An inquest is a process intended to determine the answers to four questions: who was the deceased, and when, where, and how the deceased came by his death? It must reach a conclusion as to the cause of death that must be expressed as one of a number of possible "short form" conclusions (examples of which are, "misadventure," "drug or alcohol related," "unlawful killing," "suicide") or if that is considered to be too limiting to properly describe the cause, a "narrative" conclusion (which is essentially a longer explanation of the circumstances of the death) may be used. The standard of proof is the balance of probabilities.

The conclusions of the inquest have no consequences for civil or criminal liability of the leader. It is separate procedures. The reason of the inquest is the investigation itself; however, the conclusions are often used as a springboard to civil litigation. 

In this case the jury reached a conclusion of "Unlawful killing." "Unlawful killing" means either muder, manslaughter (including gross negligence manslaughter) or infanticide.

A finding of Unlawful Killing by reason of Gross Negligence Manslaughter in an inquest must satisfy the same test that makes out the offence of Gross Negligence Manslaughter in a criminal court. In this case the test as applied to each individual Scout leader was:

(1) The leader must owe an existing duty to take reasonable care of the person.
(2) The leader must have negligently breached that duty of care.
(3) That breach of duty must have given rise to an obvious and serious risk of death.
(4) It must also be reasonably foreseeable at the time of alleged breach that the breach of that duty gave rise to a serious and obvious risk of death.
(5) The breach of that duty must have caused the death.
(6) The circumstances of the breach must be truly exceptionally bad and so reprehensible as to justify the conclusion that it amounted to gross negligence and required criminal sanction.

"Neglect" is a rider that can be appended to a short form conclusion. It is not a conclusion in itself and is concerned with failings that are gross and basic. There must be a clear and direct causal connection between the conduct described as neglect and the cause of death. The conduct must have caused the death in the sense that it ‘more than minimally, negligibly or trivially contributed to the death.’

The Scout Association is the World Organization of the Scout Movement's member for the United Kingdom. The national organisation is staffed by paid employees but individual Scout groups are run by volunteer leaders. On 26/8/18 Ben Leonard (aged 16) was attending a 3-day Explorer Scout trip in North Wales with 3 leader and 8 other Explorer Scouts. On the second day of the trip, a plan to climb up Mount Snowdon in North wales was rearranged due to poor weather conditions and the group instead went to Llandudno intending to walk up the Great Orme. The Great Orme is a rocky peninsula, surrounded on 3 sides by cliffs used for rock climbing. After breakfast, the Explorer Scout Leader and his son left to move his car. The two other leaders and the remaining Scouts proceeded up the Orme led by the Assistant Explorer Scout. No instructions were given to the Scouts and no written risk assessment of the walk was done prior to setting off. Ben and two of the other Explorer Scouts split off from the main group, taking a different path up the Orme. Part way up the Orme, the Assistant Scout Leader paused and broke away from the group. Near the top, the Assistant Scout Leader saw Ben and the two other Scouts on the grassy top of the Orme. The Assistant Explorer Scout Leader did not give any instructions to regroup, to stay on the main path, nor was any supervision offered to the three Scouts. Ben and the two other Scouts were left unsupervised and proceeded to walk to the cliff edge. Ben thought he could see a quicker way down the Orme and attempted to follow animal tracks down the cliff edge, but in attempting to do so he slipped and fell from the cliff. He initially hit a lower ledge, but did not stop and he continued to fall down the continuation cliff below. He landed on the 45 degree grassy slope below the cliff and rolled down it. Paramedics attended the scene and performed medical interventions and CPR, but Ben died due to head injury.

This was an inquest into Ben's death, which is a coroner (judge) led inquiry into the circumstances surrounding the death, with findings of fact and conclusions made by a jury. Legally represented Interested Persons included Ben's family, the Scout Association, and Scout leaders. The Interested Persons are not allowed to make submissions about the facts or preferred conlcusions, but may address the coroner about points of law, including which findings are legally safe to leave to the jury. The jury were left with the options of concluding that the death was a result of misadventure or unlawful killing, with or without the "rider" that a contribution was made by neglect on behalf of The Scout Association.

The Scout Association made the following formal admissions:

The Scout Association owed Ben Leonard a duty of care. The Scout Association was in breach of its duty of
care as a result of the failings on the part of one or other of the leaders, in particular: (1) there was a lack of risk assessment; 2) there was a lack of appropriate supervision; 3) there was a lack of the provision of
instructions; 4) Ben and the two other Explorer Scouts were permitted to venture alone without any guidance into a potentially dangerous environment. These breaches of duty caused Ben's death. [The Scout Association] made no suggestion of contributory negligence and did not blame Ben Leonard for any of the circumstances surrounding his fall.

The jury concluded that Ben had been unlawfully killed by the Explorer Scout leader and Assistant Explorer Scout Leader, contributed to by the neglect of the Scouts Association. It did not (and was not required to) give reasons.

After the conclusion was reached, the Coroner exercised his duty to write a letter to the concerned organisations outlining his concerns and inviting steps to be taken to prevent similar deaths in the future. The Coroner's letter included the following concerns:

There is no robust regulator who independently and periodically audits and inspects the systems, processes and training of The Scouts Association or the granting of permits for adventurous activities, hill walking and Nights Away permits.

An internal Fatal Accident Inquiry Panel Investigation has not been undertaken.

The online risk training given to volunteer leaders was not robust.

The volunteer leaders lacked knowledge about their training regarding safety and safeguarding, giving rise to a concern that other volunteers also lacked the same knowledge.

There was a general lack of proper auditing of the provision of training, which relied too heavily on the goodwill of volunteers.

The structure of the Scouts was such that the responsibilty for safty and safeguarding was deferred from The Scout Association to local areas, with the layers of heirarchy meaning that The Scout Association did not know how health and safety was executed at ground level. 

The case is interesting because it concerns the responsibilities of adult volunteers.

The Scouts is an organisation that provides adventurous opportunities to thousands of children. It is dependant on adult volunteers to provide the grassroots organisation and leadership of the Scout groups. Although this case did not concern a death whilst intentionally undertaking a climbing activity, it concerns the provision of adventurous activities by a volunteer organisation in a climbing setting. The cliffs of the Great Orme are a nationally significant climbing destination with fixed gear that is managed by the British Mountaineering Council.

The conclusion of unlawful killing by volunteer leaders is extremely serious, and may potentially have a significant effect on the provision of adventurous activities by volunteers in the future. The positive potential effect of these conclusions and the accompanying letter sent to ministers by the coroner (which included reference to a possible future public enquiry) is that the provision of adventurous, potentially adventurous or potentially dangerous activities may become safer. The negative potential effects are:

• A potential reluctance to volunteer to lead groups in adventurous, potentially adventurous or potentially dangerous activities.
• An increase in the need for professional/employed staff to administer and audit such activities with associated cost increases.
• Increased regulation of adventurous activities.
• A potential resultant fall in participation.