Motion made, and Question proposed, That this House do now adjourn.—(Dr Thérèse Coffey.)
Before I call the hon. Member for Dagenham and Rainham (Jon Cruddas), I should advise the House that, although a date has been set for the inquest into the death of his constituent, I have exercised the discretion given to the Chair in respect of the resolution on matters sub judice to allow debate on this matter. I know that the hon. Gentleman and the Minister will refrain from discussing the matter that it is for the inquest to decide, which is the cause of death.
Tonight, I wish to raise a number of issues regarding the tragic death of my constituent Mr David Efemena.
First, I thank you, Mr Speaker, for the waiver of the sub judice rules regarding Adjournment debates, which is needed because the pre-inquest hearing begins on 17 November 2014. The issues that I will cover do not relate specifically to the findings of the coroner on the reasons for David’s death, which is why the waiver was granted, and the family very much appreciate that. Rather, I will focus on the events that took place in the camp that night, the camp protocols on the duty of care, and the questions of supervision and effective communication between adults and cadets.
David died at 14 years of age on 23 March 2014. He would have celebrated his 15th birthday last Wednesday. By all accounts, he was a strong, sporty, athletic young man. David went on an air cadet camping trip on Friday 21 March 2014 at the Bramley defence training estate in Hampshire. On Sunday 23 March, at about 9 am, his parents Zoe and Felix received a telephone call from Basingstoke hospital advising them that David was “poorly”. While they were still speaking to the hospital, the police arrived at their home in Elm Park in east London to take them to the hospital. Upon arrival, a lady detective met the family and said, “I’m really sorry for your loss.” That is how they discovered that their son had died.
I will provide a brief summary of the events that occurred on the base over that weekend before making some more specific points regarding David’s death. The summary is based on an oral report of the initial findings of the investigation that was given to the family on 27 March 2014. There are also some elements that come from the service inquiry report.
The training that weekend was to take place at training base A, with the use of areas known as A, B and C. A risk assessment, an emergency action plan and a military training plan were all included in the Bramley application for the weekend. There were 13 male cadets and two female cadets on the trip, together with three staff members. Two of the senior cadets were responsible for the supervision of the cadets at the campsite, leaving 13 cadets taking part in the exercise.
On the first night, Friday night, everyone slept in the building at training base A because the group arrived late. Following a 6 am start, the Saturday was spent setting up camp and practising patrolling, followed by an escape and evasion exercise, with four cadets evading and nine hunting, one of whom was my constituent David Efemena. The staff ordered the cadets to go back to their bashers after 10 pm on the Saturday. The staff then went back to training base A, which was 1.9 km from the cadets’ camping sites, according to the service inquiry report. It took members of the service inquiry team about nine minutes to drive between the two sites when subsequently investigating the events of the weekend.
Two-way radios were supplied to each group to retain contact. The last actual contact between staff and the group took place at 10.15 pm, according to an oral report of the initial findings of the investigation that was read out to the family on 27 March 2014. The next morning at between 6.20 and 6.30 am, as the staff leader was walking to the cadet site, he began to receive intermittent radio messages, but could not make out what was being said. At 6.45, he received a clearer message that the cadets could not wake David. The staff arrived at the campsite at approximately 7.5 am. On realising the condition that David was in, they called for an ambulance while administering cardiopulmonary resuscitation. They were joined by another ambulance and then an air ambulance and the police.
According to an interview with a fellow cadet and tent mate, David had complained on the Saturday afternoon, 22 March 2014, about an old rugby injury to his back and of feeling sick. Later, a rota for sentry patrols was established for that night, although David was excused given how hard he had worked carrying heavy equipment that day and because there was an odd number of cadets to divide up. However, I should add that it was suggested in the evidence of other cadets that he was relieved of duty because of his sore back.
