Ardi Ndembo’s trainer described the 27-year-old heavyweight as a “good guy”. Over dinner they would discuss the differences between America and Ndembo’s home country, Congo. He particularly liked to talk about his two children, who he described as his “best friends”.

Those children are now without a father. On 5 April, Ndembo stepped into a ring in Coral Gables, Florida and was knocked out in 57 seconds. Doctors placed him into an induced coma. He never regained consciousness and died three weeks later.

Ndembo should not have been fighting in Florida. He had been knocked unconscious twice in sparring sessions during the month immediately preceding the fatal bout.

In early May, the Association of Boxing Commissions issued a statement urging that the Florida State Athletic Commission “conduct a full and transparent regulatory investigation into the circumstances surrounding Ardi Ndembo’s death.”

The Florida State Athletic Commission dismissed those concerns. On 21 May, its executive director, Tim Shipman, declared, “We’re not investigating the case. And as far as our procedures are concerned, there’s nothing we’re going to change.”

Unlike the Florida State Athletic Commission, I have investigated the case. I’ve interviewed 21 people about the tragedy. Some of them asked not to be named in this article for fear of repercussion. The facts – which show systemic failures at multiple levels of the sport – follow.

Ndembo was born in Congo and lived in South Africa prior to coming to the United States in 2023. His first six fights are listed by Boxrec.com as taking place in Africa (three in Tanzania, two in Cape Town, and one in Zimbabwe). After that, he fought twice in Mexico, the second of those bouts occurring on 16 March this year. Overall, he compiled an 8-0 record as a professional boxer with seven knockouts in officially recognized bouts.

Then Ndembo agreed to fight for an organization called Team Combat League (TCL).

Team Combat League is a start-up organization with headquarters in White Plains, New York. It has 12 teams, with names like the Houston Hitmen, NYC Attitude, and Boston Butchers and hopes to expand to more cities in the United States as well as to other countries.

TCL fight cards consist of 24 one-round fights with fighters from one city matched against fighters from another. Each one-round fight is three minutes long unless cut short by a knockout. Events consist of three eight-bout cycles. No fighter can fight more than twice in a given night. There are six weight classes for men and two for women. Scoring is based on a 10-point-must system. The team with the most points after all 24 fights have been completed is the winner.

Each team has a coach. Most fighters are signed through the coach (who seeks them out or is approached by the fighter). Some of the fighters have outside promoters in which case TCL works out a deal with that promoter for the fighter’s services. Local promoters are hired as independent contractors to perform the onsite nuts-and-bolts work for each event.

BoxRec.com lists TCL bouts in a category separate from regular professional fights because of their one-round format. Some aspects of TCL are shrouded in secrecy. Madison Clavon performs a variety of tasks for the league, including marketing and publicity work.

“There are three people in charge who built the concept from scratch and are funding it,” Clavon says. “I can’t tell you who they are because they’re low-key and want to stay behind the scenes. But I can tell you that they care about boxing and are trying to change the dynamics of boxing.”

Dewey Cooper, a former professional boxer, kickboxer, and mixed martial artist who helped Frances Ngannou prepare for his fights against Tyson Fury and Anthony Joshua, is the league’s president. An attorney named Michael Utilla conducts a lot of the operational work with venues and commissions in addition to finalizing contracts with fighters and their representatives. One fighter’s representative told the Guardian: “Utilla is also the one I deal with on medicals.”

Neither Utilla or Cooper responded to multiple requests to be interviewed for this article.

TCL’s fighters are a mix of young hopefuls, journeymen, and past-their-prime combatants. The more familiar names include Jesse Hart, Ivan Golub, Cassius Chaney, and Joey Dawejko.

“Right now, our fighters can fight outside the league,” Clavon says. “We don’t want to stop them from their progress. But our long-term goal is to make our contracts exclusive.”

Team coaches listed on the TCL website include well-known trainers like Bobby Benton, Manny Robles, and Barry Hunter.

“It’s an interesting concept,” promoter Lou DiBella, who has signed provision of services contracts with TCL for three of his fighters, says. “Their fights are more competitive than most of what you see these days. Lots of times, one-round fights have a different outcome than you’d expect. Overall, my experience with them has been good. But I’m puzzled by it from a financial point of view. They have to be losing money.”

A lot of money, it would appear.

TCL’s fighters are paid reasonably well; usually between $1,500 and $4,000 a night which is more than most club fighters in their situation would get. If they travel to an event as a back-up but aren’t used, they receive a smaller amount. Some fighters augment their purses by selling tickets or engendering pay-per-view buys through their social media accounts.

“From what I see,” says Eric Bottjer, a matchmaker who works throughout boxing, “the fights are poorly attended. There can’t be much revenue from streaming. The travel and hotels are expensive. TCL has to pay the fighters, the coaches, the venue, and onsite personnel. I don’t think it’s sustainable. In fact, I don’t understand how it has gone on this long.”

Regardless, the TCL website lists 12 events as having taken place in May 2024 with 11 more scheduled for June.

