Lessons to be learnt from the investigation and coroner's report into the accident at Great Orme, Llandudno, involving the death of 16 year old Benjamin Leonard on a Scout trip.
The incident:
On 26th August 2018 Benjamin Leonard lost his life on Scout trip after falling around 200 feet at Great Orme in Llandudno and suffering a head injury. The original plan organised by the Scouts had been to climb Mount Snowdon, however, due to poor weather conditions this was cancelled. The Scout Leader decided to take Ben and the rest of the group of scouts from Stockport on a trip to the Great Orme instead. Ben and two others became separated from the main group. Left unsupervised by the Scout leaders, Ben thought he could see a quicker way down, however slipped and fell from the cliff.
The Inquest concluded with a verdict of unlawful killing by the Explorer Scout Leader and Assistant Explorer Scout Leader, contributed to by the Neglect of the Scout Association.
We would encourage everyone to read the full report:
Benjamin Leonard – Prevention of Future Death Report No.2
Lessons Learnt
This tragedy highlights the devastating consequences that can result from an absence of planning, leadership, supervision, and risk management. The areas below and quotes included highlight the key areas of concern identified in the coroner's report and require consideration by all line managers. The four main areas of concern are:
- Written and dynamic risk assessments
- Training, Qualification, and Competence
- Effective Leadership
- Health and Safety Training
- Written and Dynamic Risk Assessments
Coroner's Concern: “There is not a full understanding of what a risk assessment is”
Written risk assessments are a crucial part of the process of evaluating the risk involved in an activity. The purpose of a written risk assessment is to provide information to enable the management of risk to prevent or reduce injury or ill-health. This means putting in place appropriate control measures in place to reduce the risk. A risk assessment should focus on identifying hazards and mitigating against risk before harm occurs.
A dynamic risk assessment is the continuous process of identifying hazards especially in a changing environment. This could be a change in weather conditions, river levels, tides, water pollution, or venue for an activity.
Both written and dynamic risk assessments must be carried out. Risk assessments are required for a range of different activities not just those on the water.
It is essential that staff responsible for writing risk assessments are trained and competent to do so. The following support is available for those responsible for carrying out risk assessments:
- Paddle UK Risk Assessment eLearning
- Paddle UK Risk Assessment Template
- Paddle UK Risk Assessment Guidance Notes
- Health and Safety Executive (HSE) Risk Assessment Template and Information
Risk assessments should be reviewed by a collective rather than an individual within a staff team. It is also key that those taking part in an activity understand the risk assessment and control measures in place, this would include athletes, staff, and contractors.
- Training, Qualification, and Competence
Coroner's Concern: “there are other appointed Leaders in post who are not suitably competent or qualified in respect of the fundamental issues of safety”
Staff that are responsible for delivering or supporting paddlesport activity must hold appropriate qualifications for the remit in which they operate.
The British Canoeing Awarding Body qualification matrices and environmental definitions document provide clear information on competence, relevant qualifications, experience and the process of ensuring staff are qualified to do the job.
In addition, staff delivering or supporting paddlesport activities must be up to date with current practice, have documented continual professional development, safeguarding and first aid training.
- Effective Leadership
Coroner's Concern: “There was no effective leadership for the group”
Effective leadership, briefing, and instruction is key to ensuring activities are carried out safely. In certain circumstances, there might be more than one qualified leader, in which case it is crucial that one person is in charge overall and takes responsibility for final decisions. Without this, there will be a lack of consistency and clarity among the group which can lead to confusion and things going wrong.
A key part of the leader's role is to set a positive safety culture in which individual's feel empowered to ask questions and raise concerns.
- Health and Safety Training
Coroner's Concern: “Safety training is predominantly done online”
Although there is scope for certain health and safety training to be provided online this should be supplemented by in-person training. The quality and substance of the training should be considered particularly where it can be completed in a matter of minutes.
Line Managers whose staff are delivering or supporting paddlesport activity should be up to date with other safety requirements. Line Managers responsible for deployment must ensure records are up to date of the training that has been completed.
Risk Assessment and Change of Plans
If plans change, which they often do, an updated written risk assessment must be completed to reflect the new plans, the hazards, and how risk will be managed.
Examples: When a New Written Risk Assessment Would Be Needed
It is quite common that a location, venue, or activity might change due to weather conditions, high river levels, or poor water quality. The following list provides examples of when a new risk assessment would be needed:
- Change in filming location for a media day
- Change in venue for training, a competition or an event
- Change in the activities planned for a recreational event, for example, from on the water activities to on land team building activities