Great Orme – Fatal Accident Investigation Panel Report(s)

A Fatal Accident Investigation Panel, with an external chair and independent panel members, was initiated within 48 hours of the conclusion of the inquest. 

It is to be noted that as part of The Scout Association’s response to the Coroner’s Prevention of Future Deaths Notice, we would use the term ‘fatal incident’ instead of ‘fatal accident’ in any future reference to this incident.  

However, this report uses the term Fatal Accident Investigation Panel as that is the name the panel was commissioned under.  

Remit of the reports

The Panel’s first report provided a narrative regarding the actions taken at the time and in the immediate aftermath of the Great Orme incident. The second report covers the period from the immediate aftermath to 2024. 

The Panel’s findings do not identify or attempt to apportion individual fault or blame. However, they do identify challenges between groups and collectives, and highlight cultural differences and disagreements which may have led to certain courses of action. The findings are the Panel’s interpretation of the evidence they have reviewed. 

Fatal Accident Investigation Panel Phase 1 Report

The Panel’s first report, delivered in July 2024, made nine recommendations relating to: 

• The nights away process 
• Compliance with The Scout Association’s Policy, Organisation and Rules (POR) 
• Volunteer competence 

As part of the Panel’s second report, they reviewed the progress against the recommendations made in the first report. The Panel provided comment against the action taken so far in response to each recommendation, highlighting where The Scout Association (TSA) may want to consider additional work. These areas include: 

• Expansion of work to review permitted activity approval - now includes non-permitted activities 
• Ensure the new TSA Assurance function is fully implemented 
• Apply concerted effort to change safety culture given previous resistance to change 
• Further enhancement of digital tools to reduce volunteer workload 
• Removal of blanket requirement for all activities to be risk assessed individually, enabling greater focus on higher risk activities 

The phase 1 report and its recommendations were fully accepted by the Board of Trustees. TSA also fully accepts and is working to address the additional comments made by the Panel.  

A detailed breakdown of the recommendations and TSA’s status of delivery can be found in Appendix 1. 

Fatal Accident Investigation Panel Phase 2 Report 

The second FAIP Report contains 33 recommendations in addition to those in the first report. The Board of Trustees accepted all recommendations from this report. Many of the recommendations already being addressed either through the PFD Programme of work or our ongoing ‘business as usual’ Safety work.  

Recommendations are split across a series of outcomes: 

1. Ensure all health and safety-related incident investigations are effective, consistent, timely and systematic. 
2. Enable the Senior Leadership teams [the Panel use this term to reflect those who can influence what happens within the Movement] to manage health and safety effectively throughout the Scouting Movement, including proper serious event/incident investigation, by ensuring they have a breadth and depth of health and safety knowledge. 
3. Ensure families and members affected by serious health and safety incidents are appropriately supported. 
4. Ensure that when leaders are restricted, suspended or removed from their roles, the process is objective, consistent, logical and clear. 
5. Improve day-to-day health and safety in the Scouting Movement by ensuring its structure, and the way in which TSA and the volunteer line management chain interact, support this objective. 
6. Improve the safety culture of the Scouting Movement and ensure all members understand their legal and ethical accountability. 
7. Enable high risk activities to be delivered safely by creating a culture where planning to mitigate risk is seen as essential. 
8. TSA should manage organisational change with a thorough consideration of the risks and potential unintended impacts. 

A detailed breakdown of the recommendations and TSA’s status of delivery can be found in Appendix 2.