Jack Saunders

Jack Saunders 

Prevention of Future Deaths  

Response from The Scout Association 

22 May 2026 

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Introduction 

On behalf of The Scout Association (TSA) we are responding to the Prevention of Future 
Deaths (PFD) report dated 31 March 2026.  

We offer this response with deep respect and regret for the tragic death of Jack Saunders. 
On behalf of TSA, we express our wholehearted apology to the Saunders family, 
recognising the impact it has had. 

We recognise our responsibility to learn openly, act on what we learn, and strengthen our 
safety guidance, procedures and policies. We do this by practically supporting our Lead 
Volunteers, Trustee Boards and County Safety Advisors to challenge and influence 
behaviours highlighted in the PFD, making sure these are embedded in how Scouts is 
delivered day to day, to help reduce the risk of future harm. 

Following receipt of the PFD report, we have carefully considered the Coroner’s 
concerns. In doing so, we have:  

• 

• 

• 

• 

• 

revisited the actions we have taken following the tragic incident in 2017 

reviewed our ongoing communications to volunteer members on Carbon monoxide 
(CO) safety  

reviewed our approach to safety learning and accessibility of training 

reviewed the reach and impact of our Gas Distribution Networks (GDN) partnership, 
specifically around their support with CO awareness 

reviewed our current practices with those of similar youth, outdoor and 
uniformed organisations.  

These reviews confirmed the controls that we already have but also identified some areas 
where we will strengthen our approach further. These are set out in detail against each 
Matter of Concern below. 

In our response to the PFD report, we first consider TSA's improvements regarding safety 
and specifically CO risks since 2017. We then address each of the Matters of 
Concern identified in the PFD report. We commit to reporting our progress on the actions 
openly through our website. 

As leaders of the Scout movement, we want to state our commitment to the safety of our 
young people and volunteers. We remain true to our values of integrity, respect, care, belief, 
and co-operation, and, through these values, to learning, honesty, and transparency.   

Chair of the Board 

Chief Executive 

UK Chief Volunteer 

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 How The Scout Association functions 

TSA operates through a federated structure of over 7,000 local charities, each with its own 
trustees and volunteer leadership. Local Groups are supported by Districts, Districts by 
Counties, and Counties by the Nations and the national charity The Scout Association. 

This structure relies on layered controls at local and national level. Our volunteer 
leadership and line management have a key role in creating the local culture where safe 
behaviours are the norm. Nationally, TSA sets rules and expectations, and provides 
learning, guidance, systems and tools to support. TSA’s structure makes assurance at scale 
an organisational challenge that we are continuing to work on. We have yet to be satisfied 
that we have achieved it to the level we would like. TSA is committed to this. 

Since 2017, we have strengthened our approach to improving visibility of local practice and 
compliance with key requirements such as mandatory learning, safer recruitment and 
Nights Away permits. This has included introducing digital systems to support tracking and 
monitoring and continued development of our internal assurance approach. 

Overview of improvements in CO safety  

TSA’s CO safety management approach has changed as direct result of this incident.  The 
initial learnings were enacted by June 2018 and further improvements have continued since 
then to support volunteers in using gas stoves and appliances safely while camping, 
highlighting CO risks. Our safe premises audit includes explicit checks on CO awareness, 
detection and monitoring. In 2021, TSA formed a partnership with Gas Distribution 
Networks (GDN), to learn from external advice and expertise to help us promote CO 
awareness with our membership. 

The comments made by the Coroner from the Inquest in 2020, and our own Fatal Accident 
Investigation* in 2017, have informed a programme of changes since then, including: 

•  Strengthened guidance 
•  Shared learning 
•  Clearer information 
• 
Improved support  

*A Fatal Accident Investigation is now described as a Fatal Incident Investigation, a TSA-
commissioned review by an independent panel led by an external chair.  

TSA’s approach to safety risk assessment and management has developed since 2017 
through both ongoing improvement work and specific projects. Current work includes a 
review of the Nights Away permit process, including CO safety while camping, and a 
separate review of wider safety risk management arrangements across the federated 
charity. 

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 
 TSA’s approach to learning and supporting young adults with additional needs 

We are committed to making our learning accessible, practical and relevant to real 
situations. Our learning is designed to support different ways of learning and is quality-
assured for accessibility, including against Web Content Accessibility Guidelines (WCAG) 
2.2 AA. We review feedback and how learning is applied in practice so we can continue to 
improve it. 

