SINGAPORE - Lapses and breaches of Singapore Armed Forces (SAF) regulations were uncovered in full-time national serviceman Corporal First Class (CFC) Dave Lee Han Xuan's heat injury death, Defence Minister Ng Eng Hen told Parliament on Monday (Aug 6).
Unauthorised physical punishment of about 30 minutes was meted out to the full-time national serviceman's platoon the night before his fast march, compromising the required rest time.
The next day, there was inadequate on-site casualty management after CFC Lee's fast march, and his evacuation to the medical centre was delayed.
CFC Lee, who was a Guardsman from the 1st Battalion Singapore Guards, died on April 30 this year, two weeks after being admitted to Changi General Hospital for heatstroke.
He had completed an 8km fast march in Bedok Camp on April 18 before he showed signs of heat injury and had to be hospitalised.
The 19-year-old had also been taking medication in weeks prior to the fast march for acute upper respiratory tract infection after visiting a doctor on March 31.
These were the possible contributory factors in CFC Lee's death due to heat stroke in April, Dr Ng said as he gave the preliminary assessment of the Committee of Inquiry (COI) convened to look into the incident.
He said the COI found that the death was the result of heat stroke leading to multiple organ injury, with no physical injury sustained as verified by the autopsy report.
While the COI was unable to ascertain the direct causes that caused CFC Lee to suffer from heat stroke, it noted the possible contributory causes were "accumulated fatigue, insufficient rest, as well as CFC Lee's less than optimal state of health and his potential use of medication".
"However, the COI's preliminary assessment was that the likely reasons for CFC Lee succumbing to heat stroke were inadequate on-site casualty management and delayed evacuation to the medical centre," said Dr Ng.
He said relevant persons involved in CFC Lee's case have been removed from command and could face criminal charges from Attorney-General's Chambers, or military prosecution.
However, no evidence of foul play or medical negligence has been found, said Dr Ng, giving a detailed account of circumstances surrounding CFC Lee's death.
First, during a training run a day before the April 18 fast march, CFC Lee ran a slightly faster pace than required, with a shorter rest time in between each lap than stipulated in the lesson plan.
Dr Ng said: "These deviations were a breach of training safety regulations. The reason given was that the commander(s) wanted to enhance fitness and foster greater cohesion by keeping the platoon intact, and the soldiers running at the same pace, not in groups."
Second, unauthorised informal punishment was dished out to CFC Lee's platoon the night before the fast march, said Dr Ng.
This meant that the seven hours of uninterrupted rest required was compromised.
The scout platoon were told to assemble in their No. 4 uniform and assault bags, as the commander had wanted to punish them for a perceived lack of teamwork and the use of mobile phones after lights out, despite repeated warnings.
At about 9.45pm, informal punishment was given for about 30 minutes in the form of physical exercises, such as bear crawls, sprints, leopard crawls, push-ups and crunches. They also had water poured over them during the session, which ended with the troopers reciting the Guards creed a few times in a high kneel position.
They were sent back to their bunks at about 10.30pm.
Dr Ng said: "The COI noted that the relevant commanders did not seek prior approval for the conduct of this informal punishment or inform their superiors after the punishment."
After news broke of CFC Lee's death, there was speculation online that he and his fellow trainees were punished the night before the fast march.
At his funeral in May (2018), CFC Lee's mother, Madam Jasmine Yeo, then called for outdated traditional "tekan", or punishment sessions, to be put to an immediate stop.
For the 8km fast march the next day, the COI found the conduct of the fast march was in line with SAF regulations, except for the lack of seven hours of rest the night before.
CFC Lee had taken his temperature before the march, measuring 36.3 degrees celsius, and was observed to be fine.
He was the last person to complete the fast march, in about 100 minutes, including a 20-minute break, and appeared to be disoriented.
Personnel that attended to him had unbuttoned his uniform, gave him water and applied ice packs at his vital points.
But cooling measures were inadequate, said Dr Ng, citing the failure to use an on-site IV drop, and the improper placement of ice packs.
When his condition did not improve, CFC Lee was evacuated to the medical centre.
"However, there was a significant gap between the onset of symptoms and his arrival at the medical centre," said Dr Ng.
CFC Lee was semi-conscious when he arrived at Bedok Camp Medical Centre, with a temperature of 42.7 degrees Celsius.
Two bags of fast IV drops were administered and he was placed in the Body Cooling Unit for two cycles, but he did not respond to the treatment.
The medical officer then decided to evacuate him to Changi General Hospital, where he was admitted to the intensive care unit.
Dr Ng said: "The delay in evacuation resulted as the persons attending to CFC Lee mistook his signs and symptoms as due to physical exhaustion. Though trained, they had never encountered any previous case of heat injury themselves."
The minister added that CFC Lee was an exemplary soldier who served with commitment and was well-respected by his peers for his positive attitude. "The loss of such a good soldier like CFC Lee is deeply grievous to us," he said.
"Zero training deaths must be the norm and any mishap should be vigorously attended to by commanders to achieve this norm."
An external review panel on SAF safety - chaired by director of MMA Offshore Heng Chiang Gnee - said it agreed with the COI's preliminary findings.