Benjamin Leonard

Mr David Pojur 
Assistant Coroner for North Wales 
(East and Central)  

By email only 

Charity Commission 
PO Box 211 
Bootle 
L20 7YX 

Date: 17 April 2024 

Dear Mr Pojur 

Re: Regulation 28 Report to Prevent Future Deaths following inquest into the death 
of Benjamin Leonard 

Introduction  

1.  I refer to your Report to Prevent Future Deaths (‘the Report’) dated 22 February 2024 
concerning the death of Benjamin Leonard who died on 26 August 2018. I am replying 
as the Chief Executive Officer of the Charity Commission for England and Wales (‘the 
Commission’). Before responding to the concerns raised in the Report, I would like to 
express my sincere condolences to Ben’s family. The Commission is keen to assure 
Ben’s family and you that the concerns raised are being closely examined as part of 
our  ongoing  engagement  with  The  Scout  Association  (‘TSA’),  registered  charity 
number 306101.  

The role of the Charity Commission   

2.  The Commission is the registrar and regulator of charities in England and Wales. We 
are  an  independent,  non-ministerial  government  department  accountable  to 
Parliament. We are also accountable for the exercise of our powers to the First-tier 
Tribunal and the High Court.  

3.  As registrar, we are responsible for maintaining an accurate and up-to-date register 
of  charities.  This  includes  determining  whether  organisations  are  charitable  and 

On track to meet your deadline? 

Visit www.gov.uk/charity-commission for help 
on filing your annual return and accounts 

0300 066 9197 (General 

t: 
enquiries) 

w:  www.gov.uk/charity-commission 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 therefore  should  be  registered,  as  well  as  removing  those  that  are  no  longer 
considered to be charities, have ceased to exist or do not operate.  

4.  As  a  regulator,  we  regulate  both  registered  charities  and  charities  that  are  not 
required  to  be  registered.  We  operate  within  a  clear  legal  framework  and  follow 
published policies and procedures, ensuring that in making regulatory decisions we 
are proportionate in our approach. 

5.  The Commission has regulatory oversight of  TSA due to its status as a registered 
charity. The Scout Councils of Northern Ireland, Scotland and Wales along with Scout 
Counties, Areas, Regions (Scotland), Districts and Groups, together form the Scout 
movement  in  the  United  Kingdom.  The  majority  of  these  bodies1  are  autonomous 
charities affiliated to TSA and also fall under the remit of the Commission.    

The Commission’s statutory objectives  

6.  The  Commission,  through  the  Charities  Act  2011,  is  charged  with  delivering  five 

statutory objectives. These are to:  

a.  increase public trust and confidence in charities.  

b.  promote  awareness  and  understanding  of  the  operation  of  the  public  benefit 

requirement.  

c.  promote compliance by charity trustees with their legal obligations in exercising 

control and management of the administration of their charities. 

d.  promote the effective use of charitable resources.  

e.  enhance the accountability of charities to donors, beneficiaries and the general 

public.  

7.  Although  our  objectives  are  wide-ranging,  there  are  limitations  to  our  role  as  a 

regulator: 

•  we are not a prosecuting authority but a civil regulator. The investigation of alleged 

criminal offences is the responsibility of law enforcement agencies. 

1 There are approximately 8,000 separate local scout groups. Not all local scout groups are registered charities.  

Page 2 of 7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  we ordinarily cannot act as a trustee or be directly involved in the administration of 
a charity, unless particular circumstances apply. This means we can’t tell trustees 
what  decisions  to  make,  although  we  do  seek  to  provide  appropriate  and 
accessible  guidance  to  support  them  with  their  decisions  to  ensure  they  can 
comply with their legal duties and responsibilities.  

•  we  also  have  no  power  to  overturn  trustees’  decisions  if  they  are  lawful  and 
reasonable, even if these decisions may be unpopular. However, where trustees’ 
decisions could result in significant harm, for example loss or damage to a charity’s 
assets including its reputation, which forms part of its property, we can investigate 
how trustees manage their charity. Where it is necessary, for example if we identity 
actual or potential misconduct and/or mismanagement, we use our powers as a 
remedy to improve charity governance and management. 

Our regulatory approach 

8.  We are a risk-led regulator. Being risk-led in our regulation means being proactive in 
identifying risks and intervening, where possible, to prevent harm before it occurs; 
addressing harm effectively where it occurs; and focusing our resources effectively 
on the highest risks. Our Regulatory and Risk Framework outlines how we operate 
as a risk-led regulator and, in particular, how we identify and assess risks, how we 
respond to risks, and how we review and adapt our approach. 

9.  We  seek  to  hold  charities  to  account  to  basic  standards,  and  while  we  ensure 
concerns are investigated and intentional wrongdoing dealt with, we also focus on 
supporting trustees in getting things back on track, where possible when they do not 
go exactly as intended.  

10. We put the public interest front and centre of our approach to regulating charities – 
making sure that the public have the information they need to make informed choices 
about charities and that they are confident that our approach to regulation is clear 
and consistent. 

Trustee conduct  

11. Charity  trustees  are  the  people  who  share  ultimate  responsibility  for  governing  a 
charity  and  directing  how  it  is  managed  and  run. The  role  of  the  Commission,  as 
regulator, is to ensure that trustees are actively and effectively managing risks and 
dealing with harm relating to their charities.   

Page 3 of 7 

 
 
 
 
 
 
 
 
 
 
 
 
 12. When we are considering regulatory action, the conduct and response of the trustees 

will affect our approach. We will consider whether: 

• 

• 

• 

the trustees have acted honestly and reasonably. 
there are indications that they have been careless or reckless. 
there has been deliberate or wilful wrongdoing. 

13. If we are satisfied that the trustees have already taken appropriate steps to address 
risks or harms, we may decide to take no further action depending on the specific 
circumstances of the case in question. However, where the nature and level of the 
risk demands it, we will take action in line with the statutory framework set out in the 
Charities Act 2011. In our regulatory work, we have a range of possible actions and      
powers available to us. Parliament has set clear legal tests on when and how these 
powers can be used. 

The Commission’s role in terms of safeguarding and child safety  

14. The Commission has a key regulatory role in ensuring that trustees comply with their 
legal  duties  and  responsibilities  in  managing  their  charity.  In  the  context  of 
safeguarding and safety, the Commission has an important, but limited, role. Our role 
is focussed on the conduct of trustees and the steps they take to protect beneficiaries, 
employees, volunteers and others who come into contact with  a charity through its 
work.  

15. We have published guidance to help trustees meet their duties around safeguarding, 
Safeguarding for charities and trustees. Our guidance sets out that, as part of their 
duties, trustees must take reasonable steps to protect from harm people who come 
into contact with their charity – a charity should be a safe and trusted environment. 

16. We  expect  protecting  people  and  safeguarding  responsibilities  to  be  governance 
priorities for all charities and this is a fundamental part of operating as a charity for 
the  public  benefit.  Any  failure  by  trustees  to  manage  safeguarding  /  safety  risks 
adequately is a serious regulatory concern to the Commission. We may consider this 
to be misconduct and/or mismanagement in the administration of the charity. It may 
also be a breach of trustee duty.  

17. The  Commission  does  not  have  any  prosecutorial  or  criminal  law  enforcement 
powers. We are not responsible for dealing with individual incidents of alleged abuse 
and  do  not  administer  safeguarding  legislation.  Where  it  is  appropriate  and 
necessary, we  refer allegations  of  a  criminal  nature, or incidences  of  an  individual 

Page 4 of 7 

 
 
 
 
 
 being  at  risk  of  harm,  to  the  police,  local  authorities,  DBS  and  other  relevant 
safeguarding agencies.  

18. We  recognise  that  the  other  bodies  in  receipt  of  the  Report  have  roles  to  play  in 
helping to prevent future deaths. Where appropriate, we will liaise with them to ensure 
that  we  effectively  fulfil  our  responsibilities  to  achieve  a  successful  regulatory 
outcome. 

The Commission’s response to the Report  

19. We have been engaging with TSA on this matter since Ben’s tragic death in August 
2018. Ben’s death was reported promptly to the Commission by the Charity, with TSA 
submitting  a  serious  incident  report  on  the  day  of  his  death.2  We  subsequently 
opened a regulatory case and, since then, TSA has provided us with regular updates 
on  significant  developments.  We  continue  to  have  an  open  case  and  the  matter 
remains an ongoing, live issue for the Commission.  

20. As TSA’s regulator, we take very seriously the concerns that you have raised in your 

Report.  

21. We note the various concerns and findings identified in the Report. As set out above 
the  Commission  will  focus  on  concerns  about  the  charity  governance  issues  and 
trustee conduct throughout TSA, in line with the Commission’s jurisdiction. Therefore, 
for example, the Commission can investigate the concerns in the Report about the 
wider structure of the Scout movement and the risk that there is no robust system in 
place  to  make  sure  that  the  divisions of  the roles  between  TSA  and  the  individual 
charities  is clearly  set  out  and  understood  by  all  concerned.  The Commission  can 
also look into past conduct by the trustees and what steps had been, and are being 
taken,  to  address  all  safeguarding  and  safety  concerns  set  out  in  the  Report  and 
ensure  the  trustees  are  meeting  their  legal  duties  in  governing  the  TSA  and  have 
suitable governance and adequate procedures, including to address your concerns 
as set out in the Report. 

22. Following  receipt  of  the  Report,  our  Director  of  Regulatory  Services  requested  a 
meeting with senior personnel at the Charity to discuss TSA’s response to the Report.  

23. On  19  March  2024,  the  Commission  met  with  TSA’s  Chair  of  trustees,  CEO, 
Executive Director of Operations and Head of Governance. It was apparent from our 
meeting  that  TSA  considers  the  matter  of  Ben’s  death  as  one  of  the  utmost 

2 This was in in line with our expectations around reporting serious incidents, set out in our guidance How to report a 
serious incident in your charity.  

Page 5 of 7 

 
 
 
 
 
 
 
 
 
 seriousness. In addition to the actions TSA confirmed to us it has already taken, TSA 
has  made  clear  that  it  intends  to  make  further  improvements  to  safety  and  risk 
management  in  the  Scout  movement.  Following  the  meeting,  we  have  requested 
additional information about the actions already taken and TSA’s intended next steps, 
including the anticipated schedule for completion.  

24. TSA has assured us it will respond fully to the Report’s findings and have committed 
to  sharing  its  response  with  the  Commission.  Its  response  will  be  relevant  to  our 
decisions  about  any  regulatory  action  we  may  consider  necessary  to  assist,  or 
ensure, TSA make the changes that need to be implemented to address the concerns 
set out in the Report. We will ensure TSA and its affiliated charities are clear on the 
Commission’s view about what improvements are essential and must be made and 
we will continue to examine the concerns identified. 

25. At this stage, we cannot provide a timescale for the likely conclusion of our case. We 
are  continuing  to  examine  the  concerns  and  assess  whether  the  actions  already 
taken  by  TSA  have  been  appropriate  and  if  the  further  work  to  be  undertaken  is 
sufficient. We will be meeting with TSA again and, in line with our role and charity 
law, the Commission will support TSA to continue its vital work to further strengthen 
safety within the Scout movement and will take further regulatory action if the need 
arises. 

26. We are aware that, following the outcome of the Inquest, there is the possibility of a 
police investigation. We are in contact with the relevant police force to ensure we are 
clear on any actions that the police are taking, recognising that police investigations 
take precedence over any civil action, including our own. 

27. We  note  Ben’s  family’s  request  for  the  establishment  of  a  public  inquiry  into  TSA 
under the Inquiries Act 2005. I can confirm that, as a regulator, the Commission would 
always  cooperate  fully  with  any  public  inquiry.  We  also  note  that  you  highlight  the 
absence  of  an  external  inspection  regime  for  TSA  and  we  would  be  available  to 
support any further discussion of this by government or others, in the context of the 
existing charity law regime described above.  

Conclusion 

28. Thank you for raising these important matters with me. I hope the above response 
assures  you  that  the Commission  is taking appropriate  steps  to  fulfil  its  regulatory 
role. Please do not hesitate to contact me should you require any further information 
about the Commission’s response to the Report.  

Page 6 of 7 

 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely, 

Chief Executive 

Page 7 of 7

Response to the Coroner’s Prevention 
of Future Deaths Report No.2 in 
respect of Benjamin Leonard 

Children’s Commissioner for Wales 

17th April 2024 

Comisiynydd 
Plant Cymru 
Children’s 
Commissioner 
for Wales 

 
 
 As Children’s Commissioner for Wales, I am in receipt of the Coroner’s Prevention of Future Deaths report dated 22.2.24,  
in respect of Benjamin Leonard, who tragically passed away on a trip in north Wales. I wish to first extend my sincere 
condolences to the family and friends of Ben.  

The Prevention of Future Deaths (PFD) report sets out a history of concerning events, leading up to Ben’s untimely death 
and since then throughout the inquest process.   

My role and statutory powers do not include any regulatory or inspection functions.  My remit relates to public bodies in 
Wales delivering statutory functions; a summary of those powers can be found here1.  

I have had initial contact from the Scouts Association in respect of their actions to date but I will continue to seek updates 
on their actions to prevent future deaths or serious injuries in response to this report, alongside my counterpart the 
Children’s Commissioner for England.   

In Wales, Estyn are currently expanding their inspections framework to include a bespoke approach for the youth work 
sector.  Work is underway to develop a model that can be applied to youth work being delivered by local authorities and 
also voluntary sector organisations.   This approach will be co-designed with the sector and through engagement with 
young people accessing youth work, including a pilot of the approach during this year2. 

I meet regularly with Estyn and will ensure that a copy of the PFD report is shared with them for the purposes of developing 
and implementing their youth work inspection approach.  I will also ensure that this is discussed at my next meeting with 
their Chief Executive. 

Children’s Commissioner for Wales 

1 https://www.childcomwales.org.uk/about-us/legal-powers/  
2 https://www.estyn.gov.wales/inspection/inspecting-future-2024-2030  

Comisiynydd 
Plant Cymru 

Children’s 
Commissioner 
for Wales

David Pojur  

Assistant Coroner for North Wales (East and Central) 
HM Coroner's Office 

County Hall 

Wynnstay Road  

Ruthin LL15 1YN 

Dear Mr Pojur, 

Sanctuary Buildings, 20 Great Smith Street 

London, SW1P 3BT 

18th April 2024 

RE: Response to Benjamin Leonard: Prevention of future deaths report 

I extend my sincere condolences to the family of Ben. The circumstances set out in the prevention of 

future deaths report makes for sombre reading – both in the way the Scout Association has 

conducted itself in relation to the inquests and the extensive list of “matters of concern”. 

As Children’s Commissioner for England I do not have regulatory or legislative powers, however, my 

team will be asking the Scouts Association to provide us with updates on what, I hope will now be, a 

meaningful learning exercise to prevent future deaths or serious injuries. The first request will be 

made by 30th April 2024. I will be mindful of the Coroner’s comment that the Scout Association is 

“institutionally defensive” when considering their response.  

Organisations engaged with children need to take safety seriously so children can enjoy 

opportunities to explore the natural world. I have called for Ofsted to play a larger role in assuring 

high standards of safety and safeguarding

in youth work organisations ( The Big Ambition: 

Ambitions, Findings and Solutions | Children's Commissioner for England 

(childrenscommissioner.gov.uk).  

Yours sincerely 

Children’s Commissioner for England

David Johnston OBE MP 
Minister for Children, Families and Wellbeing 

Sanctuary Buildings 20 Great Smith Street Westminster London SW1P 3BT 

David Pojur 
Assistant Coroner for North Wales (East and Central) 
Manchester Civil Justice Centre 
1 Bridge Street West, 
Manchester  
M60 9DJ 

3rd May 2024  

Dear Mr Pojur, 

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

1.  This is the Department for Education’s (DfE) response to the Regulation 28 

Report to Prevent Future Deaths dated 22 February 2024. The report was issued 
following the third inquest into the death of Benjamin Leonard (referred to as Ben, 
in accordance with his family’s statements), who fell from a cliff during a Scout 
Association trip in 2018. 

2.  We want to begin by expressing our deepest condolences to Ben’s family and 
acknowledge the tragic nature of this incident. We appreciate that this is a 
serious and sensitive issue, which has been the cause of significant hurt and 
distress to those affected.  

3.  In that light, we would also like to thank you for your report, allowing us sufficient 
time to fully address these important issues, and your efforts to conclude the third 
inquest. The information provided by the report is vital in the Department’s 
consideration of a long-term strategy to better safeguard children. 

