Coroner raises safety concerns following a fatality during a walking activity

The inquest into the death of a teenager on Great Orme, Llandudno, in 2018 concluded recently. During, and following the inquest process, the coroner issued two reports to prevent future deaths.

The coroner’s concerns cover several areas including:

  • Organisational culture and management oversight
  • Implementation, control, and monitoring of organisational procedures
  • Leader training and assessment of competence
  • On the ground risk assessment and risk management
  • Activity leadership and supervision

Issues raised:

This incident highlights some key questions for adventure activity providers.

  1. How do you create and keep a culture where safety concerns are shared openly, where incidents and accidents are appropriately reviewed, and lessons are learned and shared?
  2. What arrangements do you have for ensuring that agreed organisational procedures are applied on the ground? How do you know these arrangements are effective?
  3. What arrangements are in place to recruit, induct, train, assess, deploy, and monitor activity leaders? Do the arrangements mean that on any given day the right young people will be doing the right activity, in the right place, with the right equipment, supervised by the right leaders?
  4. When and how are safety management arrangements reviewed and how do you ensure such reviews are open, reflective, and effective?
  5. How are activity plans approved? How do leaders know any limits to their freedom of action? How do arrangements deal with last minute changes to plans caused by staffing issues or poor weather?
  6. How do you ensure leaders are competent to correctly assess and manage the risks created by the activities, the environment, and the group?
  7. How is key safety information gathered, considered, and shared with all those who need it (e.g. the organisation, parents/carers, leaders, assistants, participants)?

The coroner’s comments in full and the reports are available at the Courts and Tribunals Judiciary website.


Posted 27/02/2024