Home / Insight / Prevention of Future Deaths: Ben Leonard

Prevention of Future Deaths: Ben Leonard


Kathryn Quinley reflects on what’s next following the conclusion of the inquest touching upon the death of Ben Leonard at the Manchester Civil Justice Centre on 22 February 2024.

Kathryn, ably assisted by Lisa Judge of Counsel (Deans Court Chambers) represented the interests of a Group Scout Leader during the course of the proceedings. The inquest was unusual given it was the third inquest after two previous aborted attempts. Disclosure amounted to over five million pages, the number of interested persons extended into double figures and there were near daily submissions on complex matters of law.


Ben Leonard was among a group of Explorer Scouts visiting Llandudno’s Great Orme when he fell 200ft (60m) from cliffs in August 2018. The group had originally planned a hike up Yr Wyddfa, also known as Snowdon, however, poor weather conditions forced a change in plans. Instead, the Scouts and their Leaders made their way to Llandudno where they embarked upon a country walk up the Orme.

Ben and two other boys broke away from the main group and took their own unsupervised route up the hillside. Evidence heard from the boys who were with Ben at the time was that he thought he could see a quicker way down the Orme. Tragically, he slipped off a narrow cliff edge and fell, suffering fatal head injuries.

After seven weeks of evidence, a jury of ten returned a conclusion of unlawful killing, contributed to by neglect.

Prevention of Future Deaths Report

Prevention of future deaths reports (PFD Reports), also known as ‘Regulation 28 Reports’, are made pursuant to Paragraph 7(1) of Schedule 5 of the Coroners and Justice Act 2009 and Regulation 28 of the Coroners (Investigations) Regulation 2013.

Under the legislation, the coroner has a duty (not a discretion) to take action to prevent future deaths where:

  1. A coroner has been conducting an investigation into a person’s death;
  2. Anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist in the future; and
  3. In the coroner’s opinion, action is required to prevent the continuation of such circumstances, or eliminate or reduce the risk of future death created by such circumstances.

In this case, HM Coroner Mr David Pojur revealed at the conclusion of the proceedings that he had already written a comprehensive PFD Report. Among the forty concerns cited, Mr Pojur states that there is no “culture of candour” within the Scouts Association and no robust regulator who independently and periodically inspects the systems, processes and training in place. Mr Pojur is critical of the training available, stating that although safety policies existed, they were “not adequately understood at grass roots level”.

Among others, Mr Pojur has sent his report to The Scouts Association, the Secretary of State for Education, the Children’s Commissioner for England and Wales and the Health and Safety Executive. The named bodies have until 18 April 2024 to formally respond.

Public Inquiry?

Public inquiries are investigations set up by Government ministers to respond to events of major public concern. In the UK, public inquiries are conducted by a senior official, often a judge, who will review documents, hear witness evidence and evidence from experts, draw conclusions and make recommendations.

Whatever the focus of the inquiry, the purposes of all inquiries remains the same – to establish the facts, find out what happened, why it happened, who may be accountable, and to try to learn lessons to prevent a recurrence of the events. Public inquiries are an inquisitorial rather than an adversarial process and those tasked with leading them cannot make decisions about a person’s or organisation’s civil or criminal liability.

The family of Ben Leonard has called for the urgent establishment of a public inquiry under the Inquiries Act 2005 as it is said there are matters of concern in respect of system issues relating to safety and safeguarding. Mr Pojur acknowledged the family’s concerns and has since written to Government ministers.

A government spokeswoman said: “Our deepest sympathies are with Ben’s family and friends. Keeping young people safe should always be the first priority.” However, as there is an ongoing investigation following referrals to the police to investigate allegations of conspiracy to pervert the course of justice (related to previous inquest proceedings), no further comment is possible at this time.

For queries or to discuss advice and representation in connection with inquest proceedings, please contact our specialist Crime & Regulatory department.



Kathryn Quinley, Associate

Email: KTurner@keoghs.co.uk

Stay informed with Keoghs


Our Expertise


Claims Technology Solutions

Disrupting claims management with innovation & technology


The service you deliver is integral to the success of your business. With the right technology, we can help you to heighten your customer experience, improve underwriting performance, and streamline processes.