Coroner issues Report to Prevent Future Deaths following tragic death of Scout in 2018

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13 March, 2020

Ridwaan Omar
Partner and Head of Regulatory

In 2018, Ben Leonard, age 16, was on an arranged Scout trip. The group went up the Great Orme in Llandudno. Ben was with two other friends when they went on a different path and split off out of sight from the rest of the group. One leader was aware of this. Ben wandered around the cliff tops, he slipped and fell 200ft. He sadly died from a head injury.

A 5 day jury inquest was held in early February 2020. During the course of the inquest, evidence revealed matters giving rise to concern. The Coroner, David Pojur, determined there was a risk that future deaths will occur unless action is taken and issued a Regulation 28 Report to Prevent Future Deaths. He listed twenty matters of concern in the report including:

  • The arranging of the trip did not adhere to the Scout Association's own safety policies.
  • There was no written risk assessment.
  • There was not a full understanding of what a risk assessment is.
  • No instruction or briefing was given to the boys.
  • Each of the three leaders assumed the three boys were with one of the leaders when in fact they were not. They were on their own.

It also emerged during the inquest that the Scout Association had failed to tell the inquest that the leaders had been placed on restricted duties after the death which had "created a misleading impression". As a result of this new information, the jury had to be discharged and a second inquest is due to be heard in July 2020 where the Chief Executive of the Scout Association is expected to be called to give evidence.

Forbes comment

The Scout Association must now respond to the PFD report within 56 days (by 3 April 2020) and their response must contain details of actions taken or proposed together with a timetable for completion.

A published statement from the Scout Association has already said:

"We were truly saddened by Ben's tragic death…. We will be carefully considering the coroner's concerns and will respond in detail. The safety of young people is our number one priority. Following this tragic event, we have strengthened our policies and procedures to ensure young people can enjoy activities safely."

Copies of the PFD report will have been sent to the Chief Coroner and any interested persons, and they shall await a response with interest.

Regulation 28 PFDs are of course intended to improve public health, welfare and safety. They form a very important part of the Coroner's duty to investigate and are issued whenever a Coroner believes that improvements need to be considered to prevent future deaths.

Concerns often emanate from exposed operational or systemic failings within an organisation's policies, risk assessments or procedures. In the instant case Coroner Mr Pojur stated;

"The lives of young people are being put at risk by the Scout Association's failure to recognise the inadequacies of their operational practice and the part this has played in the death of Ben."

A clear concern of the Coroner was the fact that the Scout Association cannot know how its health and safety is being executed at ground level due to being distant from its membership and federated branches of 8000 charities and hierarchy.

All forms of planned trips, including school trips, should be adequately and appropriately planned, controlled, supervised, monitored and managed and robustly risk assessed.

Source :

For more information contact Lucy Harris in our Insurance department via email or phone on 01254 222443.

For more information contact Ridwaan Omar in our Insurance department via email or phone on 01254 222457. Alternatively send any question through to Forbes Solicitors via our online Contact Form.

Learn more about our Insurance department here

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