“We’re giving fighters the opportunity to fight and feel important and valued,” Clavon says.

That brings us to Ndembo.

Rodney Crisler is a well-liked trainer in Las Vegas who worked with Ndembo.

“Ardi was a good guy,” Crisler says. “I really liked him. I’d invite him over for dinner sometimes and we’d talk about where he came from and the difference in our countries. He had two children in Congo and talked about them all the time. The mother was with the children back in Congo.”

Then, according to a post that Ndembo put on social media, Cooper told him about TCL. Ndembo’s first fight for TCL was scheduled for 5 April in Florida.

But there was a problem. A big one. During the month before the fight, Ndembo was knocked unconscious twice while sparring in Las Vegas gyms.

The first incident occurred at the Bones Adams Gym.

“Ndembo was sparring with [heavyweight contender] Efe Ajagba,” says one person who was there. “It’s a small gym. I was sitting in a chair not more than 10ft from the ring. Ajagba hit him with a left hook and Ndembo went down flat on his back. He was unconscious for about a minute. Then they put him on a chair. There was no medical attention. Skylar Lacy [another Ajagba sparring partner] came over and consoled [Ndembo]. It stuck in my mind even before he got killed because you don’t see that often. He was out cold.”

The second incident was equally troubling. Ndembo was sparring with heavyweight Patrick Mailata at the Split-T Management Gym and again was knocked unconscious.

Multiple sources say that, after the second knockout, Crisler pleaded with Ndembo not to fight on the TCL card in Florida. Crisler confirms those reports.

“I heard he got knocked out by Ajagba and I asked him about it. He told me it was a flash knockdown. Then he sparred with Mailata,” says Crisler. “I asked him about that and he told me that was a flash knockdown too. I told him: ‘Hold on, man. I saw the videos. That’s two times now. Something is wrong. This shouldn’t be happening. You got to get an MRI. You can’t fight like this.’ He said: ‘I need money.’ So I threw him a few bucks and told him, ‘Don’t fight.’

“Then I look on my Instagram and it comes up that he’s fighting in Florida. I called him and said: ‘You can’t do this?’ He said: ‘I’m gonna fight.’ I begged him not to go. ‘It’s dangerous for you. This is serious stuff that’s going on. You got to get an MRI and find out what the problem is.’

“After that, he came to the gym and wanted me to work with him. I said, ‘Listen to me. Slow down. Don’t spar. Don’t fight. Get an MRI and take it easy for a while. This isn’t a game. There’s something in your head that’s not right and you shouldn’t be fighting until you get this figured out.’ Then the fight in Florida happened. It sickened me.”

It is unclear whether anyone associated with TCL knew in advance of the fatal fight about the gym knockouts. A full investigation by the Florida State Athletic Commission might have answered that and other relevant questions. It was not TCL’s responsibility to provide medical treatment for Ndembo in Las Vegas.

The fatal fight occurred during a TCL competition between Ndembo’s Las Vegas Hustle and the Miami Assassins (since rebranded as the Miami Stealth). As usual, there were 24 fights on the card. It was Ndembo’s first outing for TCL. His opponent – a doughy 283-pounder named Nestor Santana – was also making his TCL debut.

Ndembo was knocked out 57 seconds into the fight and never regained consciousness.

In early May, the Association of Boxing Commissions issued a statement that read in part: “The allegation that Ardi Ndembo was knocked unconscious in training shortly before his fatal bout deeply troubles and concerns us. If true, it is our belief that his death was preventable if recognized post-knockout protocols were practiced. We urge Florida state officials to conduct a full and transparent regulatory investigation into the circumstances surrounding Ardi Ndembo’s death.”

There was no investigation. Instead, Shipman issued a statement saying that the FSAC was “saddened to hear of Ardi Ndembo’s passing” and that “our thoughts are with Mr Ndembo’s family in this difficult time.”

On 20 May, Mike Mazzulli, the president of the Association of Boxing Commissions, told the Guardian: “I have not heard back from Florida. It’s an unfortunate situation. And hopefully, they’ll figure out how this happened because there are issues with the way the process was run.”

But one day later, Shipman told the Guardian: “We’re not investigating the case. And as far as our procedures are concerned, there’s nothing we’re going to change.”

“The Florida commission,” promoter Lou DiBella says, “is an abomination. And you can quote me on that.”

One avenue for constructive inquiry into Ndembo’s death would be to consider the “Pre-Licensure Physical Sheet” that fighters are required to fill out before they can fight in Florida. A question on that form asks, “Have you ever been knocked unconscious? If yes, when?”

Was the form filled out? If so, did Ndembo fill it out himself or was it filled out by someone purporting to act on his behalf? If it was filled out, how were those questions answered?

“I can’t tell you if the form was filled out or how the form was filled out or who filled it out because that’s confidential medical information,” Shipman told the Guardian.

Additionally, Florida law imposes a duty on licensees (in this case, the local promoter, the other fighters on the card, and possibly the on-site cornermen) to disclose to the commission “all information in her or his possession concerning any mental or physical disability, injury, illness, or incapacity of a participant in a match, immediately after learning thereof.”