Communications supporting a safe culture 

Since 2018, our CO safety communications have moved from periodic guidance updates to 
regular year-round communications tailored to volunteers’ roles and responsibilities. 

Since 2018 this has included seasonal prompts, role-specific communications for leaders, 
safety advisers and trustees, and communication linked to learning and programme 
partnerships. In 2025 all our volunteers received CO safety communications three times 
which included linking to resources such as Think CO: Carbon Monoxide Awareness for 
Scouts, which was developed with the Gas Safe Charity. 

This approach has been strengthened through a partnership with Gas Distribution 
Networks (GDN), enabling nationally coordinated messaging that directs volunteers and 
young people to CO-specific resources, e-learning, activities and badge content for young 
people.  

CO safety partnership  

Accepting that we can learn from insight and experiences of others, since 2021 TSA has 
worked in partnership with GDN. GDN comprises of four operating companies: Cadent Gas, 
Northern Gas Networks (NGN), SGN, and Wales and West Utilities (WWU). The output of 
the partnership has included: 

•  GDN-partnered CO safety messaging is reinforced through Scouts programme 

planning content and targeted communications for volunteers, supporting a safety 
culture where learning is embedded, practical and repeatable.  

•  Children and young people learning through our programme is recognised through 
badges earned. In 2024-5, 14,052 Cub Scouts (8-10½-year-olds) earned their 
GDN-partnered Home Safety activity badge which includes gas safety. A further 
8,501 badges being earned in 2025–26. Across the 2024–25 and 2025–26 
reporting years, GDN-partnered CO activities available on the TSA website recorded 
12,250 unique views.  

•  The CO Awareness blanket badge has been awarded 900 times since it launched in 
November 2024, indicating CO risk awareness reaches young people beyond the 
structured learning needed to earn activity badges.  

•  The GDN partnership renewed in April 2026, with plans to expand to the older 

youth sections, including a new activity planned for Scouts aged 14–25-years-old 

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 that will focus on CO awareness. This activity will target known transition risks for 
young people leaving home for the first time.  

Section 1: Equipment instructions and guidance 
Matters of Concern 1“The equipment that had been borrowed had no instructions available 
as to their use, and although there were illustrations/instructions on the equipment itself 
warning against use in enclosed spaces, these were small and could have been clearer.”  

What we do today  

•  As a result of the incident, TSA’s guidance since 2017 

has explicit “don’t” statements on the use of 
gas, heating and cooking equipment in small spaces or 
areas where people sleep.  

•  Placing greater emphasis on practical CO safety controls, 
including CO alarms, ventilation, equipment condition and 
emergency response. This is reinforced consistently through 
guidance, learning and communications.  

•  Building CO considerations into the updates for all relevant 
guidance updates including food safety, fire safety, safe 
premises audits, camping guidance, 
emergency procedures and safety checklists.  

•  CO risk is integrated across all relevant resources to make it 

as easy as possible for event leaders and others to 
understand and mitigate the risks. This includes instructions 
for camping gas use, emergency procedure guidance, safe 
premises audits for local trustees, digital content on TSA 
website and email communications. In 2017 volunteers had 
to refer to a specific, standalone factsheet.  

•  CO and safe premises guidance is reviewed by our safety 
team on a regular basis every three years, with the next 
review due to publish in June and September 2026 
respectively. Regular, consistent promotion of CO alarms 
and warning posters are shared through safety notices to 
volunteer leadership and digital communications.  

We will keep 
improving by 

Reviewing and improving the CO information in Scout activity sites 
by October 2026. 

Strengthening the visibility of safety information and instructions at 
the point of use by October 2026. This includes:  

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 
  
 
 
 •  Providing stronger guidance with specific mention of safety 

checks for volunteers inspecting and maintaining 
equipment, including gifted and legacy-owned equipment 
held locally. 

•  Setting clear expectations that all shared, gifted, legacy-
owned or borrowed equipment must display appropriate 
safety warnings. 

•  Making additional CO warning labels and supporting 

resources available where labels are missing, unclear or 
damaged, so volunteers can readily reinforce safety 
messages at the point of use. 