DRAFT 

1 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
 Matters of Concern 

1.  Your report references a request from the Leonard family for the establishment of 
a Public Inquiry (be it statutory under the Inquiries Act 2005, or non-statutory) into 
the Scout Association. In their submission to you, the family suggest that the 
matters of concern raised through the inquest process, point to systemic safety 
and safeguarding issues, warranting the urgent need for the establishment of a 
Public Inquiry. Your report also outlines several other matters of concern for the 
relevant Minister to consider. 

2.  The MATTERS OF CONCERN, as you outline them, are as follows: 

a.  The culture of candour and independent inspection – the lack of a 

culture of candour within the Scout Association, impacting on safety and 
safeguarding; and the absence of a robust regulator to independently and 
periodically audit and inspect the systems, processes and training of the 
Scout Association, including the granting of permits for activities (overnight 
and otherwise). 

b.  Fatal Accident Inquiry Panel Investigation Report (FAIP) – the timely 

commissioning, completion, and implementation of recommendations from 
this internal Scout Association process. 

c.  Safety Training – the quality of online training used to equip leaders with 

a sufficient understanding of risk assessments to keep Scouts safe. 
d.  Restricted Duties – that the relevant Scout leaders were not subject to 

restricted duties immediately following Ben’s death; and when restrictions 
were issued there was a lack of clarity as to whether these related to the 
individuals or to specific activities. 

e.  Absence of Safeguarding and Safety Compliance – in relation to 

presence of over 18s on the trip, who were not listed as adults on the 
Nights Away Notification, nor subject to DBS checks, and a general lack of 
understanding of safety and safeguarding training.  

f.  Monitoring, Auditing and Reliance on Volunteer Line and the need for 
paid trainers – regarding the quality of systems for analysis, reporting and 
clarity of responsibilities regarding compliance and timelines for training, 
inductions, appointment to roles and the granting of permits. 
g.  Delays in Training – a lack of sanctions for missed deadlines for 

mandatory Scout Association training by staff, shortages of local training 
managers, and statistical data showing significant numbers of roles with 
over-due training requirements. 

h.  First Aid Kits – the absence of a first aid kit, and requisite planning for 
one during the Great Orme trip, issues with the quality of guidance 
regarding first aid kits on the Scout Association website, and a need to 
ensure first aid kits were available on every trip and at Scout huts, 

DRAFT 

2 

 
 
  
 
 
 
 including containing essential items like tourniquets, to enable immediate 
life-saving treatment. 

i.  First Aid Self-Certification – regarding learners being able to self-certify 
completion of further Scout Association first aid training, without checks or 
assessments for verification, and, despite reported improvements, 
prevailing concerns about the robustness of the system. 

j.  Autonomous Charities – the Scout Association's layers of hierarchy 
creating a disconnect between national staff and local clubs, as to the 
execution of health and safety. For example, having centralised 
safeguarding and safety training/policies, yet accountability for these areas 
being deferred to individual charities (i.e. local clubs and groups). 
k.  Permit / Licencing Schemes – the absence of a robust system for 

ensuring permit holders (granted the Nights Away Permit) responsible for 
children’s safety were suitably qualified, in addition to unclear permit 
requirements for activities outside regular Scout meeting places. 

Scope of Departmental Response, Definitions and Divisions of Responsibility 

3.  This response sets out the Department’s current position and further steps that 
will be taken by Government to strengthen safeguarding of children and young 
people, including in Out-of-School settings and charities such as Scout clubs and 
activities.  

4.  ‘Out-of-School settings’ is a term the department uses to describe a range of 

organisations (both commercial and charitable) or individuals that provide tuition, 
training, instruction, or activities to children and young people1 in England2. They 
exclude activities with parental supervision, and regulated education and 
childcare settings (i.e. schools, colleges, alternative provision arranged by 
schools or local authorities, and childcare providers registered with Ofsted).  

5.  It is also helpful, for the purpose of this response, to clarify the divisions of 
responsibility, relevant powers and responsible bodies within government 
regarding child protection and safeguarding, in so far as they relate to the Scout 
Association and its Scout clubs. 

a.  The Department for Education (DfE) has national policy responsibility for 
the overarching framework for child protection and safeguarding, which is 
overseen by local authorities as set out in the Children Act 1989 and 
associated legislation. This includes the policy remit for Out-of-School 
Settings safeguarding, and DfE offers extensive guidance for providers 
and parents on these issues. DfE also has responsibility for the multi-

1 “children” and “young people” are defined in this response as “people who have not yet reached their 18th 
birthday”. This follows the definition in the Children Act 1989, where a child is defined as ‘a person under the 
age of 18’. 
2 Education in the United Kingdom is devolved with each nation operating separate systems. 

DRAFT 

3 

 
 
  
 
 
 
 
 
 
 agency guidance on safeguarding, Working Together to Safeguard 
Children (2023) and Keeping Children Safe in Education.  

b.  The Department for Culture, Media and Sport (DCMS) is responsible for 
‘civil society’ policy and have specific policy responsibilities relating to 
young people, volunteering, social enterprises, social investment and 
public service mutuals in England3. It is also responsible for policy relating 
to charities, in relation to which the legal framework also extends to Wales. 
DCMS sponsors the Charity Commission for England and Wales 
(hereafter ‘the Charity Commission’). The Charity Commission is a non-
ministerial department which registers charities in England and Wales and 
regulates their compliance with charity law. The Charity Commission’s 
independence from Ministerial or Departmental direction or control is set in 
statute. DCMS also leads on non-statutory youth services and positive 
activities for young people outside of school settings in England (such as 
the Scout Association). As part of these responsibilities, they have funded 
activity to provide safeguarding resources for all domestic charities, and 
improved safeguarding training for specific areas related to youth work 
practice.  DCMS does not have responsibility for setting or monitoring 
standards of child protection.  

6.  Finally, we would note that various matters identified in your report concern the 
internal structure and workings of the Scout Association (for example their 
internal FAIP process). Where feasible, we have sought to address all matters of 
concern, but unfortunately we cannot comment on the internal set-up and 
structure of individual organisations, or charities in the case of the Scout 
Association. We understand that the Scout Association will provide a response to 
your report which we expect will address these issues. Similarly, we understand 
that the Charity Commission will provide a response which we expect will 
address matters relating to charity trustees’ legal duties and responsibilities in 
managing their charity.  

3 As the DCMS was not named in your report, DfE sought contributions where their policy remit is relevant to 
the matters of concern identified.  

DRAFT 

4 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 Department for Education Response 

1.  The Government takes the safeguarding of all children very seriously. We are 

committed to protecting children from harm across all settings, including Out-of-
School Settings and charities such as Scout Association clubs and expeditions. 
There are legal duties and supporting powers in place to protect children in these 
settings, and we expect relevant regulators (such as the Charity Commission), 
local authorities and police to use them as necessary when duties are not met. 

2.  We have set out the most relevant legal duties, guidance and best practice 
below, which directly address many of the coroner’s matters of concern. We 
strongly encourage out-of-school settings, such as The Scout Association, to 
follow our safeguarding guidance for providers. The DfE has also extensive wider 
safeguarding guidance for working with children, such as Keeping Children Safe 
in Education, and the Working Together to Safeguard Children, which may be 
useful to refer to for best practice. We expand on the full extent of existing 
guidance in Annex B, with specific advice addressing matters of concern on 
point-by-point basis in Annex C. 

3.  The Charity Commission is the registrar and regulator of charities in England and 

Wales. Elaborating on the above Division of Responsibilities, the Charity 
Commission are an independent, non-ministerial government department 
accountable to Parliament and, for the exercise of their powers, to the Tribunal 
and the courts.  

4.  Through the Charities Act 2011 (‘the 2011 Act’) – which sets out the Charity 

Commission’s statutory duties and functions – and relevant case law, it already 
has a strong regulatory framework to help ensure trustees comply with their legal 
duties and responsibilities in managing a charity. All charity trustees, whether for 
a national organisation or local clubs, have legal duties including a duty of care to 
safeguard those who come into contact with the charity and its work. A charity 
should be a safe and trusted environment. 

Specific powers 
5.  There are a wide range of regulatory powers at the Charity Commission’s 

disposal. Before any use of these powers the Charity Commission assesses 
concerns against its Regulatory and Risk Framework, to ensure it makes 
proportionate and targeted use of its resources when addressing issues of 
concern. 

6.  The Charity Commission has the power to identify, investigate and take action 
regarding apparent misconduct or mismanagement in the administration of 
charities. It may also conduct inquiries with regards to charities, either generally 
or for particular purposes. The Charity Commission may open an inquiry at the 

DRAFT 

5 

 
 
  
 
 
 
 
 
 
 same time as another agency or regulator. The supporting guidance states that 
the aim of an inquiry is to: 

a.  identify the extent, if any, of misconduct and/or mismanagement in the 

administration of the charity; 

b.  assess any risk to the charity and its assets; 
c.  and decide whether the Commission needs to act to protect the property of 

the charity.  

It further states that misconduct includes any act, or failure to act, that the person 
committing it knew, or ought to have known, was criminal, unlawful or improper. 

7.  Specifically, section 47 of the 2011 Act details some of the Charity Commission’s 
investigative powers available for use during a statutory inquiry. These include 
the power to direct any person to: 

a.  provide the Commission with accounts and statements in writing on the 

matters under investigation; 

b.  return to the Commission answers in writing to any questions or inquiries 
addressed to them, and to verify any accounts, statements or answers by 
statutory declaration; 

c.  provide copies of documents in their custody or under their control relating 

to the matter being investigated and to verify any copies by statutory 
declaration; or 

d.  attend at a specified time and place and give evidence or produce any 

documents. 

e.  provide evidence on oath or make a declaration of truth. 

8.  In practical terms, under section 47 of the 2011 Act, the Charity Commission has 
the power to obtain, evaluate and disseminate information in connection with the 
performance of any charity. In addition, with a warrant (as per sections 48 and 49 
of the 2011 Act), a member of the Commission’s staff can enter and search 
premises, take possessions or documents, take a computer disk or other 
electronic storage devices, to take copies of documents. In specific 
circumstances (as per section 84 of the 2011 Act) the Charity Commission also 
has the power to close charity services, such as educational classes and 
recreational activities.  

9.  Specifically in a safeguarding context, the Charity Commission has a regulatory 
role focused on the conduct of trustees and steps taken to protect beneficiaries, 
employees, volunteers and others who come into contact with the charity through 
its work. As part of their legal duties, trustees of a charity must take reasonable 
steps to protect from harm people who come into contact with their charity. 

10. As set out in the Charity Commission’s ‘How to report a serious incident in your 
charity guidance’, failure by charity trustees to sufficiently manage safeguarding 

DRAFT 

6 

 
 
  
 
 
  
 
 
 risks or protect people adequately would be of serious regulatory concern and 
may be considered to be misconduct and/or mismanagement.  

11. As a registered charity (no. 306101) the Scout Association must comply with 

charity law and regulation. As stated above in the Divisions of Responsibility, the 
Charity Commission is independent, including having a statutory requirement that 
it is not subject to Ministerial direction in the exercise of its functions. As such, we 
would not and could not seek to direct their ongoing engagement with the Scout 
Association. We also understand that the Charity Commission has been 
engaging with the Scout Association since Ben’s tragic death in August 2018, 
following the Scout’s serious incident report. As such, it is right that they will also 
be providing an independent response to your report and we welcome their 
contribution. We believe that for many of the matters of concern listed, the Scout 
Association’s and club trustees’ compliance with their legal duties is pivotal. 

12. The Charity Commission’s Safeguarding and protecting people for charities and 

trustees guidance clearly sets out that it expects all charity trustees to make sure 
that their charity: 

a.  knows how to spot and handle concerns in a full and open manner 
b.  has a clear system of referring or reporting to relevant agencies as soon 

as concerns are suspected or identified 

c.  is quick to respond to concerns and carry out appropriate investigations 
d.  does not ignore harm or downplays failures 
e.  has a balanced trustee board and does not let one trustee dominate its 

work – trustees should work together 

f.  makes sure protecting people from harm is central to its culture 

13. We know that the Charity Commission does investigate safeguarding-related 

matters and ensures proper compliance with charity law as needed. The Charity 
Commission publicly announces the opening of statutory inquiries into charities 
carried out under section 46 of the Charities Act 2011. We would encourage all 
interested parties to review their record here - 
https://www.gov.uk/government/collections/inquiry-reports-charity-commission. 

14. We would also highlight the Charity Commission’s updated strategy, published in 
December 2017, for dealing with safeguarding issues in charities. This further 
outlined its regulatory role and approach in overseeing the legal duties of trustees 
in relation to safeguarding. In line with this strategy, we would expect the Charity 
Commission to use its powers to intervene where there are serious safeguarding 
concerns within a charity.  

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7 

 
 
  
 
 
 
 
  
 
 
 
 Other legislation and guidance relevant to settings such as the Scout 
Association  

15. As set out above in the Divisions of Responsibility, local authorities also have 

legal responsibilities for safeguarding and promoting the welfare of all children in 
their area. These include safeguarding and promoting the welfare of children in 
need in their area (section 17 of the Children Act 1989) and investigating where 
they have reasonable cause to suspect that a child has suffered, or is likely to 
suffer, significant harm (section 47 of the Children Act 1989).  

16. There are also several other areas of legislation which govern how the local 

authority should work with multi-agency partners and relevant agencies, such as 
charities like the Scout Association and its clubs, to ensure that children are 
safeguarded and protected from harm. This includes:  

a.  Section 10 of the Children Act 2004 which requires each local authority to 
make arrangements to promote cooperation between the authority and a 
range of other local “relevant partners” (such as the police, schools and 
health services) and such other persons or bodies exercising functions or 
engaged in activities relating to children and considered by the local 
authority to be appropriate with a view to improving the well-being of 
children in each local authority area so far as it relates to: (a) physical and 
mental health and emotional well-being, (b) protection from harm and 
neglect, (c) education, training and recreation, (d) the contribution made by 
them to society and (e) social and economic well-being. Such persons or 
bodies could conceivably include charities, such as the Scout Association 
and its local clubs. 

17. The Children Act 2004, as amended by the Children and Social Work Act 2017 

also introduced stronger multi-agency safeguarding arrangements. Local 
authorities, together with the local integrated care board, and local chief officer for 
the police – as the three statutory safeguarding partners – have a shared and 
equal statutory duty to make arrangements and work together to safeguard and 
promote the welfare of all children in their local area. The arrangements should 
set out how they will coordinate their safeguarding services in a local area; act as 
a strategic leadership group in supporting and engaging others, and implement 
local and national learning, including from serious child safeguarding incidents. 
This would include serious incidents such as the death of a child on an excursion.  

18. The purpose of these local arrangements is to support and enable organisations, 
charities (such as the Scout Association and its clubs) and agencies to work 
together in a system where children are safeguarded and their welfare promoted. 
The arrangements should set out how partner organisations, charities and 
agencies collaborate, share and co-own the vision for how to achieve improved 
outcomes for all vulnerable children. It is for the three safeguarding partners to 

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 determine how these organisations and agencies will hold one another to account 
effectively and ensure that they listen and respond to the views of local children 
and their families. The safeguarding partners must publish a report at least once 
in every 12-month period which should set out how effective their arrangements 
have been in practice. 

19. As set out in the Children Act 2004, these safeguarding arrangements also place 

a duty on “relevant agencies” to cooperate if asked to be part of local 
safeguarding arrangements; and where named they would have a statutory duty 
to comply with the arrangements. The Relevant Agencies are specified in the 
Child Safeguarding Practice Review and Relevant Agency (England) Regulations 
2018 and includes charities within the meaning of Section 1 of the Charities Act 
2011 – this would cover charities such as the Scout Association and its local 
clubs.  

20. In addition to this, we also expect local authorities to work with a range of multi-
agency partners (such as, but not limited to the Police, Charity Commission and 
the Health and Safety Executive) to intervene in settings of concern, which might 
be exposing children to, or placing them at risk of harm. Across these partners, 
there are several powers under which action can be taken, which we detail in our 
advice for unregistered schools and Out-of-School Settings - Collaborative 
working between the Department for Education, Ofsted and local authorities. 

21. Beyond the role and powers of local authorities and multi-agency partners, all 

Out-of-School Settings also have a common law duty of care to protect the safety 
and welfare of children, and therefore must by law take reasonable steps to 
ensure the safety of children in their care and protect them from harm. It is also 
relevant to note that these settings are also subject to the Safeguarding 
Vulnerable Groups Act 2006 which makes it an offence to knowingly employ 
someone in 'regulated activity ' if the employer has reason to believe they are 
barred from working with children. We have published dedicated guidance to 
support them in meeting these duties.  

