On the 25"h July 2014 commenced an investigation into the death of David Oghenekaro Dibie Efemena. The investigation concluded at the of the Inquest on the 7th September 2015. The conclusion of the Inquest was a narrative conclusion David Efemena was sleeping outside on a fieldcraft training exercise with the Air Training Corps on the night of the 22nd March 2014. At around 06.15 on the 23rd March; fellow cadets became concerned about David as he was shaking violently; breathing sharp breaths and not responding to their attempts to rouse. Following a period of the cadets observing David, the cadets experienced some difficulty in making contact with adult staff who were located 1.9 kilometres away: After contact was made staff attended at around 07:05. Resuscitation was commenced and was continued by the emergency services: There was no response to resuscitation attempts and David was pronounced deceased at the North Hampshire Hospital at 09.09 on the 23d March 2014. It is likely that David suffered a seizure from an unknown cause This triggered an irreversible cardiac arrest due to the presence of an anomalous origin of the right coronary artery:

As can be seen by the narrative conclusion, David attended a fieldcraft activity exercise with the Air Training Corps between the 21st 23rd March 2014 During the course of the early hours of the 23rd March 2014, cadet colleagues became concerned for David as he was shaking violently and taking sharp breaths. He was not responding to attempts to rouse: Attempts to contact adult staff who were located 1.9 kilometres away, took between 15 30 minutes When adult staff arrived, they found David unresponsive and not breathing: Resuscitation commenced but it was not possible to save David and he was declared deceased in hospital at 09.09 on the same day During the course of the Inquest the following findings of fact were made: In determining the location of the cadets and the location of staff overnight, there does not appear to have been a risk assessment; as required by ACP 16 end 23rd

There was no proactive consideration of the proximity between the cadets and adult staff when the decision was made for staff to stay in a location which was significant distance away from the cadets. There was no proactive consideration of the means of communication by the cadets with staff during the course of the night Specifically, the radios were not tested at an appropriate time and at the appropriate location, to ensure that contact could be made with staff during the night in the event of an emergency. There was no supervision of cadets between 22.00 hours on the 22nd March 2014 and 07:00 on the 23rd March 2014. There were insufficient numbers of staff to cadets for the exercise This was in breach of ACP 16.