The State Coroner has recommended that the Singapore Civil Defence Force (SCDF) undertake a review of its structure and protocols to better deal with mental health issues among its servicemen.

This includes appointing trained mental health professionals to each SCDF camp.

The recommendation came after a coroner's inquiry into the death of SCDF full-time national servicemen Muhammad Ahad Lone, 18, who was found to have committed suicide in April last year. Ahad was found dead at the foot of an apartment block at Pine Grove in Clementi.

At the time of his death, he was living alone in a rented room in Block 1A at Pine Grove.

Ahad was born in Pakistan and came to Singapore with his family in 2007. He and his family obtained Singapore citizenship in 2009. He had been serving his national service in the SCDF since Feb 6 last year.

He had shown signs of depression and had expressed to doctors his intention to inflict self-harm during his time with the SCDF.

The coroner's report revealed that between the time of enlistment and his death, Ahad was seen on six occasions at the National University Hospital (NUH), on 11 occasions at the Civil Defence Academy (CDA) Medical Centre and once at the Institute of Mental Health (IMH).

However, his medical certificate (MC) privileges were restricted on March 27 as his unit said he had been taking multiple MCs from NUH Emergency Department (ED) whenever he booked out of camp.

He was told visits to the ED ought to be only for emergencies and to report sick in camp or to the camp's primary care doctor instead.

At that point, he had visited NUH six times that year and was advised to attend a follow-up appointment with NUH's Psychological Medicine Department after his second visit on Feb 25. Prior to that, he had visited the CDA for various reasons, including vomiting, headaches, problems with sleeping and heartburn.

The CDA referred him to the IMH after he revealed to a CDA doctor that he had thoughts of suicide and slitting his wrists. On April 24, a senior psychiatrist at the IMH saw him and diagnosed him with adjustment disorder with a depressed mood, echoing the CDA doctor's first diagnosis of Ahad on the day he enlisted.

The coroner's inquiry found that as Ahad was identified to be a suicide risk, he was given timely and appropriate treatment, and his commanding officers had taken steps to ensure his well-being within the constraints they faced.

"Ahad could have also benefited from a supervisory arrangement with a trained counsellor," said state coroner Kamala Ponnampalam, adding that the IMH resident doctor had recommended that Ahad be referred to the SCDF counsellor and the camp's psychological care centre.

She noted that the SCDF had no specialised psychological care centres in the camps, which have an orientation officer who functions as a counsellor but "has no formal training in counselling".

She recommended that the SCDF undertake a review of its structure and protocols, and implement evidence-based measures, including the appointment of trained mental health professionals to each SCDF camp.

Ms Ponnampalam said: "Mental health literacy is generally not intuitive. It is a learnt skill. Often, good intentions alone are not sufficient to support those in crisis. They require support and intervention from trained professionals."

In a statement made through their lawyer, Ahad's family said: "He was a brilliant young boy who had a promising future ahead of him. He was loving, filial and full of life. We all miss him dearly."

The family is considering its options following the findings.