Section 2: Sharing knowledge around the risks of CO poisoning 

Matters of Concern 2 

“That on the finding of the jury, whilst knowledge around the risks of CO poisoning was 
known and training had been prepared nationally, this had not reached the trainers within 
individual troops.”  
What we do today  

•  CO knowledge is checked in the TSA assessment checklist for 

a Nights Away Permit AC120900 section 5: choosing, 
organising and maintaining the right equipment for camping, 
“Understand the risk of CO poisoning and its cause.” 

•  Since 2018, our CO safety communications have moved from 

periodic guidance updates to regular year-round 
communications tailored to volunteers’ roles and 
responsibilities. These include GDN-partnered and seasonal 
volunteer communications that reinforce key safety messages 
about CO risk.  

• 

In 2020, TSA established a TSA Safety Advisor role to 
support with local advice and sharing awareness for County 
teams. In 2024 this expanded to District Safety Advisors to 
support District teams as well. 

•  CO risk is embedded and reinforced across safety training, 

Nights Away permits, camping and safe premises guidance, 
safety checklists and youth programme partnerships, rather 
than being isolated to one briefing.  

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 
 
 •  The relevant District or County Lead Volunteer or nominee is 
responsible for approving nights away for groups of adults, 
where each individual is aged 18 and over. This includes 
reviewing the risk assessment, which contributes to ensuring 
that CO risk knowledge is present in individual groups. This is 
detailed in our Policy, Organisation and Rules document 
(POR) - rule number 9a.1.3.2. 

•  Where an adult volunteer or young person may be 

considered to be lone working as part of their Scouts 
activities (i.e. where a member is operating under Policy, 
Organisation and Rules and seen to represent The Scout 
Association), the relevant District or County Lead Volunteer or 
nominee is responsible for approving it. A risk assessment 
must be completed which includes highlighting potential CO 
risks relevant to the overnight stay and the different types of 
stoves being used. An InTouch system must be in place, 
which is the system used to manage communications at all 
Scout activities and events. TSA supports volunteers to 
understand lone working through both the regular safety 
communications shared with all members and including it in 
briefings at inductions, workshops and webinars. 

•  We revised our mandatory Safety e-learning that all 

volunteers had to complete in 2025, to make people aware of 
their safety responsibilities and give them an understanding 
of safety risk management, including their responsibility to 
look for hazards and manage them. This included specific 
manager-level training as well. We engaged with the Royal 
Society for the Prevention of Accidents (RoSPA) to make sure 
technical accuracy and the learning was RoSPA Assured.  
While this does not specifically reference CO, ensuring 
people have access to the up-to-date national training and 
understand their responsibility to look for hazards contributes 
to our safety culture.  

•  Over the last couple of years, we have started to shift from 
just publishing guidance to also certifying local practice and 
compliance with key safety requirements. Self-certification 
took place in 2024 and in 2025 we took samples across the 
organisation to check how safety learning is converted into 
practice. This informs plans for sustained and ongoing self-

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 
 
 assessment against key standards in Safety, Safeguarding 
and Local Governance to be developed in 2026 and rolled out 
in 2027. Structured oversight of local practice will also be 
strengthened as a result.  

• 

Incident reporting, moderation and dashboards provide 
visibility for volunteer and staff teams in the UK charity, 
nation-level and County level, confirming that 
reporting, learning and awareness are accessible and 
available locally. On 9 February 2026 TSA wrote to and 
asked all Trustees to confirm this reporting is being 
considered. 

•  Use of incident data and near-miss reporting 

to identify learning themes, shared through case studies, 
improved guidance, direct communication and through the 
County Safety Adviser network. 

•  At the UK level we have a trustee-chaired safety committee 

with independent safety professional members, an appointed 
senior volunteer in our TSA leadership team, regular cross-
functional review of safety incidents by safety specialist staff 
with teams involved in implementing learning. 

Issuing a specific safety alert and learning notice by 26 June 2026 to 
bring this PFD and TSA’s response to the attention of all volunteers. 
The notice will require lead volunteers and board members of our 
more than 7000 Scout charities across Groups, Districts and Counties 
to: 

reaffirm their knowledge around the risks of CO poisoning  

• 
•  confirm that practices for CO safety are understood and 

• 

applied by their volunteer teams 
review and, where needed, improve CO safety information 
displayed using the TSA CO-awareness poster at meeting 
places, campsites and activity centres (referenced in Matter of 
Concern 1) 

Promoting to volunteers our safe premises audit tool, Nights Away 
permit review and CO safety as part of our annual communications 
plan to address how stoves should be used. 