22. Similarly, the Scout Association is part of the Youth Sector, where substantial 

guidance and training has been provided by the National Youth Agency (NYA), 
funded by the Department for Culture Media and Sport. 

Further measures to strengthen safeguarding within the sector 
23. The Government is committed to ensuring all settings, including Out-of-School 
Settings and charities such as Scout clubs, are as safe as possible and have 
been progressing a programme of safeguarding work with this aim in mind. 

24. Recent work on Out-of-School safeguarding has included: 

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 a.  Provision of over £3 million funding to selected local authorities, between 

2018 to end of 2021, to run a series of multi-agency pilots aimed at 
boosting local capacity to identify and intervene in settings of concern; and 
building the evidence based on the extent of risks in the sector, and the 
utility of relevant agencies’ existing legal powers to conduct safeguarding 
activity in these settings. Despite the pandemic disrupting many settings, 
the outputs from this work (an independent evaluation report published 
November 2022) can still be used to help inform the need for, and 
development of, any national approaches to further strengthen 
safeguarding and oversight. 

b.  Dedicated workstreams to support the sector’s understanding of how to 

run a safe setting, and their wider understanding of expected safeguarding 
standards (through the development of a safeguarding code of practice)  

c.  Development of parental safeguarding guidance on Out-of-School 

Settings, to help parents both make informed choices when seeking safe 
settings for their children, and to know what to do if they do have 
concerns.  

d.  An ongoing review of existing guidance for local authorities and multi-

agency partners on safeguarding in Out-of-School Settings, to share best 
practice from the pilots, and to ensure local authorities are fully utilising 
both theirs and multi-agency partners’ powers to identify and intervene in 
settings of concern.  

25. We have also maintained an ongoing dialogue with sector representatives and 
safeguarding partners on safeguarding in Out-of-School Settings using this to 
inform ongoing reviews and updates to existing guidance. Following the 
conclusion of the pilot programme and culminating evaluation report, we have 
also been working closely with these stakeholders on the development of 
potential options for further enhancing safeguarding and oversight, to help inform 
our upcoming Call for Evidence.  

Existing Work on Regulatory Models 

26. In addition, and at times as part of, the programmes above, we have continually 
considered and assessed the case for further regulation, and practicalities of any 
future system. 

27. Specifically, in November 2015, we consulted on a proposed model of regulation 
for Out-of-School Settings, based on registration and risk-based inspection4. 
However, the strong negative feedback received from respondents, including that 
the proposed model risked placing unnecessary burdens on the many settings 
already providing enriching education and activities in a safe environment, 

4 This was published in 2015, with a Government response in 2018. 

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10 

 
 
  
 
 
 
 
 
 
 limiting parents’ choices on how they educate their children, as well as 
suggestions that existing legal powers were sufficient to intervene and take action 
in Out-of-School Settings of concern.  

a.  This included the wide range of legal powers held by the Charity 

Commission, as referenced above. In particular their powers to intervene 
where Trustees are not complying with their safeguarding duties. 

28. The Government took the decision not to proceed with the proposed model of 
regulation, and to instead progress an alternative package of safeguarding 
measures aimed at enhancing safeguarding of children in this diverse sector.  

29. While we have not ruled out further regulation of the sector, it is imperative that 
any system of regulation is proportionate, complements, and builds on existing 
legal powers. 

30. As part of our ongoing work to ensure these settings are as safe as possible, we 

have therefore been working closely with safeguarding partners, sector 
representatives, and parent groups on the development of potential options for 
further enhancing safety of the out-of-school settings sector, with the intention of 
launching a call for evidence this summer. 

Wider Work across Government sector 

31. Government also funds the NYA to provide generic safeguarding resources 
available to domestic charities, and to renew the youth work curriculum and 
qualifications, including updated safeguarding training tailored specifically 
towards the youth work sector. 

32. In 2018-2020 DCMS partnered with the charity sector on a Charity Safeguarding 
Programme to drive activity through a comprehensive cross-sector programme of 
projects.  

33. The programme focussed on improving the generic guidance and support 

available to all charities whatever their size or sector of interest to ensure that 
basic standards were clearly set and communicated, including to:  

a.  Provide charities with clear, consistent and easily accessible guidance and 

reporting processes 

b.  Create the right culture in charities as the foundation for effective handling 
of safeguarding incidents, promoting strong leadership and challenging 
poor practice to change behaviour 

c.  Provide digital solutions giving simple and accessible ways for anyone to 

report a concern to the right person at the right time 

d.  Provide access to training, support and advice in one place that is free, 

accessible and sets a basic standard.  

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11 

 
 
  
 
 
 
 
 
 
 
 
 34. A fuller overview of our historical and ongoing work with the sector, and actions to 

improve standards, is set out in Annex A. 

Request for a Public Inquiry 

35. We recognise the specific call to action within the report and families’ public 
statements – seeking a public inquiry – and share that desire for improved 
standards to come from Ben’s tragic death. Whilst a public inquiry could help 
draw out unacceptable safeguarding practices and the impact on those affected, 
we believe it would not be the best route to meaningful change. 

36. Our planned Call for Evidence, expected to launch this summer, would better 

serve any need to address systemic safeguarding or safety issues in the sector, 
and progress options for effective and proportionate safeguarding reform.  

a.  Given our commitment to ensure these settings are as safe as possible, 
we are keen to seek the widest possible range of views, as swiftly as 
possible, regarding options for strengthening safeguarding and oversight 
of the sector. 

b.  However, any inquiry would likely be of a significant length and cost, with 
legislative requirements (and so probable further delays) if on a statutory 
basis. This may also delay or place resourcing pressures on ongoing work 
to evaluate and take forward any policy options for longer-term 
safeguarding reform.  

37. We will carefully consider this report as crucial to the development of our Call for 
Evidence, given the many helpful insights into where further measures may be 
needed. We strongly encourage yourself and all interested parties to contribute to 
this upon launch. Ben’s tragic death has redoubled the Government’s 
commitment to improving safeguarding standards in Out-of-School Settings.  

Specific matters of concern 

38. As referenced above, we cannot comment on the internal workings and structure 

of the Scout Association, or their implementation of internal policies and 
procedures. However, we have tried within Annex B and C, to address each 
matter of concern identified in your report. We hope this clearly sets out the 
current government position and guidance on these important issues. We would 
be very happy to discuss any particular issue further as and if needed. 

39. We will also be giving consideration, as part of our regular review and 

refreshment of DfE guidance, to any points which could be strengthened further 
in light of your report, or where we could seek to further improve signposting to 

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12 

 
 
  
 
 
 
 
 
 
 
 
 
 wider legislation or other government guidance relevant to the matters of concern 
identified.  

40. Finally, we would again thank you for giving us the opportunity to respond and 

express our condolences to the family and friends of Ben Leonard.  

Yours sincerely, 

David Johnston OBE MP 
Minister for Children, Families and Wellbeing 

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13 

 
 
  
 
 
 
 
 
 
 
 
 
 ANNEX A: Department for Education’s Historical and Ongoing Action on Out-
of-School Settings 

1.  In November 2015, the DfE published a Call for Evidence concerning specific 

proposals to introduce a new regulatory system of registration and inspection in 
Out-of-School Settings. This would have required Out-of-School Settings 
providing ‘intensive education’5, to register with their local authority and be 
subject to risk-based inspections by Ofsted. It would also have enabled 
intervention and sanctions (e.g. barring individuals from working with children, or 
closure of premises), as appropriate where settings were found to be undertaking 
‘prohibited activities’6.  

2.  We received significant interest with over 18,000 responses, three-quarters of 

which were opposed to proposals exploring a mandatory registration system and 
sector regulation. Concerns included: fears of potential impact on religious 
freedoms, the significant burden on smaller and voluntary-run providers, a lack of 
consensus and clarity about the level for a prospective threshold for mandatory 
registration, and a belief that existing safeguarding legislation was sufficient.  

3.  Therefore, the Government response (published April 2018) confirmed our 

intention not to pursue the model proposed, but instead build the evidence base 
for a national approach, whilst taking forward a significant package of measures 
aimed at enhancing the safeguarding of children in this diverse sector.  

4.  This package included the development of a new safeguarding code of practice 
for Out-of-School Settings, published in October 2020; and the provision of over 
£3 million of targeted funding to selected local authorities, between Autumn 2018 
and December 2021, aimed at building local capacity to identify and tackle 
settings of concern. The intention of these pilots was to test: 

a.  different approaches to multi-agency working to support safeguarding 

practices in Out-of-School Settings; and 

b.  the utility of existing legal powers held by local authorities and held by 

relevant agencies (such as the Police, local Fire and Rescue Services, the 
Charity Commission for England and Wales, and Ofsted) to identify and 
intervene in settings of concern.  

5.  These multi-agency pilots were subject to an independent evaluation, the 

outcome of which was an independent report (published November 2022). This 
report demonstrated the benefits of improved multi-agency working between local 

5 The call for evidence suggested a threshold could be set around 6-8 hours per week. Though some 
respondents highlighted that the nature of the activity should also be considered. 
6 The prohibited activities were focused around areas designed to keep children safe and promote their 
welfare, such as: failure to adequately ensure the safety of the children in their care, including accommodating 
children in unsafe premises; appointment of unsuitable staff; undesirable teaching; and corporal punishment). 

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14 

 
 
  
 
 
 
 
 
 
 
 authorities and relevant agencies, including community-based organisations such 
as charities, and how existing legal powers can be best used alongside 
community engagement and outreach to address safeguarding concerns. 
However, it further identified important safeguarding risks in some settings.   

6.  In recognition of the seriousness of those risks, the department committed to 
taking forward further safeguarding activity and interventions aimed at raising 
safeguarding standards in these settings in both the immediate and longer-term.  

7.  Immediate measures to tackle these issues have included:  

a.  As referenced above, the publication of guidance for providers and 

guidance for parents and carers in October 2020, with a major update in 
September 2023. This set out the safeguarding standards providers are 
expected to meet, supported them to fulfil their duty of care and helped 
parents make informed choices when choosing settings for their children. 
b.  An accompanying, free-to-access e-learning package, will shortly launch 
which complements the guidance and helps make it accessible for all 
providers. 

c.  An ongoing review of existing guidance for local authorities on 

safeguarding in Out-of-School Settings. This will help ensure they are fully 
utilising their existing legal powers (e.g. child protection legislation, health 
and safety, etc.) alongside those of multi-agency partners (e.g. the Police, 
Ofsted, Fire and Rescue, etc.), to identify and intervene in settings of 
concern. 

d.  Extensive and continuous engagement with key stakeholders across the 
sector to discuss, refine and spread safeguarding best practice. This has 
included engagement through our dedicated departmental steering groups 
with representatives from the Out-of-School Settings sector, local 
authorities and other safeguarding partners. 

8.  Alongside this, the department has been working closely with sector 

representatives, safeguarding partners and parents on the development of 
potential longer-term options to ensure these settings are as safe as possible, 
and parents feel confident that they are sending their children to safe settings.  

9.  This engagement has reinforced our understanding that there is not a single, 
simple solution for improving standards in the sector. However, alongside 
previous research with parental focus groups, it does strongly suggest that further 
parental engagement is vital to any solution. As such, the upcoming Call for 
Evidence will seek to understand parents’ and provider’s safeguarding priorities, 
tested against a range of prospective long-term options for improving sector 
standards.  

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15 

 
 
  
 
 
 
 
 
 
 10. It will seek views from parents, carers, providers, local authorities, safeguarding 

partners and other interested individuals and organisations on existing 
expectations for safeguarding standards in Out-of-School Settings, as well as 
potential options for strengthening safeguarding further. We aim to learn more 
about how respondents currently assure themselves, or provide assurances, as 
to a setting’s safety; any challenges to doing so; and what further support or 
action may be needed to make these settings as safe as possible. We will further 
utilise focus groups to enhance parental engagement and gain deeper insight into 
parents' roles in checking settings for their children. 

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16 

 
 
  
 
 
 
 ANNEX B: Relevant Guidance from Government and Government Partners 

1.  This annex aims to highlight key guidance from Government and trusted 

safeguarding partners, broadly relevant to the issues raised. The examples below 
do not constitute an exhaustive list, nor cover every example used in Annex C 
below. However, they are intended to demonstrate the extensive support 
available to help those who seek advice for best practice in safeguarding and 
safety. 

Department for Education Guidance 
2.  The Department provides guidance to support Out-of-School Settings in their 

discharging their legal duty of care to ensure the safety of children attending their 
settings and protect them from harm.  

a.  First published in October 2020, the safeguarding guidance for providers 
and accompanying guidance for parents have recently been updated in 
September 2023 to reflect key changes to legislation and statutory 
guidance, as well as learnings from the Out-of-School Settings multi-
agency pilot programme.  

b.  The guidance for parents is intended to help them make informed choices 
about settings they are choosing for their children, and includes red flags 
to look out for, as well as the steps they should take where they have 
concerns. 

c.  The guidance for providers will also be accompanied by a free-to-access 
e-learning package, shortly due to launch, to help make the guidance 
accessible for all providers and support their understanding of 
safeguarding obligations, and the standards they would be expected to 
meet. 

3.  Beyond this, the Out-of-School Settings guidance also references relevant 

resources such as Keeping Children Safe in Education, Health and Safety on 
Educational Visits, (both of which are statutory guidance for schools and 
colleges) and statutory guidance Working Together to Safeguard Children.  

4.  In particular, the Working Together to Safeguard Children statutory guidance, 

revised in December 2023, clarifies the roles and responsibilities of safeguarding 
partners (police, health, and local authorities) and relevant agencies. 

a.  It sets out the legislative requirements which apply to individuals, 

organisations, and agencies, as well as a framework for safeguarding 
partners and relevant agencies to work together in their local area. 
b.  In relation to voluntary, charity or social enterprise (VCSE) organisation 
(which would include Out-of-School Settings), and so also the Scout 
Association, the guidance recommends that these organisations should be 
aware of and comply with the published arrangements set out by the local 
safeguarding partners policies in place to safeguard and protect children 
from harm, as well as systems to ensure compliance. 

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 Department for Culture Media and Sport Charity Safeguarding Programme 
5.  Through the Charity Safeguarding Programme (2018-2020) DCMS supported 

and worked with the Commission to provide clear, consistent and easily 
accessible guidance and reporting processes as follows: 

a.  Safeguarding and protecting people for charities and trustees 
b.  How to report a serious incident in your charity 
c.  Report serious wrongdoing at a charity as a worker or volunteer 

6.  DCMS funding also supported the National Council for Voluntary Organisations 
(NCVO) and a range of safeguarding expert charities to develop safeguarding 
help and guidance including access to training support. In partnership with the 
National Lottery Community Fund, a Safeguarding Training Fund, was launched 
in October 2019, which disseminated the training and guidance materials through 
charity networks across England.  

7.  DCMS guidance to help charities in England to handle the reporting of 

safeguarding issues in their charity was also published (please note, this is 
currently offline whilst it is being updated, but is expected to be back online in 
May). 

Cross-Government standards and requirements for funding  
8.  The Government Code of conduct for suppliers and grant recipients clearly sets 
out the behaviours expected of suppliers delivering services on behalf of, and 
grantees receiving funding from, the Government. This includes behaviours 
expected when interacting with vulnerable groups, such as children and young 
people. 

9.  DfE and the DCMS further build on this, by placing a priority on the importance of 
safeguarding and protecting the wellbeing of children and young people in any 
awarding of funding. We are committed to the active application of safeguarding 
policies and practices, throughout our supply chains. Therefore, our suppliers and 
grant recipients must meet minimum safeguarding standards and comply with 
relevant guidance, as a condition of our funding.  

a.  Grantees must confirm and provide evidence: 

i. 

ii. 

that the organisation provides a safe and trusted environment which 
safeguards anyone who the organisation has contact with, including 
customers, service users, staff and volunteers;  
that the organisational culture prioritises safeguarding, so that it is safe 
for those affected to come forward, and to report incidents and 
concerns with the assurance that they will be handled sensitively and 
properly;  

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18 

 
 
  
 
 
 
 
 
 
 iii. 

iv. 

that the organisation has adequate governance structures, 
safeguarding policies, procedures and measures to protect people and 
these are shared and understood; and  
that the organisation has clear processes on how incidents and 
allegations will be handled should they arise, including reporting to the 
relevant authorities.   