Sometime after 11 pm, the cadets went to bed. David’s tent mate has said that he was woken on up to 10 separate occasions through the night by strange noises and shaking from David. Each time he tried gently to shake David to wake him, but at no time did he succeed. At 5 am, David’s tent mate relieved two others for sentry duty, which began about 4 metres from where David was sleeping. His tent mate says that he then heard what were described as “wild animal noises” coming from the direction of the tent and assumed it to be a wild animal. Those sounds were heard another two or three times that morning, and the tent mate, covered by a fellow 14-year-old cadet, went to see David, who by that stage was shaking violently. At about 6.55 am they again went to check on David, and they noticed that his eyes were wide open and realized that they could not wake him up. David’s tent mate woke the other cadets and was left with David for about 30 minutes until adult staff arrived.
There are slight discrepancies in timings throughout between the statements of the tent mate and the adults, but that is the basic series of events according to the police liaison officer assigned to the case.
On the cause of death, the family had a meeting on 28 March 2014 with the coroner’s officer David Richards, who had notified them that the coroner’s report would be completed after the receipt of reports from both Home Office and paediatric pathologists, the police report and the service inquiry report. During the meeting, David Richards stated that the preliminary medical report showed that David had a scarred indent kidney, fluid in his lungs, an enlarged heart and a swollen brain. Mr Richard discussed with the family the possibility that David’s heart was enlarged, and that it could have been hereditary and the reason for his death.
On 9 May, the family received a letter from the coroner Andrew Bradley, stating that he could
“confirm that Professor Sheppard has completed her examination and I have a natural cause of death for David. In those circumstances I have concluded my Investigation and released David for burial.”
Cardiac specialist Mary Sheppard had reported a discovered heart defect and concluded that death was due to natural causes. However, the forensic pathologist had not completed his report at the time, so the family’s concerns about the circumstances surrounding David’s death, particularly the lack of adult supervision, communication and early intervention, were not taken into consideration before the case was closed.
The family, my office and solicitors have made a number of requests for the reasons for the delay in completing the pathologist’s report and how Mr Bradley had come to his conclusion, but they have not been answered. Subsequently, the family had a phone call on Wednesday 3 July, and then they received a formal letter on 4 July that stated:
“Having regards to the history of the case and your concerns it seems appropriate for the matter to go forward to Inquest and for that purpose I have transferred jurisdiction to your local Coroner in Walthamstow.”
As you said, Mr Speaker, there are a number of questions to be answered about the process that cannot be covered here tonight. Instead, I want to raise a number of points relating to the events on the base that weekend. Following David’s death, the family were assigned a police liaison officer from the Hampshire major investigation team and a warrant officer from RAF Northolt. On 24 March 2014, the family presented the police liaison officer with a list of questions that needed answers regarding events at the camp on that Saturday night and Sunday morning. In an e-mail dated 2 April 2014, the police liaison officer said that
“these questions will be fully answered in time as all the information regarding the case is gathered together.”
The parents notified both the police and the RAF that they would carry out an independent examination, and the independent examination report was presented to the family last Thursday, 6 November 2014. The service inquiry report, with three A4 ring binders of reference documents, was handed to them last Saturday, 9 November, by the president of the board of the service inquiry team, Squadron Leader Paul Ellis, and Warrant Officer Duncan Andrews. Therefore, until last Saturday, the family’s only account of what had happened to their son had been provided on 27 March 2014—some seven and a half months earlier—when the police liaison officer and the RAF warrant officer verbally explained their initial findings surrounding the events of that night.
Despite the service inquiry report with three A4 ring binders of reference documents, many of the initial questions submitted by the family in late March 2014 remain unanswered. Those concerns cover three general areas, the first of which is the time taken to alert the adult in charge as to David’s condition that night, and therefore the medical attention given to David. The second is the protocols on the base regarding the supervision of cadets, and third is the possibility that the camp communication systems were faulty. The family believe that those factors might have made a difference to David’s survival that night, which is why I am asking these questions this evening.
Having read the completed service inquiry report, the following areas still need to be resolved. On the diagnosis of David’s condition and communication on the base that weekend, the following questions need to be answered: when David initially declared that he was unwell, how was that managed and monitored, and by whom? It would appear that the adult in charge did not have the next of kin information. The parents were informed of David being “unwell” from Basingstoke hospital, and did not receive any communication from the RAF. As I mentioned earlier, they were informed that David had passed away by the hospital on arrival in Basingstoke, but prior to that there had been no contact between the RAF and the family.