Implementing a new assurance framework that will require more 
regular self-assessment. Adding support and structure for Districts 

We will keep 
improving by 

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 and Counties to check self-assessments and support local charities 
in the improvement plans that result from the self-assessment. 

Strengthening our County Safety Advisor network through regular 
briefings. 

Provide a new CO safety awareness activity with the GDN 
partnership for Scouts aged 14–25-years-old and update the GDN-
partnered learning content to include more on the danger in tents. 

Section 3: Learning styles and observing incorrect practice 

Matters of Concern 3 

“That Jack, even if informed of the risks, had observed other adult leaders using gas-
fuelled equipment in tents, particularly mess tents, on previous camps, and due to his 
visual learning style, would have placed greater reliance on the same.” 

What we do today 

TSA recognise that while national guidance and learning existed, it 
was not sufficiently embedded in local practice and leadership 
behaviours to prevent unsafe practices being seen and learned. 
While TSA has no evidence that gas equipment misuse is normal 
practice TSA recognises that the practices people see around them 
are what they are likely to practise regardless of learning 
preferences. We influence local leadership behaviour and practice 
by: 

•  ensuring access for volunteer leaders to training about 
inclusion and supporting young people with additional 
needs, contributing to our commitment to inclusion. 

•  continuously improving learning and training based on 

gathering insights from volunteers and to what extent they 
find the learning practical, relevant, useful and applicable to 
their role. 

•  prompting to consider the specific additional needs of 
individuals in a group through our risk assessments, 
following the Health and Safety Executive (HSE) 5 steps 
approach to risk assessment where in step 2 the assessor 
decides who might be harmed and how. 

•  explicitly making safety a leadership responsibility, with 

expectations around visibility, challenge and learning from 
incidents. These clear expectations for leaders about role-

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 
  
 
 modelling safe practice and challenging unsafe behaviours, 
are reinforced through guidance, briefings and shared 
learning. 

•  safety expectations are reinforced 

through role-specific safety checklists (Trustees, Lead 
Volunteers, Team Members).  

•  safety is maintained as a standing agenda item at trustee and 

leadership meetings.  

• 

leadership briefings, webinars and regular volunteer 
communications which have been introduced since the 
incident, including the GDN-supported CO risk 
resources, materials and engagement through social media.  

•  ongoing promotion of near-miss reporting and learning 

reviews, and tracking that near-miss reporting is improving 
as part of a positive safety culture 

 We will keep 
improving by 

Including CO safety in the leadership briefing to County Safety 
advisors during their next quarterly meeting. 

Including CO safety in the bi-monthly briefings for lead volunteers 
and trustees with safety and premises responsibilities. 

Improving education on and guidance for how volunteers enhance 
how reasonable adjustments are considered in activity planning. 

Introducing a simple visually-led poster that improves likelihood of 
understanding by those with visual learning styles or preferences. It 
will show the signs of CO poisoning and how to respond in a clear 
pictorial design. These will be made available as printed posters 
from Scout Store and downloadable from our website to be 
displayed in meeting places, campsites, residential buildings and 
activity centres.  

Continuing to strengthen how we target support and interventions, 
so that the CO risk is understood by leaders and acted upon. 

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 
 
 
 Sharing learning with other providers 

TSA’s view is that other organisations should also learn from this tragic incident and TSA 
will continue to share learning about CO risks with other providers over the next 12 
months. TSA also continues to learn from other organisations, meeting with National 
Governing Bodies for outdoor activities regularly. At these meetings safety learning is 
discussed, including CO safety and support for volunteers to lead safely. We also meet 
regularly with other uniformed youth and outdoor activity organisations. 

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 
 Consolidated actions 

Matter of Concern 

Action 

Action 
ID 
1 

2 

Matter of Concern 1: 
Equipment 
instructions and 
guidance 
Matter of Concern 1: 
Equipment 
instructions and 
guidance 

3 

Matter of concern 2: 
Sharing knowledge 
around the risks of CO 
poisoning 

Timing 

By October 
2026 

By October 
2026 

By 26 June 
2026 

Reviewing and improving the CO 
information for Scout activity sites by 
October 2026. 