10. As such, where any Out-of-School Setting has or will benefit from Government 
funding, they should be aware of the importance of, and need to, meet these 
requirements. As the Scout Association has previously been a recipient of 
Government grant funding and is currently receiving funding from DCMS, they 
should be aware of the above standards.  

The Charity Commission for England and Wales 
11. The Charities Act 2011 sets out the Charity Commission’s statutory duties and 
functions. It has an important regulatory role, with a range of powers to ensure 
that charity trustees comply with their legal duties and responsibilities in 
managing their charity. 

12. The Charity Commission published an updated strategy for dealing with 

safeguarding issues in charities in December 2017, outlining its regulatory role 
and approach, and the legal duties of trustees in relation to safeguarding.  

13. Further detail is available in the Charity Commission's published guidance on 
Safeguarding and protecting people for charities and trustees, which covers 
charity and trustees duties in this area, as well as NCVO Safeguarding 
Resources; and DCMS’s Guidance on handling safeguarding concerns or 
allegations in a charity (again, please note this is currently offline and due to be 
live in May 2024, as mentioned above). 

Youth Sector Guidance – The National Youth Agency (NYA) and Department for 
Culture, Media and Sport (DCMS) 
14. DCMS provide funding to the National Youth Agency, the national body for youth 
work, and the Professional Statutory Regulatory Body for youth work in England 
to ensure up-to-date, appropriate standards are in place for youth work. 
a.  DCMS currently provides NYA with funding to carry out their core 

functions: delivery of youth work qualifications, maintaining a youth work 
and youth services registry, and provision of safeguarding support. 

15. DCMS has further funded the NYA to develop their Safeguarding and Risk 

Management Hub, freely accessible via their website, and promoted via NYA’s 
social media, Youth Work One, and during face to face and online events. This 
helps to promote good practice across the youth sector by providing safeguarding 
guidance, support, advice, and access to training resources. 

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 a.  Through DCMS funding, the NYA has appointed an external risk 

management specialist: Pharos, which supports the creation of resources 
hosted on the hub. 

b.  The NYA run trainings at a discounted rate to the sector – bespoke to 
youth work delivery (i.e. Risk Assessments for the Youth Sector and 
Offsite Safety Management). The Risk Assessment training supports 
workers who are responsible for either writing risk assessments or 
approving those written by colleagues or perhaps external providers they 
work with.  

Wider Relevant Guidance 
16. Finally, it is also worth noting that the Department for Health and Social Care and 

the DfE jointly published the ‘Child Death Review Statutory and Operational 
Guidance for England’ in October 2019, advising NHS Trusts on how they should 
support, communicate and engage with families following the death of someone 
in their care.  

a.  This is not targeted at, nor compulsory for, Out-of-School Settings such as 
the Scout Association. However, it may still be useful to reference and 
consider for best practice in a similar circumstance. 

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20 

 
 
  
 
 
 
 
 ANNEX C – Examples of Guidance Specifically Relevant to Concerns Raised 

1.  This annex aims to highlight exemplar guidance from Government and trusted 
safeguarding partners, directly relevant to the specific issues raised. Whilst the 
examples do not constitute a comprehensive response or solution to the 
concerns raised, they do demonstrate the extensive support available to help 
those who seek best practice advice in safeguarding and safety. 

2.  Beyond these examples, there are also resources within guidance, which may 

also prove useful, but are not easily quotable here. 

a.  For example, the DfE guidance for Out-of-School Settings providers also 

points to a checklist document, covering minimum safeguarding 
arrangements that all providers should have in place, to ensure the safety 
of children and protect them from harm. It specifically covers best practice 
on safeguarding and child protection, suitability of staff and volunteers, 
health and safety, governance, as well as other areas for consideration, 
such as educational visits and overnight stays. 

The culture of candour and independent inspection – DfE, Charity Commission 
and internal commercial guidance for Government which sets out responsibilities for 
candour, oversight and reporting incidents. 

3.  In its guidance on safeguarding and protecting people for charities and trustees 
the Charity Commission expects all charity trustees to ensure that their charity: 
a.  knows how to spot and handle concerns in a full and open manner 
b.  has a clear system of referring or reporting to relevant agencies as soon 

as concerns are suspected or identified 

c.  is quick to respond to concerns and carry out appropriate investigations 
d.  does not ignore harm or downplays failures 
e.  has a balanced trustee board and does not let one trustee dominate its 

work – trustees should work together 

f.  makes sure protecting people from harm is central to its culture 

4.  Page 128 DfE Working together guidance – Working Together notes that VCSE 
organisations (which cover Out-of-School Settings) may be subject to charity law 
and regulated either by the Charity Commission and/or other ‘principal’ 
regulators. Charity trustees are responsible for ensuring that those benefiting 
from, or working with, their charity, are not harmed in any way through contact 
with it.  

5.  Page 145 DfE Working together guidance – sets out the framework for local 

responsible bodies regarding making arrangements to review child deaths. ‘When 
a child dies, in any circumstances, it is important for parents and families to 
understand what has happened and whether there are any lessons to be learnt. 
The responsibility for ensuring child death reviews are carried out is held by ‘child 

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 death review partners’, who, in relation to a local authority area in England, are 
defined as the local authority for that area and any integrated care boards 
operating in the local authority area.’ 

Fatal Accident Inquiry Panel Investigation Report (FAIP) – Health and Safety 
Executive (HSE), DfE, Department of Health and Social Care (DHSC) and NYA 
guidance covering reporting duties, best practice when making reports and during 
reviews/inquiries, as well as wider advice for critical incidents.  

6.  Amongst wider information and guidance available on their website, the Health 

and Safety Executive Guidance on Reporting of Injuries, Diseases and 
Dangerous Occurrences Regulations (RIDDOR 2013) states – ‘Fatal accidents 
arising out of, or in connection with, work requiring reporting under RIDDOR. The 
requirement to report fatal accidents to persons not at work (children, members of 
the public, etc) is the responsibility of the person who for the purpose of a work-
related activity was in control of the premises where the accident happened.’ 

7.  Page 27 Child Death Review Guidance - makes it clear that the family should be 
assigned a key worker to act as a single point of contact for the bereaved family, 
who they can turn to for information and who can signpost them to sources of 
support.  It is the duty of the key worker to ensure that there is clarity regarding 
information and support.  

8.  Page 38 Child Death Review Guidance - makes it clear that the family of the child 
should be given the opportunity to raise concerns about the care that their child 
received. These concerns should be picked up and addressed at the local review 
meeting, with feedback provided to the family by their key worker. 

9.  Page 2 NYA Incident Reporting guidance – ‘It is good practice to report all near 
misses as well as all accidents that result in harm… Reporting helps to identify 
problem areas, raises awareness of hazards and risk, and helps organisations 
and workers to make informed decisions and take effective preventive or 
corrective actions to help prevent similar or more serious incidents from 
reoccurring… Incident reporting practice should promote a culture of thorough, 
timely and accurate reporting, and must ensure that relevant workers are 
adequately trained in the incident reporting procedure defined by the 
organisation. Most organisations produce an incident report template for workers 
and copies of this should be provided to workers who are delivering offsite 
activity.’  

10. Page 2 NYA Incident Reporting guidance - When reporting incidents, only factual 
information should be provided, including as much detail about the incident as 
possible. Workers should make an accurate record of the incident as soon as 
possible to help safeguard against memory fade. Workers should complete their 

DRAFT 

22 

 
 
  
 
 
  
 
 
 
 
 organisation’s incident reporting form, or if not immediately available make notes 
to report formally later. The following information should be recorded as 
applicable: 

a.  Time and date of the incident 
b.  Incident location (be as accurate as possible) 
c.  A detailed description of what happened 
d.  Who was involved and details of any injuries 
e.  Names of any other uninjured parties 
f.  Relevant environmental information (e.g. weather, ground/water 

conditions) 

g.  Actions taken, including all communications 
h.  Details of any moves from the incident site (times, who moved, where to, 

how) 

i.  Names and contact details of witnesses 
j.  Any other useful information such as the registration numbers of any motor 

vehicles involved 

k.  Proposed actions to follow 

11. Page 7 NYA Critical incident response guidance - ‘All incidents should be 

reported and organisations should have a robust system in place to promote a 
culture of reporting and incident review. Following a critical incident, a full 
review/investigation should be undertaken to establish the cause(s) and the full 
facts surrounding the incident. A robust process to identify all lessons learned 
and ensure practical application into future practice should be implemented…’ 

Safety training – DfE, Charity Commission and NYA guidance offering best 
practice, examples of training, a suitable approach to risk assessments and wider 
safety advice. 

12. Page 35 DfE guidance for providers – A competent person should ‘differentiate 
between regular activities and special events, (including trips) which will need a 
case-by-case risk assessment.’ 

13. The Charity Commission sets out guidance for Trustees on how to Manage the 

Risk – ‘expect all trustees to make sure that their charity: 

a.  sets out identified risks and how they will be managed in a risk register 

which is regularly reviewed’ 

14. Page 2 NYA Critical Incident Response guidance - ‘Critical incident response 
should be considered for all youth work activities, programmes and services – 
response procedures should be written down and effectively communicated to all 
workers… Young people should be aware of key elements of procedures such as 
how to contact workers or raise the alarm’. 

DRAFT 

23 

 
 
  
 
 
 
 
 
 
 
 15. Page 3 NYA Critical Incident Response guidance - As part of effective planning 
for any youth work programme, a clear plan should be established which takes 
into account both routine and emergency communications… In the event of a 
critical incident, organisations must ensure that an effective communications 
system is in place that will allow the organisation to reliably and swiftly establish 
and maintain contact with:  

a.  group(s) directly affected by the incident  
b.  Duty Officer  
c.  Critical Incident Response Team colleagues  
d.  Senior management   
e.  external agencies and support as may be required  
f.  other stakeholders 

16. Page 7 NYA Critical Incident Response guidance - ‘Following a critical incident… 
Relevant workers must receive appropriate briefing and training relevant to their 
role and understand the procedures and actions they should follow in an 
emergency’. 

17. Page 2 NYA Group Management Good Practice guidance - ‘Youth organisation 

workers should also ensure that each young person under their care:  

a.  Knows who their leader(s)/ workers are at any given time and how to 

contact them, and who else is in their group  

b.  Understands any instructions or briefings given to them 
c.  Understands the main risks involved in the activity, measures in place to 

manage them and how their own behaviour may affect these  

d.  Is able to alert a staff member if someone is missing or in difficulties 
e.  Has a clear understanding of any restrictions or parameters in place i.e. 

geographical boundaries; curfews or time limits; what they are/are not able 
to do with or without informing a staff member 
Is aware of any designated meeting place and any action they should take 
if they become lost or separated from the group’. 

f. 

18. Page 3 NYA Risk Assessment Process guidance - ‘Risk assessment should 
involve a logical process that involves prior consideration by individuals with 
suitable knowledge and competency in the proposed activity/settings and working 
with young people… Risk assessments should be in place for all venues (indoor 
and outdoor)’ 

19. Page 9 Risk Assessment Process NYA guidance - ‘Risk assessments should be 
written down i.e. be ‘recorded’... Risk assessment documents should specify:  
a.  The programme, activity or venue to which the assessment pertains  
b.  The hazards/risks that reasonable to foresee 
c.  The associated control measures against each hazard/risk 
d.  Date of the assessment 

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24 

 
 
  
 
 
 
 
 
 e.  Who carried out the assessment 

20. Page 10 NYA Risk Assessment Process guidance - ‘Organisations should make 
risk assessments available to all workers as applicable and support them to 
understand the contents and their associated responsibilities. Workers should as 
a minimum be briefed on the risk assessment(s) and any key controls in place, 
particularly those that rely on the action of workers to be properly implemented.’ 

21. Page 2 NYA Safety Briefings guidance - ‘It is good practice for all workers, 

particularly those working directly with young people, to receive a structured 
briefing at the beginning of any programme and/or after any significant change. 
This briefing should include a summary of the risk assessment, identifying key 
hazards and any key control measures that apply to the forthcoming activity… It 
is important that young people are also provided with a structured briefing at the 
beginning of any programme and after any significant change.’ 

22. Page 2 Weather NYA guidance - ‘Youth work organisations should consider the 

potential effects of adverse weather when planning youth sector programmes and 
activities. This is particularly important for any plans involving outdoor activity’. 

Restricted Duties – NYA guidance concerning how restrictions might be raised, 
placed against staff members, and resolved. 

23. Page 2 NYA guidance on allegations against staff and volunteers  - ‘Any 

allegation or concern that an employee or volunteer has behaved or may have 
behaved in a way that has hurt/harmed, or potentially harmed, a child or young 
person, must be taken seriously and dealt with sensitively and promptly, 
regardless of where the alleged incident took place… Any allegation against a 
member of staff must be reported within 24 hours to the County LADO Service, 
by the DSL including a dated and timed note of what has been disclosed or 
noticed, said or done. This referral will determine whether allegation reaches the 
harm threshold to justify involvement from a LADO in the management of the 
allegation… Depending on the outcome of the LADO referral, appropriate next 
steps may involve: 

a. The police investigating a possible criminal offence. 
b. Your local child protection services making enquiries and/or assessing 
Whether a child is in need of support. 
c. your organisation following the relevant disciplinary procedures with 
individuals concerned.’ 

24. Page 3 NYA guidance on allegations against staff and volunteers  - ‘Should the 
outcome of the allegation against the member of staff determine that harm has 
been caused, the organisation will follow their own internal procedures of 
disciplinary, investigation and/or hearing… the member of staff could be asked to 

DRAFT 

25 

 
 
  
 
 
 
  
 
 
 
 undertake further training, or ultimately be dismissed. Referral to the DBS must 
be made if a person in regulated activity has been dismissed or removed due to 
safeguarding concerns.’ 

Absence of Safeguarding and Safety compliance – DfE, Charity Commission, 
NYA and OEAP7 guidance on the importance of safety and safeguarding training, 
overnight stays, DBS checks and over 18s interacting with children. 

25. Page 32 DfE guidance for providers – ‘You should regularly monitor and review 
staff members and volunteers. This is to ensure they continue to be well suited 
and have the necessary skills and training to carry out their role and 
responsibilities. It should include ensuring staff have appropriate training on 
health and safety and child protection. Ideally, you should have physical proof of 
the training that has been undertaken (for example, copies of certificates).’ 

26. Page 35 DfE guidance for providers – ‘Providers with 5 or more staff must… have 

a written health and safety policy, including a risk assessment section.’ 

27. Page 51 DfE guidance for providers – ‘Educational visits or overnight stays are 
subject to risk assessments. Your risk assessments should include reasonable 
steps you’ll take to ensure the children in your care are safe…’.  
This guidance also signposts the DfE guidance on educational visits which 
covers health and safety on educational visits in more detail. 

28. Page 78 DfE KCSIE guidance (referenced for OOSS as good practice to note, if 

not compulsory) – states that you should ‘undertake a written risk assessment’ for 
volunteers and should consider: 

a.  ‘the nature of the work with children, especially if it will constitute regulated 

activity, including the level of supervision 

b.  what the establishment knows about the volunteer, including formal or 
informal information offered by staff, parents and other volunteers 
c.  whether the volunteer has other employment or undertakes voluntary 

activities where referees can advise on their suitability 

d.  whether the role is eligible for a DBS check, and if it is, the level of the 

check, for volunteer roles that are not in regulated activity.’ 

29. Page 129 DfE Working Together to Safeguard Children – ‘Individual practitioners, 
whether paid or volunteer, should be aware of their responsibilities for, and how 
they should respond to, child protection concerns. They should also know how to 

7The Outdoor Education Advisers’ Panel offers guidance, advice and training related to outdoor learning and 
educational visits in England and Wales. They are referenced in DfE guidance as an additional resource for 
guidance for the management of outdoor learning, educational visits, and adventurous activities.  

DRAFT 

26 

 
 
  
 
 
 
 
 
 
 
 
 make a referral to a local authority children’s social care or the police, if 
necessary.’ 

30. As flagged in the main response, the Safeguarding and protecting people for 

charities and trustees guidance from the Charity Commission expects all charity 
trustees to ensure that their charity: 

a.  has appropriate policies and procedures in place, which are followed by all 

trustees, volunteers and beneficiaries 

b.  has enough resources, including trained staff/volunteers/trustees for 

safeguarding and protecting people 

c.  conducts periodic reviews of safeguarding policies, procedures and 

practice 

d.  follows statutory guidance, good practice guidance and legislation relevant 

to their charity: this guidance links to the main sources of information 

31. Page 2 NYA Workforce information guidance  - ‘All workers, including volunteers 

need to be trained in matters of health and safety relevant to their role… 
Organisations must ensure that workers have understood the relevant 
information, how it affects them and their associated responsibilities…’ 

32. Page 3 NYA Worker competency guidance - ‘Workers’ training needs should be 
reviewed periodically and key training requirements should be repeated at a 
frequency identified by their employer.’ 