But there is no indication that the Florida commission has made any effort to determine whether any of its licensees knew of Ndembo’s history and failed to report it.

One gets the feeling that the Florida State Athletic Commission is treating Ndembo’s death as a publicity problem rather than the tragedy that it is.

Meanwhile, when asked about Ndembo’s death, TCL’s Clavon says, “I can’t speak to that. Any questions about Ardi should go to our lawyer. But I can tell you that I was there that night and I was heartbroken.”

Virtually everyone in boxing parrots the line that the health and safety of fighters is their primary concern. Now people are sending deepest condolences to Ndembo’s loved ones and want others to know that he’s in their prayers, which are tired platitudes.

Viva Promotions had a promotional agreement with Ndembo and issued a statement that read: “We at Viva Promotions mourn the loss of Ardi Ndembo, a talented Congolese boxer who tragically passed away after a knockout in a Team Combat League match on April 5. RIP Ardi Ndembo!”

TCL set up a GoFundMe page “to assist the Ndembo children” and has said that it will match donations up to a total of $25,000. It’s unclear how these funds will be administered and distributed.

Dr Margaret Goodman is one of boxing’s foremost advocates for fighter safety, and notes that Ndembo should have done more to protect himself.

“Fighters have to take responsibility for their own wellbeing,” Goodman says. “The fact that this fighter was knocked unconscious in the gym twice during the month before the fight and still fought makes it clear that he didn’t understand or respect the dangers involved.”

However, Goodman says that state commissions must also step up.

“Neurologists talk about second impact syndrome,” she continues. “The risk of serious damage from a second concussion is far greater than from the first. This was third impact. Having MRIs for every fighter before every fight isn’t practical. It would be cost-prohibitive. But you have to ask how thoroughly the fighter was tested by the Florida commission. Better screening of fighters by state athletic commissions is a must.”

In addition, promoters have to become more sensitive to medical issues rather than treating them as a nuisance.

“I asked the people at TCL what medical insurance coverage they have,” one fighter representative who does business with the company recalls. “And I didn’t get an answer. I guess the answer is that they have whatever coverage is required by the state where a fight card is contested. I know the New York team fights in Connecticut which circumvents New York’s insurance requirements which are pretty expensive.”

There’s an old marketing slogan: “What happens in Las Vegas stays in Las Vegas.” As a matter of safety and common sense, when a fighter is knocked unconscious in sparring, it shouldn’t stay in the gym in Las Vegas.

“I’ve been saying through 30 years of doing this that these tragedies begin in the gym,” says Michael Schwartz, the founder and former president of the organization that is now the Association of Ringside Physicians. “And it’s a problem. Other than the questionnaires that a fighter is required to fill out prior to a fight, there’s no regulation of any kind. The manager isn’t going to tell us if his fighter was knocked out in the gym. The trainer isn’t going to tell us. The promoter isn’t going to tell us. If a fighter’s seconds aren’t protecting his health, they shouldn’t be in this business. If they know about something like this, they should say to the commission: ‘My fighter should be pulled.’ But almost nobody ever does.”

Bruce Silverglade, who owns Gleason’s Gym in New York agrees. “It’s a problem,” he says. “If I’m aware that a fighter has been concussed, the fighter can train in the gym but I suspend him from sparring for 30 days. But a lot of fighters travel from gym to gym. There’s zero communication between most state athletic commissions and the gyms. And there’s no rule in place in New York that I’m aware of that requires concussions suffered in the gym to be reported to the commission.”

California is one jurisdiction that does have a statute requiring that knockouts in a gym be reported to the state athletic commission. But that law is seldom followed.

“To be honest, we don’t get many reports,” California State Athletic Commission executive director Andy Foster says. “Freddie Roach reported knockouts in the gym to us a couple of times that led to our taking fighters off a card. And I think Robert Garcia did it once.”

So what’s the solution? Combat sports gyms should be licensed. And there should be rules in place to the effect that any licensee (including but not limited to fighters, trainers, managers, and promoters) who knowingly fails to report a concussion to the governing commission is subject to the loss of his or her license. A license is a privilege, not a right.

“When something like this happens in the gym, you just hope that someone who knows about the situation will do the right thing,” says Mazzuli.

But too many people in boxing don’t do the right thing.

Boxing has a culture of silence when it comes to gym injuries. The other side of the coin is that there are very few secrets in boxing. It’s hard to believe that no one involved with Ndembo’s fatal fight knew beforehand that he had been knocked unconscious twice in the gym.

Some tragedies in boxing happen without warning. There are no danger signs. This wasn’t one of those tragedies. There are people who should be ashamed for the role they played in the death of Ardi Ndembo. They know who they are even if the rest of us don’t.

• Thomas Hauser’s email address is thomashauserwriter@gmail.com. In 2004, the Boxing Writers Association of America honored him with the Nat Fleischer Award for career excellence in boxing journalism. In 2019, he was selected for boxing’s highest honor – induction into the International Boxing Hall of Fame.