What are the protocols for determining a suitable camping area, or on the distance between adult supervisors and cadets? What are the emergency protocols in such environments? In this case, the service inquiry report details the distance from the camp site where the cadets were based to training base A where the adults were as some 1.9 km—approximately a nine-minute drive. According to the service inquiry report, the original camp area that was planned to be used that weekend had been changed, and an alternative camp area had to be used due to the cadets’ late arrival on the base on Friday 21 March 2014. The service inquiry report highlights that no risk assessments or other checks were carried out on the alternative site prior to its use.
From the time that David was first believed to be shivering at about midnight, causing initial concern in his fellow cadet, were the first aiders made aware of his condition? What “escalation process” was in operation that night for cadets if they had concerns about their tent mates? As I have mentioned, David’s tent mate had concerns throughout the night and attempted to wake him on approximately 10 separate occasions. The parents were not informed of David’s condition before the police attended the scene, so why was that the case? Overall, from about midnight until around 5 am on 23 March 2014, David had shown symptoms giving rise for concern. Would earlier medical intervention have given him an opportunity to survive if an adult, and not a fellow 14-year-old cadet, had assessed his situation?
The second area of concern relates to supervision on such training camps. Are parents aware when their children go on training trips that they are being cared for by 17-year-old senior cadets and not necessarily by adults? Should parents be made aware that there is not 100% adult supervision at all times, prior to signing the “Activities, Consent and Health Form”? If adults are not within close proximity to the cadets at the camp site, what protections should ensure communication between the sites in the event of illness and escalating health concerns? Should camp protocols ensure that “experienced” and not just “qualified” first aiders are available at the camp site. The three senior cadets in charge had received “Heart Start” first aid training, but did not know what to do when David’s situation was assessed—that point is made in the service inquiry report.
Did any of the adults know that David had been unwell prior to leaving the camp that Saturday night, and were any plans in place to monitor his health? Why did the cadets not contact an adult on 22 March 2014 from about midnight, when there was first cause for concern? The report suggests a “lack of process” or “non-compliance of process”. Is that because of the lack of effective camp protocols in terms of supervision and medical diagnosis and care?
The third area relates to equipment. The preliminary report from the police investigation highlighted that the communication system was not working and that it took one of the cadets approximately 30 minutes to alert one of the adults, who were not at the camp area with the cadets. Were the communication devices tested, once the camp site had been determined, based on range? The service inquiry report details that the distance was 1.9 km. We know that six radios were issued for the camping exercise. In May 2014, three of the six radios were tested. Of the three radios that were tested, they had a range shortage of approximately 200 metres between the cadets’ camp site and where the adults resided that night. It is unclear whether the two handsets issued to the cadets were among the three that were tested. The service inquiry report classified the three tested radios as “unserviceable”. It is unclear whether the handsets issued to the cadets had a fault range of greater than 200 metres. That raises questions regarding emergency procedures and the effectiveness of communications devices on the base that night. That is obviously of vital importance if cadets are miles away from their adult supervisors.
These questions need to be answered. It has been nearly eight months since the death of my constituent David Efemena. Throughout, the family have battled to find out what happened to their beloved son that night. Answers to those questions, and many others concerning other elements of the case, are needed so that we might be reassured that our young people are safe when attending weekend military camping trips. If protocols on our military bases need to change, the family would take some comfort that other families might not have to experience what they have had to experience in the past seven and a half months following the tragic death of their son David Efemena.
I congratulate the hon. Member for Dagenham and Rainham (Jon Cruddas) on securing this debate.
