Delayed evacuation, inadequate management contributed to CFC Dave Lee's death: State Coroner

Wan Ting Koh
·4-min read
Committee of Inquiry convened to investigate death of NSF Dave Lee
NSF CFC Dave Lee. (PHOTO: Facebook)

SINGAPORE — The death of a full-time national serviceman (NSF) following a fast march was ruled by the State Coroner on Wednesday (27 January) to be from a heat stroke contributed significantly by the “inordinate delay” in his evacuation and “abysmal” site management.

Corporal First Class Dave Lee Han Xuan, 19, a Guardsman from the 1st Battalion Singapore Guards, had collapsed and showed signs of heat injury following the 8km fast march on 18 April 2018.

He died from his injuries at Changi General Hospital on 30 April 2018.

There was no basis to suspect foul play, said State Coroner (SC) Kamala Ponnampalam in her findings. An independent medical expert had stated that the mortality rate would have decreased from 33 per cent to 10 per cent if CFC Lee had been evacuated within 10 to 15 minutes of his collapse, she added.

Instead, it took between 35 minutes and 1 hour to evacuate CFC Lee to the medical centre at Bedok Camp.

When CFC Lee collapsed after the fast march, the Supervising Officer for the fast march CPT Tan Baoshu delayed his evacuation repeatedly, even approving the dismissal of a safety vehicle that could have evacuated CFC Lee in a more timely manner.

Inadequate measures were also applied, said the SC, referring to a health expert who stated that CFC Lee should have been moved to a sheltered area, and that a ground sheet placed on him was counter-productive as it prevented heat loss.

“The ensuing on-site management was abysmal. The first-aid rendered was suboptimal, and there was inordinate delay in evacuating CFC Lee to the medical centre,” said the SC.

The night before the fast march, CFC Lee’s platoon had been punished for various infractions. The platoon members were made to do exercises including crunches and pushups, reducing their time of rest from the mandated seven hours to six hours and 15 minutes. The punishment was carried out without the sanction of supervisors.

This accumulated fatigue and insufficient rest could have made CFC Lee more prone to heat injury, the SC said. CFC Lee had no known medical condition that could have made him predisposed to a heat stroke.

“By all accounts, CFC Lee was a good soldier, who gave his best during his training in the Scout Platoon, Support Company, 1st Battalion Singapore Guards. His death is truly a sad loss to his family and to the nation,” the SC said.

Speaking to the media following the findings, CFC Lee’s mother Jasmine Lee, who attended the hearing with her husband and daughter, said tearily that she had “only sadness”.

“It is unforgivable lapse, is totally unforgivable...Too outrageous and is unacceptable... who can understand and who can believe that such a thing can happen in the camp under the army’s care?

“We hand our boys to them. It is totally not acceptable especially coming from the officers. How can an officer make such a judgement? Anybody who falls on the floor, we will send them to the hospital immediately.”

Asked if the verdict had given her any closure, she said, “Let’s put it this way, any parents who lost a child will never have any closure. It will only be sadness till the day they meet their child.”

When asked by the media if the family intended to pursue any civil action, the mother said that the family was not ready.

Following the incident, Minister of Defence Ng Eng Hen said that the Singapore Armed Forces (SAF) had enhanced its training safety processes, including lowering the bar for immediate evacuation and additional methods to cool servicemen during training. Portable cooling methods, such as purpose-built cooling pads, would soon replace less effective ice packs to be used on the spot.

SAF will also ensure that commanders will be able to better recognise symptoms of heat stroke and have a lesson plan to improve heat injury prevention.

As a result of the incident, CPT Tan, 31, was charged on 31 October 2018 with committing a rash act causing CFC Lee’s death. The officer was given a discharge not amounting to an acquittal on 8 January last year, after he was diagnosed with stage 4 cancer. He died on 13 February last year.

Six other servicemen were referred to the SAF for internal investigations on 31 October 2018. The six servicemen were charged in the military court on 20 February last year.

Each was sentenced to a fine of between $1,800 and $4,500, with three demoted to the rank of corporal.

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