A day after his return from a two-week work trip to London and Oslo, New Zealander Simon Brinsley Gould participated in his first Green Corridor Run.
Tragically, it was also his last, as the 29-year-old Norges Bank Investment Management senior analyst died of heatstroke close to the end of the 10.5km race on March 6 .
The court heard that Mr Gould had not been properly acclimatised to the local climate and high humidity, and had not run for three weeks before the race, which was on a stretch of greenery from Tanjong Pagar Railway Station to Bukit Timah Railway Station.
It was at the 9km mark that Mr Gould stumbled and fell, shortly before 9am.
He was taken by stretcher to a private ambulance in Greenleaf View some 600m to 1km away.
However, the ambulance was one of three not equipped with an automated external defibrillator (AED).
This device, to restart a heart that has stopped beating, was in three other ambulances along the route.
On Monday, State Coroner Marvin Bay agreed in his findings with Dr Nelson Yit Ling Fung, who had treated Mr Gould at National University Hospital (NUH), that AEDs should be readily available at all sporting events, though the doctor had noted it was not clear if the device would have helped in this case.
The coroner noted that oxygen deprivation had set in because of Mr Gould's prolonged condition in an asystole state (when his heart stopped beating).
"I should also add that it would be beneficial for all ambulances covering such events to be equipped with inotropic drugs, such as adrenaline, and where practicable, be installed with appropriate mechanical resuscitation devices,'' he said.
The coroner said there was also a need for careful coordination of evacuation routes in the event of an emergency such as this.
Major races should have a system in place to facilitate speedy clearance of the route to the medical station, in the event of a grave emergency. Runners and assisting personnel should be aware of the impending arrival of an ambulance and given ample notice to clear the way for the passage of the vehicle.
In this case, the paramedic and ambulance driver decided to take Mr Gould to NUH as they were concerned about the ambulance having to negotiate a slope, traverse the route of runners, who might be in the way, and then reverse to the medical tent.
The decision to go to NUH was made on the thinking that this would save time.
Before the race, Mr Gould told a colleague he had drunk about two litres of water and coconut water.
The court heard that when a paramedic asked Mr Gould, who was on the ground after he had fallen, if he needed help, he said he wanted to continue running even though he looked "very pale'', was cold and clammy and could hardly stand.
Coroner Bay said a guarantee of ready and expeditious access to an AED and resuscitative drugs and devices would do much to assure that the participants could compete with confidence.
He said Mr Gould's death, occurring from oxygen deprivation to the brain, was a "sad misadventure''.