33. Page 6 NYA Safeguarding for youth work guidance - ‘…ensure that an 
assessment is made, specific to the programme to ascertain staffing 
requirements, which will enable effective supervision of young people and 
effectively manage the associated risks.’ 

34. Page 4 of the Activity Leader responsibilities, available to download from OEAP 

guidance webpage, provides an outline of Activity Leader responsibilities (below) 
and an additional checklist for Visit and Activity leaders; 

a.  ‘Be aware of the activity location and any specific hazards at it; of relevant 

information about the participants (e.g., age, health information, 
capabilities, special needs, safeguarding and behavioural issues); of 
emergency procedures (including how to access participants’ emergency 
contact details and medical consent etc.) 

b.  Assess the risks involved in the activities you will lead, and ensure that 

they are planned to appropriately balance benefits and risks… 
c.  Follow the advice in the OEAP National Guidance documents about 

specific types of activity and hazard that are relevant to the activities you 
will lead 

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27 

 
 
  
 
 
 
 
 
 
 d.  Ensure that you are clear about which participants you are responsible for 
at any particular time, and that there is a clear handover to and from other 
leaders 

e.  Carry a list of all participants, and conduct regular headcounts 
f.  Have an alternative plan (a ‘Plan B’) in case the activity needs to be 

changed 

g.  Have the means to contact the Visit Leader or other leaders, or to call for 

help in an emergency’ 

35. Page 1-2 of the Adult Participants guidance, available to download from OEAP 

guidance webpage, provides information on groups with both Adult and Younger 
Participants:  

a.  You could ask the adults to agree to the same code of conduct as under-
18s. It should be made clear whether such a code of conduct applies 
throughout the visit, including during any ‘free time’ such as evenings 
during a residential visit. 

b.  It is not necessary, and not legally allowed, to obtain a DBS check on 
adults who are simply participating in a visit alongside under-18s. Any 
safeguarding concerns should be addressed through supervision.  

c.  However, if any such adult participants have a role that places them in a 

position of trust, such as being a voluntary helper or supervisor, then they 
should be subject to appropriate vetting. If this role involves ‘regulated 
activity’, then a DBS check will be required unless they are themselves 
under supervision. 

Monitoring, Auditing and Reliance on Volunteer Line and the need for paid 
trainers, and Delays in training – HSE guidance outlines monitoring and review 
procedures for training programmes. 

36. HSE Health and Safety training guidance – ‘Employers must ensure that all 

employees are provided with adequate health and safety training when they start 
work. Monitoring and review procedures can help highlight when training is 
required. Ongoing training must also be provided in response to changes, such 
as: 

a. meeting the needs of new students 
b. the identification of additional risks 
c. a change in the needs of existing students leading to a change in the way 
that risks arising from their needs are managed’. 

First aid provision and training – DFE, HSE, OEAP and NYA guidance outlines 
recommended first aid training and requirements for trained staff. 

37. Page 10 DfE guidance for providers – ‘You should have first aid training and a 
first aid kit to hand as well as awareness of what to do in an emergency…’  

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28 

 
 
  
 
 
 
 
 
 
 38. Page 34 DfE guidance for providers – You should have ‘…at least one staff 

member who has first aid training’ 

39. Health and Safety Executive Guidance on First Aid at Work – The First Aid 

Regulations do not place a legal duty on employers to make a first-aid provision 
for non-employees such as the public or children in schools (i.e. not a legal 
requirement for volunteer Scout leaders and Scouts).  However, HSE strongly 
recommends that non-employees are included in an assessment of first-aid 
needs and that provision is made for them. 

40. Page 2 NYA First aid provision guidance - ‘Higher risk settings, activities or the 
likelihood of complex participant needs may result in the requirement for an 
increased level of training’. 

41. Page 5 of the Activity Leader guidance, available to download from the OEAP 

guidance webpage – Activity leaders should ‘have access to a first aid kit, and be 
trained in first aid or know how you can get immediate help if necessary.’ 

Autonomous Charities – DfE guidance on the responsible safeguarding lead, 
applicable at all levels of any organisation, alongside guidance concerning 
responsibilities of trustees overseeing charities. 

42. Page 14 DfE guidance for providers – ‘Detailed information on a DSL’s duties 
and relevant training is provided in DfE Keeping children safe in education 
(KCSIE), under Part two: The management of safeguarding. Although KCSIE is 
the statutory safeguarding guidance for schools and colleges, we signpost to it, 
as it may also be useful for Out-of-School Settings as ‘best practice’.’ 

43. Page 7 DfE KCSIE guidance – states that ‘the designated safeguarding lead (and 
any deputies) are most likely to have a complete safeguarding picture and be the 
most appropriate person to advise on the response to safeguarding concerns’ 

44. Page 163 DfE KCSIE guidance Annex C – offers further guidance on the role of 

the DSL in the context of schools and colleges, which we reference as an 
example of good practice for Out-of-School Settings, such as the Scout 
Association. 

45. As flagged in the main response, page 128 DfE Working together guidance – 
Working Together notes that VCSE organisations (which cover Out-of-School 
Settings) may be subject to charity law and regulated either by the Charity 
Commission and/or other ‘principal’ regulators. Charity trustees are responsible 
for ensuring that those benefiting from, or working with, their charity, are not 

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 harmed in any way through contact with it. The Charity Commission for England 
and Wales provides guidance on charity compliance which should be followed. 

46. Page 128 DfE Working together guidance – Working Together notes that VCSE 
organisations (which cover Out-of-School Settings) may be subject to charity law 
and regulated either by the Charity Commission and/or other ‘principal’ 
regulators. ‘Charity trustees are responsible for ensuring that those benefiting 
from, or working with, their charity, are not harmed in any way through contact 
with it. The Charity Commission for England and Wales provides guidance on 
charity compliance which should be followed.’ 

Permit and Licensing Schemes – DfE & OEAP guidance on ensuring suitability of 
staff and permits for activities. 

47. Page 24 DfE guidance for providers – ‘You should… regularly review the 

performance and suitability of staff and volunteers after their appointment’. 

48. Page 32 DfE guidance for providers – ‘You should regularly monitor and review 
staff members and volunteers. This is to ensure they continue to be well suited 
and have the necessary skills and training to carry out their role and 
responsibilities. It should include ensuring staff have appropriate training on 
health and safety and child protection. Ideally, you should have physical proof of 
the training that has been undertaken (for example, copies of certificates).’ 

49. Page 1-2 of the Adventure Activity Licensing guidance, available to download 

from OEAP guidance webpage – ‘The Activity Centres (Young Persons’ Safety) 
Act 1995 requires anyone who provides certain adventure activities to young 
people under the age of 18 in return for payment to have a licence and abide by 
its conditions. The Adventure Activity Licensing Regulations 2004 give full details 
about the providers and activities in scope of the licensing scheme. The licensing 
scheme is operated by the Adventure Activities Licensing Authority (AALA) and is 
an assurance that a provider meets safety standards. Trekking is affected by the 
scheme and is defined as: 

a.  Journeying on foot, horse or pedal cycle, or skiing, over terrain which is 
moorland or more than 600 metres above sea level; and from which it 
would take more than 30 minutes travelling time to reach any accessible 
road or refuge; This includes hill walking and mountaineering.’ 

DRAFT 

30

Mr David Pojur 

Assistant Coroner for North Wales (East and Central) 

Health and Safety 
Executive 

Chief Executive 

Redgrave Court 

Merseyside L20 7HS 

16 May 2024 

Dear Mr Pojur, 

Thank  you  for  sharing  a  copy of  your Regulation  28  report,  with  the  Health  & Safety 
Executive (HSE), following the inquest into the tragic death of Ben Leonard, in 2018, 
while on a scouting trip to North Wales. This was clearly a tragic incident and I would 
like to offer my condolences, and those of HSE, to Ben’s parents and family for their 
loss. 

In your report you have noted that, in your opinion, action should be taken to prevent 
future deaths. Whilst you have referred your report to a number of parties, you have 
raised two main areas of concern that appear to fall to HSE to address: that there is no 
independent or robust regulator who independently and proactively audits and inspects 
the Scout Association’s arrangements for adventurous activities and that these activities 
are otherwise exempt from regulation by the Health and Safety Executive (HSE). Whilst 
more detail is provided in this response, I would highlight here that, whilst it is true that 
the Scout Association is exempt from regulation by HSE’s Adventure Activities Licensing 
Authority, as are all voluntary associations providing services to their own members, it 
is  not  correct  that  this  equates  to  a  wider  exemption  from  all  HSE  regulation  and 
oversight. 

HSE  is  Britain’s  national  independent  regulator  for  workplace  health  and  safety.  We 
work  to  ensure  people  feel  safe  where  they  live,  where  they  work  and  in  their 
environment by providing worker protection and public assurance. 

I can confirm that the Scout Association, as a volunteering organisation with employees, 
is required to comply with workplace health and safety legislation and that their scouting 
activities are not exempt from regulation by HSE.  Under the Health and Safety at Work 
etc. Act 1974 (HSWA) and associated regulations the Scout Association has duties to 
protect their employees, and others, from risks arising from their work activities.  We 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
   
  
 have  powers  under  HSWA  to  enforce  those  duties  where  necessary,  including  by 
prosecution, as do our local authority co-regulators. 

With regard to the provision of scouting activities, Section 3 of HSWA places a duty on 
the Scout Association to conduct their undertaking in such a way as to ensure, so far as 
reasonably practicable, that persons not in their employment are not exposed to risks 
to  their  health  and  safety.    This  duty  includes  protecting  volunteers,  scouts,  and 
members of the public from risks that may arise from scouting activities.   

The Scout Association is furthermore required by the Management of Health and Safety 
Regulations 1999 to make a suitable and sufficient assessment of the risks to the health 
and safety of persons not in their employment arising out of or in connection with the 
conduct of their undertaking.  This is for the purpose of identifying the measures they 
need to take to comply with their statutory duties to protect others from harm.  They are 
also required to make appropriate arrangements for the effective planning, organisation, 
control, monitoring and review of the preventative and protective measures identified. 

As  referred  to  above,  HSE  is  also  the  licensing  authority  for  the Adventure Activities 
Licensing Regulations 2004.  These regulations require persons providing facilities for 
adventure  activities,  in  return  for  payment,  to  hold  a  licence  granted  by  HSE  in 
accordance  with  the  regulations.    Persons  are  not  required  to  hold  a  licence  where 
facilities are provided by a voluntary association to its members and on this basis the 
provision of licensable adventure activities to scouts by the Scout Association or scout 
groups is exempt from the regulations. 

The  Health  and  Safety  (First  Aid)  Regulations  1981  require  employers  to  make 
adequate and appropriate first aid arrangements for their employees but do not place a 
legal  duty  on  employers  to  make  first-aid  provision  for  non-employees  such  as 
volunteers or the public.  However, our guidance accompanying the regulations strongly 
recommends that non-employees are included in assessments of first aid needs and 
that provision is made for them. 

Enforcement of health and safety legislation is split between HSE and local authorities.  
Policy  responsibility  for  health  and  safety  regulation  rests  exclusively  with  HSE.  
Investigations into health and safety incidents involving scouting are allocated between 
HSE and local authorities according to the occupancy of a premises and the main work 
activity carried on there.  As Ben’s death took place at the Great Orme country park and 
nature reserve, which is managed by Conwy Council, HSE is the enforcing authority for 
any investigation under the Health and Safety at Work Act. 

Fatal  accidents  arising  out  of  or  in  connection  with  work  are  reportable  under  The 
Reporting  of  Injuries,  Diseases  and  Dangerous  Occurrences  Regulations  (RIDDOR) 
2013.    Where  accidents  involve  persons  not  at  work,  the  person  in  control  of  the 
premises where the incident took place is responsible for making the report.  In the case 
of  Ben’s  death,  Conwy  Council  would  have  been  responsible  for  submitting  a  report 

 under  RIDDOR  as  they  manage  the  Great  Orme  country  park.    Whilst  HSE  has  no 
record of a report being submitted in relation to Ben’s death, I understand that, at the 
time of its occurrence, your office contacted the local HSE office to inform them of the 
incident and was advised that Ben’s death fell to Conwy Council to investigate. This was 
not correct – please accept my apology for the fact that an incorrect response was given 
at that time. 

I have also been made aware that,  following the conclusion of the 2020 inquest, this 
mistake was perpetuated as HSE colleagues, having  identified Ben’s death as requiring 
investigation, incorrectly informed Conwy Council that they were the enforcing authority 
and not HSE.   

Our  investigation  Division  have  now  begun  an  investigation  into  Ben’s  death  in 
accordance  with  the  Work-related  Death  Protocol  to  determine  the  cause,  identify 
lessons  and  actions  needed  to  prevent  any  recurrence  and  take  appropriate 
enforcement action. I have asked the team to ensure the investigation is given priority, 
given the unacceptable delays that have already occurred.  

If supported by the findings of our investigations, we will also look at how we intervene 
generally with volunteering organisations that provide activities to young people such 
as the Scout Association to identify lessons for the future regulation of this sector.  

In addition, I am aware that prior to the inquest North Wales Police, at your request, 
sought  advice  from  HSE  on  the  application  of  health  and  safety  legislation  to  the 
circumstances of Ben’s death, and that the advice provided to North Wales Police was 
not consistent with the position set out above.  I apologise for any misunderstanding 
this may have caused and assure you that it had not been our intention to mislead the 
inquest. 

The error in not identifying, repeatedly, that this was a matter for HSE to investigate was 
clearly unacceptable and I would like to apologise to Ben’s parents and family that an 
investigation  has  not  been  undertaken  sooner.  HSE  will  undertake  an  appropriate 
review to identify how this error occurred, and to ensure that it is not repeated. We also 
will be writing directly to Ben’s family to offer them an apology. 

Yours sincerely 

Chief Executive

Gweinidog y Gymraeg ac Addysg  
Minister for Education and Welsh Language  

Ein cyf/Our ref 

David Pojur 
Assistant Coroner for North Wales (East and Central) 

18 March 2024 

Dear David Pojur, 

Thank you for your correspondence dated 23 February providing your Prevention of Future 
Deaths report into the Benjamin Leonard Inquest. 

I have noted the recommendations from the report and passed these on to the relevant 
Welsh Government officials for further consideration.  

In relation to the recommendation for the establishment of a Public Inquiry under the 
Inquiries Act 2005 into the Scout Association, as this terrible accident took place during a 
trip organised by the UK Scout Association, the UK Government are best placed to respond 
to this recommendation.  

I’ve noted you have already provided a copy of the report to the relevant Secretary of State 
and Minister for State within the UK Government. 

Thank you once again for providing a copy of the report. 

Yours sincerely, 

Gweinidog y Gymraeg ac Addysg  
Minister for Education and Welsh Language  

Bae Caerdydd • Cardiff Bay 
Caerdydd • Cardiff 
CF99 1SN 

Canolfan Cyswllt Cyntaf / First Point of Contact Centre:  
0300 0604400 
Gohebiaeth.Jeremy.Miles@llyw.cymru 
Correspondence.Jeremy.Miles@gov.wales 

Rydym yn croesawu derbyn gohebiaeth yn Gymraeg.  Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd 
gohebu yn Gymraeg yn arwain at oedi.  

We welcome receiving correspondence in Welsh.  Any correspondence received in Welsh will be answered in Welsh and corresponding 
in Welsh will not lead to a delay in responding.