Strengthening the visibility of safety 
information and instructions at the point of 
use by October 2026. This includes:  

•  Providing stronger guidance with 

specific mention of safety checks for 
volunteers inspecting and 
maintaining equipment, including 
gifted and legacy-owned equipment 
held locally. 

•  Setting clear expectations that all 
shared, gifted, legacy-owned or 
borrowed equipment must display 
appropriate safety warnings. 
•  Making additional CO warning 

labels and supporting resources 
available where labels are missing, 
unclear or damaged, so volunteers 
can readily reinforce safety 
messages at the point of use. 
Issuing a specific safety alert and learning 
notice by 26 June 2026 to bring the PFD 
and TSA’s response to the attention of all 
volunteers. The notice will require lead 
volunteers and board members of our more 
than 7000 Scout charities across Groups, 
Districts and Counties to 

• 

reaffirm their knowledge around the 
risks of CO poisoning  

• 

•  confirm that practices for CO safety 
are understood and applied by their 
volunteer teams 
review and where needed improve 
CO safety information displayed 
using the TSA CO-awareness poster 
at meeting places, campsites and 
activity centres, referenced in Matter 
of Concern 1. 

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 Action 
ID 
4 

5 

6 

7 

8 

9 

10 

Matter of Concern 

Action 

Matter of Concern 2: 
Sharing knowledge 
around the risks of CO 
poisoning 

Promoting to volunteers our safe premises 
audit tool, Nights Away permit and CO 
safety as part of our annual communications 
plan to address how stoves should be used. 

Matter of Concern 2: 
Sharing knowledge 
around the risks of CO 
poisoning 

Implementing a new assurance framework 
that will require more regular self-
assessment. Adding support and structure 
for Districts and Counties to check self-
assessments and support local charities in 
the improvement plans that result from the 
self-assessment. 

Timing 

July 2027 

Complete 
pilot by 
March 
2027 

Matter of Concern 2: 
Sharing knowledge 
around the risks of CO 
poisoning 
Matter of Concern 2: 
Sharing knowledge 
around the risks of CO 
poisoning 

Matter of Concern 3: 
Learning styles and 
observing incorrect 
practice 
Matter of Concern 3: 
Sharing knowledge 
around the risks of CO 
poisoning 
Matter of Concern 3: 
Learning styles and 
observing incorrect 
practice 

Strengthening our County Safety advisor 
network through regular briefings 

March 
2027 

Provide a new CO safety awareness activity 
with the GDN partnership for Scouts aged 
14–25 years and update the GDN-
partnered learning content to include more 
on the danger in tents. 

By April 
2027 

Including CO safety in the leadership 
briefing to County Safety advisors during 
their next quarterly meeting. 

Including CO safety in the bi-monthly 
briefings for lead volunteers and trustees 
with safety and premises responsibilities. 

Improving education on and guidance for 
how volunteers enhance how reasonable 
adjustments are considered in activity 
planning. 

30 June 
2026 

31 July 
2026 

July 2027 

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The Scout Association, May 2026 – Prevention of Future Deaths Response 

 
 
 
 
 
 
 
 
 Action 
ID 
11 

Matter of Concern 

Action 

Matter of Concern 3: 
Learning styles and 
observing incorrect 
practice 

Introducing a simple, visually-led poster 
that improves likelihood of understanding 
by those with visual learning styles or 
preferences. It will show the signs of CO 
poisoning and how to respond in a clear 
pictorial design. These will be made 
available as printed posters from Scout 
Store and downloadable from our website 
to be displayed in meeting places, 
campsites, residential buildings and activity 
centres.  

Timing 

30 
September 
2026 

12 

13 

Matter of Concern 3: 
Learning styles and 
observing incorrect 
practice 

Continuing to strengthen how we 
target support and interventions so that CO 
risk is understood by leaders and acted on. 

Sharing learning with 
other providers 

Continue to share TSA’s CO learnings with 
other providers over the next 12 months 

Ongoing 
work, next 
review 
point in 
April 2027 
Summer 
2027 

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The Scout Association, May 2026 – Prevention of Future Deaths Response