SINGAPORE - A full-time national serviceman (NSF) who died of heatstroke in April 2018 was only evacuated to a medical centre about 40min after he was seen to be suffering from signs of heat injury, investigations revealed.
The delay in the evacuation was a contributing factor in Corporal First Class (CFC) Dave Lee Han Xuan's death, the state coroner heard on Wednesday (Jan 13) in an inquiry into the NSF's death.
CFC Lee, then 19 and a guardsman from the 1st Battalion Singapore Guards, had just completed his 8km fast march at Bedok Camp on April 18 when he collapsed.
He was later admitted into Changi General Hospital (CGH) and died on April 30, 2018.
The incident had sparked discussion on training safety and lapses in the Singapore Armed Forces (SAF), after Defence Minister Ng Eng Hen gave a detailed account in August 2018 of the events preceding CFC Lee's death.
The late SAF captain Tan Baoshu, who was the supervising officer of the fast march, was charged in October 2018 with causing death by performing a rash act, including failing to evacuate the victim in a timely manner.
He was also accused of disallowing the necessary treatment for CFC Lee.
Tan, 33, was given a discharge not amounting to an acquittal in January last year, after he was diagnosed with stage 4 cancer. He later died on Feb 13 last year.
CFC Lee started the fast march at 6.45am on April 18, 2018, and was observed to be walking and running normally, said Station Inspector (SI) Aliden Hamad, who conducted police investigations on the NSF's death.
He only had a cramp in his calf during the final 2km portion and was given permission to stretch his leg.
But he was seen to have difficulty walking and speaking after he crossed the finishing line at 8.25am, said SI Aliden.
CFC Lee was also observed to be incoherent, breathing heavily and drooling from the mouth.
His load-bearing vest was then taken off and his shirt unbuttoned, before ice packs were applied to his neck, armpit and groin, and water sprayed on his face.
The NSF was also given isotonic water but he was unable to swallow the liquid.
SI Aliden said that the medic for the fast march failed to diagnose CFC Lee as having heat injury.
He added that Capt Tan rejected suggestions from other army personnel to evacuate the NSF to the camp's medical centre, saying that the soldier was only suffering from physical exhaustion and would recover after resting.
The officer also rejected a suggestion for CFC Lee to be administered an intravenous drip.
Both actions were in breach of army regulations, said SI Aliden.
Capt Tan instead directed that a ground sheet be used to cover the NSF as his arm was cold.
The officer later ordered CFC Lee to be evacuated, and he arrived at the camp's medical centre at around 9.05am.
Despite receiving medical treatment at the centre and later at CGH, his condition deteriorated and he eventually died.
SI Aliden said that the delay in evacuation was a contributing factor in his death, but no foul play is suspected.
Dr Kenneth Heng, senior consultant in the emergency department at Tan Tock Seng Hospital, who was appointed to give an independent medical report for this case, said on Wednesday that Capt Tan's orders to cover CFC Lee with a ground sheet was counterproductive.
The NSF would not have been able to sweat, said the doctor.
Dr Heng also said that CFC Lee should have been moved to a shady area and fanned with his shirt removed to increase evaporation of sweat.
He added that evacuating CFC Lee to the medical centre should have been the priority, and that a 40min delay to do so was "too long".
A 10 to 15-minute delay would have been reasonable, Dr Heng said.
Noting that CFC Lee and his fellow soldiers were made to do physical activities including push-ups and crunches the night before the incident, the doctor said the exertion and subsequent reduced rest might have contributed to the NSF's heatstroke.
State Coroner Kamala is expected to give her findings on Jan 27.
Since the case, the SAF has introduced enhancements to existing heat injury management and prevention measures, such as implementing a simplified evacuation protocol.
Six other SAF servicemen were charged in military court over CFC Lee's death and were last September fined between $1,800 and $4,500 each. Three of them were also demoted from the rank of third sergeant (NS) to corporal.