Ben Leonard Inquest  
Prevention of Future Deaths Report  
Response from The Scout Association 
April 2024 

Prevention of Future Deaths Response – The Scout Association 

Page 1 of 42 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Contents 

Introduction .............................................................................................................................. 3 

Section 1: Culture of Candour and Independent Inspection ........................................................ 5 

Section 2: Fatal Accident Inquiry Panel Investigation Report (FAIP) now termed “Learning Review”
 ................................................................................................................................................ 8 

Section 3: Safety Training......................................................................................................... 13 

Section 4: Restricted Duties .................................................................................................... 16 

Section 5: Absence of Safeguarding and Safety Compliance ..................................................... 18 

Section 6: Monitoring, Auditing and Reliance on Volunteer Line and the need for paid Trainers ... 21 

Section 7: Delays in Training .................................................................................................... 24 

Section 8: First Aid Kits ............................................................................................................ 26 

Section 9: First Aid Self Certification to meet Module 10 First Response requirement. ............... 27 

Section 10: Autonomous Charities .......................................................................................... 28 

Section 11: Permit/ Licencing Schemes ................................................................................... 31 

Appendices ............................................................................................................................ 33 

Appendix A – Planned actions & delivery dates ...................................................................... 33 

Appendix B – Fatal Accident Investigation Term of Reference ................................................. 36 

Appendix C – Safety changes since 2018 .............................................................................. 40 

Appendix D – ‘Growing Roots’ Overview ................................................................................ 42 

Prevention of Future Deaths Response – The Scout Association 

Page 2 of 42 

 
 
 
 
 
 
 
 
 
 
 
 
 Introduction  

On behalf of The Scout Association, we would like to express our wholehearted apology to the 
Leonard family – both for the death of Ben and for the anguish they have experienced over the 
past five and a half years. It was not the intention of anyone at Scouts to contribute towards any 
further pain, but we recognise that we have caused further distress and for that we are truly sorry.  

This inquest and HM Coroner’s Prevention of Future Deaths report has led to significant soul 
searching and reflection, with extensive discussions taking place within our Board and with wider 
stakeholders. It has rightly dominated our thinking and we pledge that it will continue to do so. As 
a result, we are proposing fundamental changes to our approach to safety throughout the Scout 
movement.  

Throughout this report, we have addressed the concerns of HM Coroner using the same sub-
headings in his Prevention of Future Deaths notice. In each section, we outline our response to 
these concerns and the actions we have taken since the inquest, the actions we will take from 
this point forwards, as well as capturing actions that have been taken since Ben’s tragic death in 
2018. This response further builds on the work we have undertaken after receiving the Prevention 
of Future Deaths notice in February 2020, and the further update provided in February 2021 to HM 
Coroner1.  

There are 25 key actions we will be undertaking, but we highlight the following:  

1.  A Fatal Accident Investigation Panel for Ben’s death with an external chair and 

independent panel members was initiated within 48 hours of the conclusion of the 
inquest and is due for completion in June.   

2.  A Critical Incident and Investigation Policy and a Duty of Candour Policy will be agreed 
by the Board in July 2024 (with these principles implemented immediately). This will 
provide a consistent framework in how we respond in future to serious incidents, 
emphasising the need for transparency and to quickly capture learning.  

3.  We are commissioning a new strategic partnership with a nationally recognised 

organisation that is a leader in safety to review our current safety practices, and this 
party will act as a Third-Party reviewer. We anticipate that this partnership will be in place 
by May, with an initial review completed by October 2024.  

4.  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). This is designed to further 
support volunteers and assure us that they understand what is required of them in terms 
of safety, and have the required competencies and knowledge in relation to risk 
assessments, terrain definitions, and requirements within our Policy Organisation & Rules 
(POR).  

5.  We are investing in several new systems and resources that will transform access to 

information and monitoring.  

1 Responses to this PFD Report were provided from The Scout Association dated 1.4.20 and then an 
updated response dated 12.2.21. 

Prevention of Future Deaths Response – The Scout Association 

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 These include: 

•  A new, movement-wide assurance framework to support local leaders, and 

monitor and audit compliance, including in relation to safety. 

•  Additional staffing resource to support areas of safety, adventurous activities, 

training support, and local compliance.  

•  The implementation of a new approach to the auditing of adult training, 

including the provision delivered by County Training Managers under our new 
Audit & Assurance approach. 

•  We are undertaking a full review of Permitting. 
•  A new Learner Management System and training packages, which will provide 
significantly enhanced role specific training, including compliance data for 
volunteers and volunteer management roles across the movement.   

•  A new Adult Membership System that will provide far greater access to key 

information and transform how we assess, approve, and audit our Nights Away 
Application processes.  

We have attached our delivery plan in Appendix A to ensure our response to Ben’s death is more 
than words, and that the changes already undertaken, along with those planned, will enable the 
thousands of volunteers who deliver Scouting to continue to do so safely.  

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.  

As leaders of the Scout movement, we want to state our commitment to ensuring that this is a 
transformative moment for Scouting at all levels. We are committed to learning, being honest and 
transparent, and building the trust of parents, young people, and wider stakeholders so that we 
remain true to our values of integrity, respect, care, belief, and co-operation. 

Chair of the Board 

Chief Executive 

UK Chief Volunteer 

Prevention of Future Deaths Response – The Scout Association 

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 Section 1: Culture of Candour and Independent 
Inspection 
Concerns 1–2 (and Concern 39) 

1.  I am concerned that there is not a culture of candour within The Scout Association (‘TSA’) 

and the impact that this has on safety and safeguarding. 

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 Scout Association or the granting of permits for adventurous 
activities, hill walking and Nights Away permits. Further, The Scout Association permit 
scheme for adventurous activities is exempt from regulation by the Health and Safety 
Executive (‘HSE’). 

39. The Scout Association press release within moments of the jury’s conclusion 

demonstrates a failure of The Scout Association to accept any accountability and 
understanding any proper learning from Ben’s death. The Scout Association is 
institutionally defensive. 

Culture of Candour 

The Scout Association is committed to learning from Ben’s tragic death. We know we can and 
must do better. We have carefully considered the Coroner’s concerns in detail and will act with 
greater openness and transparency.  

We agree with the Coroner that a culture of candour is essential in relation to safety and 
safeguarding, and we recognise there is more we must do in this respect. We have therefore 
agreed to put in place concrete measures to adopt an enhanced culture of candour. These 
include new policies and training in respect of how we respond to critical incidents. This will 
ensure we are clear with parents when things go wrong, we work with them, so they know the 
actions we are taking, and publish learning to ensure transparency and accountability.  

We wholeheartedly apologise for any lack of candour in the past. Across Scouts, we strive to have 
an open and transparent culture and we accept improvement is needed. 

Regulation & Audit 

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.  

We have significantly reflected on the Coroner’s concerns and, irrespective of any government 
proposals, we are going further in terms of seeking Third Party external review, inspection, advice, 

Prevention of Future Deaths Response – The Scout Association 

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 and assurance. In the actions section below, we outline the work we are now undertaking to 
engage in external strategic reviews and identify learning from National Governing Bodies 
(NGBs) that would enable a strengthened model for Scouting.  

Finally, with regards to Concern 39 specifically, we wholeheartedly apologise to the Leonard 
family for the timing of our press release. While we stand by the commitment that we made to 
learning in the statement, we accept that it was released too soon. We hope the details in this 
response demonstrate our commitment to ensuring clear accountability.  

Actions 

Culture of Candour 

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). 

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). 

Audit & Inspection 

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 this party 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: 

•  A comprehensive independent review of our current safety practices (including 

the risk assessment process – identification, mitigation, change, review and sign-
off) to assess if learning is successfully delivered, appropriate and effective. 
•  A review of the required competencies and skills to inform our syllabus and 

approach to safety training and best practice. 

•  The development of a revised safety framework and associated standards. 
•  A yearly independent review of all safety policies and processes, along with 

review of these safety practices to align to internal and external learning and best 
practices. This is similar to the work already undertaken by the NSPCC on our 
safeguarding policies and procedures. (first review September 2024) 

The Board has agreed to invest in the required resources, including additional staffing, 
based on the findings of this review. This initial strategic review will report within six 
months (October 2024) with planned recommendations and proposed action. 

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 

2 Third Party Reviewer – an independent organisation or body providing services in areas such as inspection, 
investigation, audit, and assurance. 

Prevention of Future Deaths Response – The Scout Association 

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 better external scrutiny and oversight can address the concerns raised by the Coroner 
and support the external review outlined above. This will be initiated by June 2024. 

Other key areas of work 

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.  

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: 

i.  Enable volunteers to undertake key safety tasks more efficiently (including 
suspensions, permitting, Nights Away applications and approvals). In 
particular, it will transform how we approve and monitor Nights Away and 
Permitting by moving all applications and approvals online with a 
mandated requirement to upload all required paperwork, including risk 
assessments. The approver (Senior Volunteer) will be able to see all 
volunteers attending the trip, their training and disclosure status and 
assess all documentation when deciding whether to approve or decline 
the trip. The system will enable a full audit trail of all processes.  

ii.  It will allow the integrated production and visibility of real time reporting at 

local and national levels for all training and wider compliance data. 

iii.  It will integrate with our recruitment, onboarding and learning tools, as well 
as existing tools including disclosure checking, so local managers have 
access to all volunteer automated data and can validate compliance and 
safety vetting. 

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 Section 2: Fatal Accident Inquiry Panel 
Investigation Report (FAIP) now termed “Learning 
Review” 
Concerns 3–11  

3.  Following Ben’s death, as indicated by Chapter 7 of The Scouts’ Policy, Organisation and 

Rules (Rule 7.2 version May 2018), at that time required the Charity and Company 
Secretary of the Association to establish an enquiry on behalf of the Board of Trustees. 
This should have detailed authorisation, training, equipment, briefing and leadership of 
the party involved together with their observation of the sequence of events and possible 
causes of the fatality. 

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 
Scout Association maintaining this was due to a live police investigation initially, and 
latterly due to this inquest. 

5.  Without a timely internal Fatal Accident Inquiry Panel Investigation Report (FAIP), this 

gives me great concern that issues of safety and safeguarding are not properly 
considered, transparently engaged with and then addressed formally in respect of a child 
fatality. 

6.  The evidence provided by The Scout Association has been inconsistent as to when it is 
said a FAIP report is commissioned and completed in circumstances where there is an 
inquest. 

7.  An FAIP investigation initiated by the Charity and Company Secretary, should have 

engaged with the early identification by the District Commissioner, County 
Commissioner, and The Scout Association Headquarters staff who had concerns and 
noted failings relating to the planning, risk assessment, supervision and approval for the 
trip including the absence and non-attendance of the identified and necessary first aider, 
the presence of over 18 year olds on trip which had not been disclosed or approved by the 
District Commissioner and concerns around the competence of the leaders. 

8.  The Scout Association reconstruction trip to the Great Orme after Ben’s death on 9.10.18 
attended by The Scout Association Senior Scouting leadership and lawyers with the 
actual leaders from the trip indicates a desire by The Scout Association headquarters staff 
to control the narrative, especially surrounding dynamic risk assessment. Any 
investigation by County or District level was prevented by headquarters at Gilwell. The 
District and County Commissioners had identified failings and concerns relating to safety 

Prevention of Future Deaths Response – The Scout Association 

Page 8 of 42 

 
 
 
 
 
 
 
 
 and safeguarding on the day Ben died and the extent of the failings were known and many 
identified further, following the trip to the Great Orme on the 9.10.2018. 

9.  In this investigation, the evidence I have heard leads me to a concern as to a general 

reluctance by The Scout Association to engage in a meaningful learning exercise to 
prevent a recurrence of the issues pertaining to Ben’s death. This inquest was stated as 
the reason preventing a FAIP report. 

10. However, a FAIP relating to another death in Scouting of a 21-year-old leader was 

considered in evidence. This FAIP and recommendations were completed before that 
Inquest. However, it is not clear as to whether this report and recommendations was 
shared with the relevant Coroner. It is also not clear if, even when FAIP reports have been 
completed, whether they are provided to the relevant Coroner. 

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. 

Fatal Accident Investigation 

We wholeheartedly apologise for not completing a Fatal Accident Investigation (FAI) prior to this 
inquest and accept that our decision to not do so was wrong. This will not happen again.  

We recognise that the lack of a FAI report into Ben’s death has added to the distress experienced 
by the Leonard family and to the challenges within the inquest process.  While we followed legal 
advice regarding the timing of the FAI after Ben’s death, we accept it was wrong not to initiate a 
FAI in advance of the inquest. We recognise that undertaking an FAI would have allowed greater 
information to be available earlier in relation to Safety and Safeguarding matters and would have 
prompted quicker action in key areas.  

Critical Incident Response & Learning 

Learning from any incident is central to our commitment to continuous and cultural 
improvement. As such, we are fully reviewing our approach to Critical Incidents. This will now 
include a new approach that we will call a Fatal Incident Investigation3. 

We are reviewing current policies and creating a new Critical Incident & Investigation Policy and 
procedure, which will form part of our wider learning review process for any incidents. This will 
make sure any future critical incidents are immediately and robustly investigated, and learning is 
gathered quickly. Should a fatality occur again, all investigation findings will be provided to His 
Majesty’s Coroners of England and Wales (and devolved nation equivalents) ahead of any inquest 
proceedings.  

We acknowledge the concerns raised by HM Coroner with regard to the perception that members 
of The Scout Association tried to control the narrative. To the best of our knowledge, it was not the 

3 Moving forwards, and after discussion with external experts, we have agreed to remove the term ‘accident’ 
from Fatal Accident Investigation and use the term ‘Incident’ instead. This recognises that using the term 
‘accident’ may reduce the importance of how an incident is seen and hinder the ability to identify the root 
causes.  

Prevention of Future Deaths Response – The Scout Association 

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 intent of any individual within The Scout Association to attempt to do so, however we have 
learned from this. As detailed in point 2 below, we will now appoint a member of the Executive 
Leadership Team, who will report into the Board to ensure full transparency and accountability.  

Our new Critical Incident & Investigation Policy will also set clear rules regarding site visits and 
how information is gathered. The policy will include a commitment to share all relevant 
information with statutory agencies in a fully transparent manner.  

We recognise the concerns raised about poor communication with local leadership. We are 
committed to changing and learning from this. In future, we will ensure there is greater clarity 
about the roles and responsibilities of different parties, especially where any fatality has 
occurred. We will ensure that guidance is clear and update POR where a national policy, such as 
the new Critical Incident & Investigation policy, is implemented.  

With regards to Concern 10 specifically, we would like to add some information regarding the 
tragic death in Scouting of a 21-year-old leader that was considered in evidence. We would like to 
clarify that The Scout Association did provide a copy of the fatal accident inquiry panel report to 
inquest investigators before the inquest commenced. Specifically, the report was shared with the 
Senior Environmental Health Officer (EHO) at Preston City Council, who the Coroner had 
instructed to provide a report to the inquest. Learning from this and in future, the new Critical 
Incident & Investigation Policy will ensure we have a consistent approach to the provision of such 
information.  

Actions 

Learning from Ben’s Tragic Death 

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.  
As part of our commitment to transparency, the findings will also: 

•  Be shared across the wider charitable and youth sector to enable wider learning. 

This will form part of our new Safety Report.   

•  Be provided to the organisation we appoint to undertake our external strategic 
safety review to ensure that the learnings from this FAI are embedded in future 
ways of working.  

To lead the FAI panel, we have appointed an independent Chair with a robust senior 
health care background in the NHS and two independent panel members with 
significant safety expertise, along with two internal senior volunteers who are 
unconnected to any matters relating to this tragedy (see Appendix B) 

Prevention of Future Deaths Response – The Scout Association 

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 Future Critical Incidents & Learning 

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.  

The new policy will ensure a consistent approach that is founded in learning and the need 
to robustly investigate, act on, and learn from critical Incidents, including fatalities.  

Specifically, in relation to fatalities, it will include the requirement to initiate a Fatal 
Incident Investigation (FII) as soon as practically possible after a fatality has occurred, the 
need for independence within the process and, where appropriate, use external experts 
and chairs. The Critical Incident and Investigation Policy will set out in detail how any 
process is to be conducted. When this policy is produced and shared publicly, we would 
welcome feedback from any interested party.  

In terms of the governance of the Critical Incident process: 

•  As is the current procedure, any Critical Incident is overseen by the Safety 

• 

Committee (a sub-committee of the Board of Trustees, which includes additional 
expert and external members). The full report is presented to the Board with a list 
of recommended actions. 
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.  

•  The Critical Incident & Investigation process will be commissioned by Safety 

Committee on behalf of the Board within 72 hours of any future incidents, which 
will ensure the timely capture of all required information in one central location, 
and its findings will be presented to any statutory agencies on an open disclosure 
basis. This will be accompanied by an overall learning review for all critical 
incidents.  

Other key areas of work 

3.  We will be developing bespoke training packages to support our new approach to 

Critical Incidents to build competency and ensure this approach is clearly understood by 
all key stakeholders.  

4.  We will conduct an annual Critical Incident scenario exercise to ensure the policy 

remains live and institutional knowledge is not lost. This will be independently reviewed 
and assessed to ensure learning is objectively identified and applied. (first scenario 
exercise December 2024) 

5.  Since Ben’s tragic death in 2018, Scouts have made over 50 changes to our policies, 
systems, processes, and ways of working. These include changes to our Policy 
Organisation and Rules (POR), updated guidance and policy on risk assessments, Terrain 

Prevention of Future Deaths Response – The Scout Association 

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 definitions, improvements in training and auditing compliance (see appendix C for a full 
list of these changes).  