I express my sympathy and offer my condolences to the family and to everyone who knew and loved David Efemena. Those of us who are parents cannot think of anything worse than the death of a child. Burying a child is every parent’s nightmare, but one does not need to be a parent to know and understand that. Our sympathies go out to his family. In these circumstances, it is undoubtedly the case that the awful grief they must bear is made all the worse when they do not know everything that has happened. It is a terrible feature of such cases, but I fear that it is almost inevitable that, to ensure we know everything that happened and are therefore able to learn the lessons, statements need to be taken and post mortems conducted, and pathologists, doctors and other experts all need to make their inquiries. Inevitably, that takes time. It behoves those who are charged with those dreadful tasks to act as swiftly as possible. That has to be in everybody’s interests, but most importantly it is in the interests of the family who are suffering in grief.
I am placed at a severe disadvantage. I gently chide the hon. Gentleman in this respect: if I may say so, I think he has pre-empted the coroner’s inquest. This is a very serious matter. The death of a cadet is taken extremely seriously, not only by the air cadet organisation in this particular instance but by everybody and anybody associated with such a matter, as one might expect. What then happens is that there is a service inquiry, which delivers its report. I do not know whether the hon. Gentleman has seen the report. I certainly have not, but I make no complaint about that because the service inquiry report was only delivered to the family on Saturday, when two members of the RAF, including the family liaison officer, attended them. That must be the right way. The first people to find out what the service inquiry has looked at and found must be the family, and that is why two members of the RAF attended. The coroner has not received the report yet, so I make no complaint that I have not. It would be a grave discourtesy to the coroner were I to see it before her.
The coroner’s inquest will be rigorous, transparent and honest. I would like to draw on my own experience as a Member of Parliament. I do not know whether you were in the Chair, Mr Speaker, but not long after my election I secured a debate about a constituent killed by his grandson. It was a terrible case—I will not trouble anybody with the details because we are talking about David Efemena’s death—and in due course there was a coroner’s inquest, some of which I attended, which lasted longer than the two days currently set aside for the inquest into David’s death.
It is not just the Nottinghamshire coroner; all coroners conduct extremely good investigations into all matters leading up to a death, as well as the cause of death, and they do so with rigour, honesty and transparency. In what I realise are dreadful circumstances, I know that the hon. Gentleman will take that assurance to the family, whom I know are legally represented, which is important. To be blunt, I hope they have had the benefit of legal aid. If not, I will do everything to ensure that they do. Furthermore, they should know that the coroner will bend over backwards to get all the answers. The family will be at the heart of the investigation.
The hon. Gentleman quite properly asked a series of questions on behalf of the family, not only about the events leading up to David’s death but about the events after he died. Normally, a coroner cannot look into the latter, but regardless of whether the hon. Gentleman brings this back to the Chamber, I give a solemn promise that I shall ensure as far as possible that all these incredibly important questions are answered. Even if nothing and no one could have saved David, because of some inherent heart problem or condition or whatever it may be, I am told that the service inquiry has nevertheless made more than 20 recommendations arising from the hon. Gentleman’s important questions about supervision.
It is the nature of these exercises—be it the Duke of Edinburgh Awards or the cadets—that they contain an element of excitement and risk. Nevertheless, everything must be done to ensure that children are as safe as possible, and important questions have been raised about the distance between where the youngsters were camping and the adult volunteers. I do not know the recommendations of the service inquiry—possibly some of that has already been addressed—but certainly the coroner will look into it. On the way the family were informed, which the hon. Gentleman mentioned, I do not know if there is ever a good way to deliver such dreadful news, but he asks an important question that needs to be answered.
I do not think there is anything else to add until the coroner has conducted her inquiry and we know her findings, at which point I will be more than happy to answer all these questions as fully as possible.
In this particular case, David’s family will, of course, always grieve for the loss they suffered because they no longer have their beloved son, but we must remember that other youngsters were involved—not just the youngster in the tent, but another young man who came to assist—and, indeed, the adult volunteers who came when they were told what had happened. The other young cadets must have suffered a terrible experience to know that somebody in their tent, one of their number, had become so terribly ill and died. Their welfare is also in my mind.
I am more than happy to take any interventions from the hon. Gentleman if he wishes me to assist him further. Mr Speaker, I think that everybody here would join him in expressing our condolences and sympathy to the Efemena family. We hope that all their questions can be answered and that, in time, perhaps some peace could settle upon them.
Question put and agreed to.