns in your Report.  As we hope to have demonstrated 

by this letter, these are matters that we take very seriously.  We hope that you and Ben’s family will gain 

reassurance from the further information in this letter.  And that, in the light of this response, your concerns 

will have been allayed.  TSA looks forward to assisting you and your jury in your further investigations. 

Yours sincerely 

Chair of the Board of Trustees 
The Scout Association 

Page 19 of 19