6.  Over the past five years, we have undertaken five key learning reviews for critical incidents 

and a range of reviews for other accidents. We will now review our approaches aligned to 
the new Critical Incident and Investigation policy to ensure we capture learning for any 
incident. 

7.  Safety & Safeguarding reports have been reviewed by the Board of Trustees at each of their 
quarterly meetings since 2020. There are Safety & Safeguarding Committees in place, as 
sub-committees of the Trustee Board, with independent chairs (who are Trustees with 
professional roles external to Scouting, meaning they have relevant expertise) and 
additional expert members to contribute knowledge of outside trends and learning. 

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 Section 3: Safety Training 
Concerns 12–13  

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. 

13. While reference material is available in the course, it is not mandatory reading and not 

required in order to complete the click through course. 

Online Safety Training  

The Scout Association made the decision to bring its safety training exclusively online in 2020. 
This was to ensure volunteers were appropriately trained and there was consistency, including in 
terms of validation. In light of the concerns expressed by HM Coroner in the PFD report, we are 
now reviewing the balance of online training versus face-to-face training, and this will form part of 
our external strategic safety review (Section 1, point 3). This will ensure we are focusing even 
more on assessing competence, suitability and building a prevailing culture of safety.  

We think it is important to highlight that safety training is just one component of our initial training 
suite, which also includes Safeguarding and First Response training, with the latter including an 
in-person practical component. We also provide clear guidance, further resources, and tools on 
our website which are available at all times and updated regularly. However, we recognise we 
must do more to support volunteers, so we can assure they have the right capabilities and better 
validate, evidence and audit delivery.  

We accept the HM Coroner’s concern that, if individuals chose to do so, they could complete our 
current training in 12 minutes. We have now acted on this, so the course cannot be undertaken in 
such a manner, which is explained below in point 1. As before these changes, at the end of the 
training module, the person being trained also needs to answer all safety questions to the pass 
mark of 100% to achieve completion and certification. 

Actions 

1.  The Scout Association has urgently reviewed the safety training provided online, so 
a candidate cannot simply ‘click through’ the material and made the reading of the 
materials mandatory. Individuals are required to complete a self-declaration stating 
they have read all required materials, and they still need to achieve 100% in the final 
test. 

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 

Prevention of Future Deaths Response – The Scout Association 

Page 13 of 42 

 
 
 
 
 
 
 volunteers who will be delivering nights away or adventurous activities as our priority. 
For any volunteer who does not complete the training in the agreed time frames we 
will introduce agreed restrictions or suspension in line with the detail provided within 
Section 7 (Compliance & Suspensions). This new training is designed to further 
support volunteers, assuring us that they understand what is required of them in 
terms of safety, and they have the required competencies in the following four core 
areas: 

•  How to conduct and complete risk assessments (written and dynamic)  
•  Terrain definitions 
•  The related requirements within our Policy Organisation & Rules (POR)  
•  Permitting  

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.  

Other key areas of work 

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: 

i.  Mitigate the risk that only individuals with the correct access can 

undertake specific training programmes (lessening the risk of training 
being undertaken by one person on behalf of another).  

ii.  Validate and assess volunteers for competency after undertaking 

relevant courses.  

iii.  Enable full auditing of training compliance and check training is 

undertaken in a timely manner. It will drive greater consistency and will 
ensure that only nationally endorsed and up-to-date materials are 
being used. 

5.  As outlined in Section 1(point 6), we have significantly invested in a new Adult 

Membership System (AMS). 

6.  The new AMS will also enable all Nights Away Applications and associated 
Permitting to be done online, including the submission and verification of all 
required paperwork in line with POR. There will be the ability to approve or decline any 
application by the relevant line manager or approver and to check for appropriate 
training and disclosures, as well as a full audit capability that will form part of our new 
national Audit & Assurance framework.  

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 7.  As part of our volunteer transformation programme which started the design work in 
2018 and launched at the start of 2023, we are developing a new approach to how we 
manage and equip volunteers. We have devised a completely new approach to 
training across the UK, replacing the requirement to undertake Wood Badge training. 
Instead, the most important elements from the Wood Badge training will now form 
part of our mandatory training to be completed within six months of becoming a 
volunteer. This includes a requirement to undertake Safeguarding and Safety training 
within the first month of becoming a volunteer. Without up-to-date Safeguarding or 
Safety training, volunteers will not be allowed to lead or plan activities and will be 
supervised at all times. If a volunteer has not undertaken their training (within a one-
month window), they will be suspended until this has occurred.  
(For a full overview of all training areas above, please refer to Appendix D). 

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 Section 4: Restricted Duties 
Concerns 14–15  

14. There was a plain reluctance to prioritise the safety of young people following Ben’s death 
in that, the leaders Sean Glaister, Mary Carr and Gareth Williams 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, Sean Glaister and Gareth Williams 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 Sean Glaister. 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. 

15. Suspension of Sean Glaister and Group Scout Leader Brian Garraway was only imposed 

in November 2022, four years after Ben’s death, following the second inquest that needed 
to be adjourned due to non-disclosure. Suspension exists to ensure the safety and 
safeguarding of children until the investigation to establish facts has been undertaken. 

Compliance & Suspensions  

We acknowledge that Ben’s death was initially treated as a tragic accident. In hindsight, we were 
wrong to take that approach and we apologise for it. We also recognise than a timely FAI would 
have identified concerns. We followed legal advice at the time that informed our approach to 
implementing restricted duties on the leaders. Again, we made the wrong decision and should 
have suspended those involved. We have now changed our practices to underpin a culture of 
transparency and learning, making several immediate changes to ensure this will not happen 
again. 

Actions 

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 polices 
and safety suspension powers, learning from how we currently operate within our 
Safeguarding team.  

2.  As set out in Section 2, we have agreed a new approach to Critical Incident 

Investigation. While the full policy is being finalised, the Board has agreed to enact 
the key requirements immediately. The new process will identify the key facts and 
enable robust and swift action where issues are identified within a framework of Root 
Cause Analysis to capture learning promptly. 

3.  In the event of a fatality, a senior level staff member (Executive Director level) will be 
designated as the senior accountable person for collating information and liaising 

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 with relevant statutory agencies. They will report directly to the Board, ensuring clarity 
and communication at all levels.  

4.  We will review our assessment criteria for Safeguarding to ensure that any future 

critical incidents are automatically seen within a Safeguarding framework and can be 
assessed as such; by identifying any safeguarding concerns, and putting appropriate 
actions in place. 

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 Section 5: Absence of Safeguarding and Safety 
Compliance 
Concerns 16–19  

16. The nominal Explorer Scout Leader Sean Glaister in place when Ben Leonard died was 
subsequently appointed on Compass as a “District Section Leader Reddish Unit at 
Stockport” in November 2019. The formal interview to appoint Sean Glaister to the role 
the Reddish Explorer Scout Leader took place in 2020 after his appointment on Compass. 
It concerns me that notwithstanding the known failures in the planning and execution of 
the trip, and it having been identified by the County Commissioner, the District 
Commissioner, the Head of Safeguarding and Head of Safety at The Scout Association 
headquarters that Sean Glaister had lied in the planning for the trip at which Ben died. 

17. Over 18-year-olds were allowed on this trip, by Sean Glaister, having not been listed on 
the Nights Away Notification (‘NAN’) form as adults, nor registered on the Scouts’ 
Compass system or having undergone Disclosure Barring Service (‘DBS’) safeguarding 
checks. 

18. In addition, the inquest has identified the limited knowledge and understanding of Sean 

Glaister of any of his training undertaken throughout his time acting as a volunteer leader 
for the Scouts. The lack of understanding of training was a similar picture for the other 
Leaders on the trip at which Ben died and for other Scouting witnesses. 

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. 

Competent and trained volunteers 

Competent and effectively trained volunteers are vitally important to ensure the safety of all 
children and young people. We understand this must be underpinned by an effective culture of 
safety and prevention, and we recognise we have more to do to further improve both areas to 
enable consistency.  

We accept the concerns raised by the Coroner. There was clearly a breakdown in our internal 
systems that enabled Sean Glaister to be fully appointed to a role supervising young people, for 
which we take full accountability and have acted to prevent a similar situation being repeated. 

As part of our volunteer transformation programme (highlighted in section 3, point 7), we have 
also introduced key changes and new ways of working. We are continuing to invest in new 
approaches so that we can make sure everyone is fit and proper to undertake their roles with a 
culture of safety at the foundation. When volunteers apply for any role within Scouts, there is a 
local appointment process to assess suitability for each role including full references and 
appropriate disclosure and vetting checks conducted nationally. The recruitment process is 
overseen by our Regional and County Commissioners (senior volunteers). In addition, our 
strategic portfolio includes significant investment in a new adult membership system (AMS), 

Prevention of Future Deaths Response – The Scout Association 

Page 18 of 42 

 
 
 
 
 
 
 
 learning management system (LMS), and associated processes that will make appointing, 
tracking, and monitoring the competency of our volunteers more effective (detailed in Section 1, 
point 6, and Section 3 point 4). 

To assure ourselves that all our individual volunteers have the skills and knowledge to keep young 
people safe, we are urgently undertaking a process to provide enhanced supplementary training 
and validation to support and ensure the competency of our 145,000 volunteers. Furthermore, we 
are working alongside the volunteer leadership to assure ourselves that other local appointments 
have been made in line with our policies and rules. 

It was wrong for Sean Glaister to be appointed to the role of Explorer Leader in 2020, and we 
accept that anyone over the age of 18 should not have been on this trip without the correct 
planning and permissions.  

We accept that Sean Glaister and others said they had limited knowledge of our training. In 
Section 3 (points 2 and 3), we have described the movement-wide review we are undertaking of 
our training to ensure these issues are robustly addressed.  

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. 

Actions 

1.  The Scout Association Board have agreed to invest in and recruit sufficient safety and 
training focused staff to deliver the commitments within this document, which will be 
informed by the external strategic safety review. However, we are already taking action. 
The Scout Association has already started to recruit to new roles into our safety team, and 
we are currently designing a new structure. A permanent structure with additional staff in 
the areas of safety and training support will be agreed at the October 2024 Board meeting.   

2.  The Scout Association are currently commissioning enhanced supplementary safety 
training and validation for all 145,000 volunteers with the new course available by 
September 2024 (detailed in Section 3, point 2). 

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.   

4.  We have agreed to fully review our new approach to training delivery and training 

content in light of the findings from this inquest. This will be undertaken as part of our 
external strategic partnership. As in point 1 above, the Board have agreed to invest in and 
recruit the required staffing levels to support this commitment.  

Prevention of Future Deaths Response – The Scout Association 

Page 19 of 42 

 
 
 
 
 
 5.  As set out in Sections 4 (point 1), we have made changes to our systems and approach 
to enable suspensions for serious safety matters. This will include the flagging and 
pausing of any changes to appointment for a volunteer role during any suspension and 
thorough investigation.  

6.  We will create new, additional mandatory training and support that is focused for our 

senior leaders (District and County levels) 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.  

7.  We will provide further training to all District and County Commissioners on the issues of 
over 18-year-olds and update the relevant guidance. This will be cascaded to all our 
volunteer leaders.  

Other key areas of work 

8.  We have made changes to our systems for those who turn 18, so they do not 

automatically become Network Members. This addresses the safeguarding concern 
raised by HM Coroner in Concern 17 above. 

a.  This will safeguard that: 

i.  If anyone wishes to attend camp and they are over 18, they will need to 

have the correct membership level within our systems. 

ii.  If they are assisting in the running of the camp, the relevant disclosure 

check has occurred prior to camp. 

iii.  If they wish to participate in a camp with under 18s present, then the 

correct applications, staffing ratios, supervision and camp set up has been 
agreed prior with the District Commissioner (or approver) as part of the 
Nights Away Notification process.  
(This will also form part of our new Audit & Assurance review process (as 
detailed in Section 1, point 5). 

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. 

Prevention of Future Deaths Response – The Scout Association 

Page 20 of 42 

 
 
 
 
 
 Section 6: Monitoring, Auditing and Reliance on 
Volunteer Line and the need for paid Trainers 
Concerns 20–25  

20. I have heard evidence that The Scout 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 Scout Association require from 
the County and District in respect of: 

Training compliance; 

i. 
ii.  Completion of induction training within 5 months; 
iii.  Completion of the full adult training scheme/ wood beads within 2 years; 
iv. 
v.  Granting of permits. 

Appointment to roles – both pre provisional, provisional, and full appointment; 

21. I heard evidence from the County Training Manager (‘CTM’) for Greater Manchester East- a 
volunteer role and he himself accepted that he had historically delivered training based 
on out-of-date factsheets and volunteered that he needed to update his own knowledge. I 
have been told that an urgent audit of the CTM occurred after his evidence to the inquest. 

22. I have a concern therefore as to the general audit and inspection of County Training 

Managers nationally. 

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. 

24. The provision of training relies heavily on the goodwill of volunteers and is time 

consuming. The expert to the inquest Mr Rosser recommended – as exists for other 
organisation and Charities – that there should be a paid regional individual with a 
responsibility for training who would serve as a point of contact for local volunteers 
should they require any support with their training and to ensure quality training and 
compliance. 

25. Mr Rosser identified that this required a paid individual that was missing in the current 
chain between the volunteer line and The Scout Association necessary for training and 
delivery of activities. 

Monitoring, auditing, and supporting the volunteer line management  

We agree with HM Coroner that we need to do more to ensure that, across Scouts, there is 
absolute clarity for Counties and Districts on the areas identified. This includes providing more 
support to local volunteers and to volunteer leadership.  

Prevention of Future Deaths Response – The Scout Association 

Page 21 of 42 

 
 
 
 
 
 
 
 
 
 
 
 We have already changed our approach: 

• 

In 2023, we launched a new volunteer transformation programme, which has 
introduced changes to volunteer roles and leadership, training, systems and 
provided far greater clarity on expectations, including guidance and 
responsibilities.  

•  We changed existing Executive Committees (those running the 8,000 charities) to 
Trustee Boards, with greater clarity on expectations and their responsibilities. 
•  Since 2020, training compliance is monitored at local (89 counties), regional and 

national levels, including by The Scout Association Board. 

•  Local compliance data is produced monthly with swift action, including in relation 

to those not compliant (detailed Section 7 – Compliance & Suspensions).  

Additionally, as highlighted in Section 5, point 1, The Scout Association Board have agreed to 
invest in further staff resources to support our safety work, adventurous activities, and training 
support, which responds to the recommendations made by Mr Rosser in concerns 24 and 25.  

We accept that the County Training Manager for Greater Manchester East was using an out-of-
date fact sheet in 2014, and that he needed to update his knowledge. We have undertaken an 
independent local review to provide assurance and to implement swift corrective actions. 

Finally, as we outline below, we will keep investing in many areas to ensure we continue to build a 
culture that has safety, assurance, and accountability at its core.  

Actions 

1.  In response to concerns 20–23, we are investing in key new systems and resources 
that will transform access to information and monitoring these including. These 
include: 

a.  A new Learner Management System, which will provide significantly 

enhanced information and data for volunteers and volunteer management 
roles across the movement (detailed in Section 3, point 4). 

b.  A new Adult Membership System, that will provide far great access to key 

information (detailed in Section 1, point 6). 

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). 

d.  Additional staffing resource to support areas of safety, adventurous 

activities, training support, and local compliance (detailed in Section 5, point 
1). 

e.  A strategic partnership that will review future safety training and ensure we 
have identified the correct competencies and skills required to inform future 
training design, delivery, and validation (detailed in Section,1 point 3). 
f.  The implementation of a new approach to the auditing of adult training 

including the provision delivered by County Training Managers under our 
new Audit & Assurance approach (detailed in Section 1, point 5). 
g.  As we detail in Section 11 below, we are undertaking a full review of 

permitting. 

Prevention of Future Deaths Response – The Scout Association 

Page 22 of 42 

 
 
  Other key areas of work 

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.  

3.  The Scout Association Board will receive regular UK-wide heat mapping4, showing 

data in relation to training, safety, suspensions, and complaints.  

4.  In Greater Manchester East, we have undertaken a full review of training provision 
and put in place a volunteer and staff supported robust plan to enable the ongoing 
consistency and quality of provision. The plan includes changes to support, peer 
review, moderation, and leadership. 

5.  Since 2020, we have implemented new suspension protocols for any volunteer 
who has not completed their training. This includes notification at 60 and 30 days 
prior to the expiry of any certification (usually three years), as highlighted in Section 7 
(Suspensions & Compliance). 

6.  All training guidance, fact sheets and materials are available from our website. 

We have removed the ability to download fact sheets, so individuals must access the 
most up-to-date versions. We will continue to make sure our communications are 
clear on all relevant updates and changes. 

4 Heat Mapping uses data from various agreed sources to provide a coloured visual map. The colours, 
usually red, amber, and green, highlight where there may be issues or concerns within a specific geographic 
location after analysing all available data and identifying trends for further investigation.  

Prevention of Future Deaths Response – The Scout Association 

Page 23 of 42 

 
 
 
 
 
 
 
 
 
 
 Section 7: Delays in Training 
Concerns 26–31 

26. 

27. 

Gareth Williams and Mary Carr had not completed their mandatory training within the 
5-month period: Gareth Williams’ training was 3 years and 9 months’ late; Mary Carr’s 
was 2 years and 1 month late. 

Sean Glaister had not completed his wood beads training within the 2-year period; it 
was completed 2 years and 9 months late. There was no apparent sanction for having 
missed deadlines for training. 

28. 

I was then provided with the following statistics, provided by Mr Kidd, the former UK 
Chief Commissioner of The Scout Association: 

i. 

ii. 
iii. 
iv. 

“On 7 September 2018, there were 373 open roles in Stockport District that were in 
scope for Getting Started and Wood Badge training. The 373 roles were held by 318 
volunteers. 
There were 180 roles (48%) overdue for completing their Getting Started training. 
There were 94 roles (25%) overdue for their Wood Badge training. 
There were 318 volunteers in Stockport District that were in scope for first aid training. 
Of those 318 people, there were 57 (18%) who were overdue their first aid training. The 
rules at that time did not require first aid to be up to date at all times” 

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. 

30.  Whilst the training statistics have notably improved, this is based on what I have 

considered on superficial and basic training which raises concerns around whether 
the core underlying principles such as risk assessments are being adequately 
understood. 

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”. 

Training delays (please also see Section 3 – Safety Training) 

We accept the above concerns expressed by HM Coroner, regarding delays in training and wider 
compliance issues across the movement in 2018. We have made significant progress since then, 
and there is now 98% compliance for Safety and Safeguarding training. However, we acknowledge 
the concerns raised by HM Coroner with regards to the training compliance statistics today, and 
as detailed in Section 3 (point 2), we are currently commissioning enhanced supplementary 
safety training and validation for all 145,000 volunteers to make certain that key issues, such as 
risk assessments and underlying principles, are understood.  

Prevention of Future Deaths Response – The Scout Association 

Page 24 of 42 

 
 
 
 
 
 
 
 
 
 
 We recognise that the effective delivery, quality, and governance of training is vital, and as 
detailed in Section 5, point 1, we are investing in additional paid training staff to ensure we 
respond to the concerns raised and issues identified.  

Compliance & Suspensions  

Since 2020, we have monitored training compliance at local and national levels across the 
movement. We have introduced new local powers to suspend volunteers significantly reducing 
non-compliance across Scouting. We are now going further and introducing a system whereby 
any volunteer who is not compliant with our mandatory Safeguarding and/or Safety training 
requirement will not be allowed to lead or plan activities and will be supervised at all times (to not 
be alone with children or young people).  

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. 

We accept the concerns of the HM Coroner with regards to the local training manager and have 
taken prompt action. This includes a full review into local practices and ways of working in 
relation to training. The result of this process is a bespoke action plan for Greater Manchester 
East to respond to the issues identified.  

Actions 

1.  As outlined in Section 5, point 1, The Scout Association Board have agreed to invest the 
necessary staff resources in order to ensure effective oversight of local delivery. This 
will include a team of both new staff and senior volunteers. We are currently reviewing the 
requirements and future structure, which will be informed by our external strategic review, 
but will require significant investment into additional staffing.  

2.  Since 2020, we have implemented new suspension protocols for any volunteer who 

has not completed their training. This includes notification at 60 and 30 days prior to the 
expiry of any certification (usually three years).  

3.  As we highlight in Section 6 (but detail here for ease of reference), we are also investing in: 

a.  A new Learner Management System, which will provide significantly enhanced 
information and data for volunteers and volunteer management roles across the 
movement as highlighted in Section 3, point 4. 

b.  A new Adult Membership System, that will provide far great access to key 

information as highlighted in Section 1, point 6. 

c.  A new movement wide assurance framework to support local leaders, monitor 

and audit compliance as highlighted in Section 1, point 5. 

4.  We would like to confirm we are actively working with Greater Manchester East and 
Stockport to ensure they have sufficient training managers. We are also providing 
additional staffing and volunteer support to make sure all issues are responded to.  

Prevention of Future Deaths Response – The Scout Association 

Page 25 of 42 

 
 
 
 
 
 
 
 Section 8: First Aid Kits 
Findings 32–33 

32. 

33. 

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. 

The Scout Association guidance on the website about first aid kit requirements is 
basic and the evidence I heard from Mr Killick gives me a concern that more should be 
done to ensure on every scouting trip and at scout huts there are appropriate first aid 
kits and contents including tourniquets to enable, if necessary, immediate life-saving 
treatment to be provided. 

First Aid Kits 

We accept the concerns raised by HM Coroner. All leaders should have had a first aid kit suitable 
for the nature of the activity they were undertaking. As a result of the Coroner’s concern, we have 
now reviewed this approach and our guidance. 

Actions 

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). 

2.  We are revising our guidance to make clear to all volunteers that first aid kit 

requirements are directly linked to the type of activity (including terrain) and that they 
must also be informed by risk assessments. We will also provide example risk 
assessment to support this (to be completed by May 2024). 

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). 

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). 

Prevention of Future Deaths Response – The Scout Association 

Page 26 of 42 

 
 
 
 
 
 
 
 
 
 
 Section 9: First Aid Self Certification to meet 
Module 10 First Response requirement. 

Findings 34–35 

34. 

35. 

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. 

I have heard evidence as to improvements that have been made to the learning gap 
and training to supplement a First aid at Work certificate as First Response Module 10 
compliant, however, I am still concerned that the system lacks robustness. 

First Aid certification to meet module 10 requirement   

We accept that the system in place at the time was not suitable and our guidance was not clear. 
At the time, we also acknowledge that our Policy, Organisation and Rules (POR) was not explicit 
on the nature of additional validation for child-specific elements that were not within most First 
Aid at Work qualifications (FAW), such as hypothermia, meningitis and child CPR.  

Over the past five years, we have made several changes to our approach to our First Response 
training, and this is overseen by our First Aid Working Group.  

In order to address HM Coroner’s concerns, we have taken action to provide consistency across 
the movement and enable the robustness required.  

Actions 

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. 

2.  Any volunteer who has already used a FAW as the basis for First Response within the 
past two years is now required to undertake a validation meeting with a First Aid 
accredited trainer if they have not already done so. (to be completed by November 2024) 

3.  Moving forwards, we will monitor and track at Safety Committee (a sub-committee of 
the Board) all First Aid at Work conversion within The Scout Association and ensure, 
as part of our ongoing audit cycle, that conversions and associated requirements are 
monitored and assessed through the appropriate audit process. 

Prevention of Future Deaths Response – The Scout Association 

Page 27 of 42 

 
 
 
 
 
 
 
 
 
 
 
 Section 10: Autonomous Charities 
Findings 36–37 

36. 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. Training and POR are generated centrally, yet The 
Scout Association defer accountability for safeguarding and safety to the individual 
charities. 

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 
Scout Association. 

Federated model of the Scout movement 

The issues identified by HM Coroner in concern 36 of the PFD notice have caused us to reflect 
hard on our structures and the challenges inherent in the scale of our activity. In particular, we 
have reflected on how we can strengthen relationships, support, communication and 
accountability, and introduce Third Party inspection and assurance within the movement.  

We recognise that, in some cases, local charity governance has not been consistently well 
delivered and in some instances we have not provided sufficient support to local Scout Trustees. 
We are taking steps to address this as part of our transformation work that commenced at the 
start of 2023, which includes additional support and training to local Trustees, with support on 
safety responsibilities, good governance and building local accountability.  

We know good governance underpins a culture of safety and accountability, rather than hindering 
it. However, if our federated structure presents barriers to the future safety of young people as we 
make the changes set out in this response, we are prepared to act and will propose to our Council 
(our most senior governing body) any changes we think are needed. 

We accept that The Scout Association has a clear responsibility to ensure that it is not distant 
from its membership and that we learn from the issues and concerns raised during the inquest 
and by HM Coroner. 

We have outlined a number of steps in this response which underpin our commitment to ensuring 
health and safety is consistently and reliably executed at ground level. This includes new systems 
for auditing and support of training, additional staff resources from working in partnership with 
our volunteer leadership, and clear powers for both staff and volunteer senior leaders so that 
volunteers do not supervise activities unless they have received the relevant training and/or 
Permits.  

During the inquest, it became clear that knowledge at certain levels of our Policy, Organisation 
and Rules (POR) was not robust or clear. It is incumbent on us to change our systems and 
communication, so everyone in Scouts knows what is required of them and they have the 

Prevention of Future Deaths Response – The Scout Association 

Page 28 of 42 

 
 
 
 
 
 
 information they need. We will now review our approach and improve the clarity we provide to the 
charities within our federation and all our volunteers.  

While local Scouts charities are responsible for the governance and decisions within their own 
separate charity, we take overall responsibility and accountability for safeguarding and safety 
within The Scout Association. Our central Safeguarding staff team and central Safety staff team, 
accountable to the Executive Director of Operations, hold the responsibility that all safeguarding 
and safety concerns are investigated and supported. Everyone in Scouting has a personal 
responsibility and accountability to ensure they uphold our safeguarding and safety requirements 
as outlined in our Yellow and Purple Cards. We would not expect this responsibility to be 
abdicated to local groups (even though they clearly do have a responsibility for safety within their 
group).  

We also acknowledge the observation by HM Coroner that our Safeguarding team and Safety 
team in terms of resource and reach are not on par with each other, and that safety has a different 
structure and approach. While there are historical reasons for this, we have listened carefully to 
the concerns raised. As outlined in Section 5, point 1, we are investing in and designing a new 
structure with significantly increased staff resources. This new staff team will work in partnership 
with a team of senior volunteers with appropriate skills and experience.  

Actions 

1.  As outlined within previous sections of our response, we are: 

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. 

b.  Investing in new staffing resources to significantly bolster our safety, 

adventurous activities, and training teams to work in partnership with our 
volunteer leadership. The new structure is to be agreed by the October 2024 Board 
meeting (with additional resources being recruited now). 

c.  Creating new safety suspension powers as part of how we operate. 
d.  Reviewing our approach to training at all levels, so we provide the right 

competencies, access to information and are clear on our rules with particular 
focus on safety requirements (linked to our external safety review) 

e.  The Scout Association Board have invested in a new Assurance & Audit staff 

team that is already starting to be built.  

2.  Additionally, to underpin our approach moving forwards, we are in the process of 

commissioning a new external strategic safety review. As outlined in Section 1 (point 
3), this will lead to: 

a.  A comprehensive independent review of our current safety practices (including 

the risk assessment process – identification, mitigation, change, review and sign-
off) to assess if learning is successfully delivered, appropriate and effective. 
b.  A review of our safety training and required competencies and skills and future 

approaches and syllabus. 

c.  The development of a revised safety framework and associated standards. 
d.  A yearly independent review of all safety policies and processes, similar to the 

work already undertaken by NSPCC on our safeguarding policies and procedures.  

Prevention of Future Deaths Response – The Scout Association 

Page 29 of 42 

 
 
 3.  Since 2018, we have held all-member calls, open to all volunteers with attendance of the 
entire volunteer leadership Team and Executive (staff) Leadership Team. We have a range 
of other communication methods so we can provide relevant and accurate information, 
and open communication. 

Prevention of Future Deaths Response – The Scout Association 

Page 30 of 42 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Section 11: Permit/ Licencing Schemes 
Finding 38 

The example of Sean Glaister 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. 

Permit Scheme 

We accept that Sean Glaister should not have been granted a Nights Away permit based on the 
information he provided.  

Permitting is a fundamental component to how Scouting operates and has a vital part to play in 
keeping people safe, especially in higher risk activities. To provide further assurance, many permit 
holders hold an externally recognised accreditation, which is used to assist with permit granting. 
This includes an external validation in areas such as mountaineering, water sports and 
adventurous activities.  

We accept the Coroner’s concerns regarding the Nights Away permit system and the 
circumstances when a permit is required. We will address them through the improvements in our 
permitting system outlined in detail in Section 3, point 6, as part of our new Adult Membership 
System. This will include the ability for all permitting to be fully digitised and auditable through the 
new online system. The new system will improve oversight, evidence, and approvals, so we have a 
consistent approach across Scouting.  

As we have detailed in Section 1, point 5, our new Audit & Assurance work has Permitting as one 
of the initial areas of focus. It will continue to make sure we deliver the safest of provision and that 
it is effectively monitored at UK, County and District level. However, we have taken immediate 
steps to undertake a full UK-wide review of permit holders to confirm they have been issued in 
line with our policies and rules.  

Finally, we are committed to externally reviewing our permitting scheme, working both with other 
NGBs and as part of our externally led strategic safety review. This will identify key issues and we 
will commit to any required changes. 

Actions 

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). 

Prevention of Future Deaths Response – The Scout Association 

Page 31 of 42 

 
 
 
 
 
 
 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). 

Prevention of Future Deaths Response – The Scout Association 

Page 32 of 42 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendices 

Appendix A – Planned actions & delivery dates 

As detailed within Section 2, page 10, we are currently undertaking a Fatal Accident Investigation 
into the Bens death. This will provide clear learning and recommendations shared with the family 
and HM Coroner including other relevant internal and external stakeholders. The main report is 
due in June 2024 

Below are the other key actions we are undertaking.  

Action 

No. 
1.    Develop and adopt a new Duty of Candour 
Policy which will be published by July 2024. 

2.   

Publish a new annual Safety Report that 
outlines our in-year learning reviews, lessons 
learnt, and actions taken. 

Delivery date 
July 2024 

Page 
6 

Annual – intended first 
report April 2025 

3.    Commission a new strategic partnership with a 

May 2024  

nationally recognised organisation that is a 
leader in safety to review our current safety 
practices, and act as a Third Party reviewer. 

4.    Working with our strategic partner, we have 
undertaken a comprehensive independent 
review of our current safety practices with clear 
recommendations for action. 

-  Review all existing and proposed safety 

training and seek external 
accreditation. 

5.    Working with our strategic partner to undertake 

a yearly review and audit of all safety policies 
and processes at The Scouts, similar to the 
work already undertaken by the NSPCC on our 
safeguarding policies and procedures. For 
2024, this review will form part of the 
comprehensive independent review above and 
be repeated annually. 

Initial review by October 
2024 

Annually – first review 
September 2024 

6.    We will engage with National Governing Bodies 

Initiated by June 2024 

6 

(NGBs) and other relevant partner 
organisations to understand how they exercise 
external oversight and apply standards to their 
subject areas. We will use this research to 
develop an improved approach to external 
oversight in Scouting. 

7.   

Introduce a new internal assurance function 
consisting of staff and volunteers, to monitor 
and audit at local level all our 8,000 charities 
and provide reporting nationally to the Board. 

April to November 2024 

7 

Prevention of Future Deaths Response – The Scout Association 

Page 33 of 42 

6 

6 

6 

6 

 
 
 
 
 
 
 
 
 8.   

9.   

Introduce the new Adult Membership System 
and associated improvements to managing 
safety compliance.   
Introduce a new Critical Incid

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

Scout Insurance Services Limited trading as Unity Insurance Services has received a copy of 
the prevention of future death and acknowledges receipt. As a subsidiary of The Scout 
Association, and with nearly 100 years of Scouting insurance experience, keeping young 
people safe from harm remains our priority, and we are working with the insurers and the Scout 
Association to support our customers. 

I believe, I was incorrectly named in the inquest as the Chair of Unity in 2018, however, the 
Chair at that time was Michael Trip.  

We take the conclusion of the inquest extremely seriously. We want to restate our 
wholehearted apology to Ben Leonard’s family and our deepest sympathies continue to be with 
his family and friends.” 

Kind Regards 

Chair of the Board 
Unity Insurance Services