NSF Dave Lee's death by heat stroke truly a sad loss to his family and to the nation: Coroner
A framed photo of NSF Dave Lee at his wake on May 2, 2018. (Photo: Howard Law)
SINGAPORE: The death of a 19-year-old national serviceman by heat stroke after an 8km fast march in 2018 was truly a sad loss to his family and to the nation, the state coroner said in her findings into his death on Wednesday (Jan 27).
Calling Corporal First Class (CFC) Dave Lee Han Xuan "a good soldier" who did his best, State Coroner Kamala Ponnampalam pointed to "abysmal site management" after he collapsed following the fast march in Bedok, and the "inordinate delay in evacuation".
She found no foul play in his death, adding that the lapses contributed to his demise.
CFC Lee's parents and sister attended the hearing, with his mother and sister wiping away tears as they listened to the findings.
When asked by CNA if she had any comments on the findings, CFC Lee's mother Jasmine Yeo said she had "only sadness". She later told the media that the lapses were "too outrageous" and "totally unacceptable".
READ: Officer rejected suggestions to evacuate NSF Dave Lee, who died of heat stroke: Coroner's court
CFC Lee had died of heat stroke after the 8km mandatory fast march as part of his training in the scout platoon of the 1st Guards Battalion.
The night before the march, instead of having the required seven hours' rest, three section commanders turned out the entire scout platoon at 9.40pm to punish them for various infractions.
These included a perceived lack of teamwork and the use of mobile phones before lights out the night before.
The platoon performed bear crawls, leopard crawls, crunches, sprints and push-ups, and the commanders punished them without the sanction or knowledge of their superiors, before sending them back with lights out at 10.45pm.
As a result, CFC Lee received about 45 minutes' less rest than he was supposed to receive. He woke up the next morning and began his march at about 6.45am after a meal of oatmeal crackers and a chrysanthemum beverage.
He was observed to be well for most of the march, but suffered cramps in his calf and took several 10-second breaks in the last few kilometres of the march.
Captain Tan Baoshu, the officer commanding of Support Company, 1st Guards Battalion and the supervising officer of the march, joined CFC Lee in the last 300m of the march and urged him to run.
Although visibly tired, CFC Lee agreed and jogged to the finish line. He was the last to complete the march, but finished it within the required time and fell to his knees at the table where they recorded his timing.
He was helped to a rest area but was swaying, incoherent, drooling from the mouth and breathing heavily before turning unresponsive.
His equipment was removed and his shirt was unbuttoned, with water poured or sprayed on his face. Commanders attempted to give him isotonic water but the liquid simply flowed out.
CPT Tan assessed that CFC Lee was suffering from physical exertion instead of heat exhaustion, rejecting suggestions to evacuate him to the medical centre.
He repeatedly asked to wait for CFC Lee to recover after resting, and rejected a commander's suggestion to place him on intravenous fluids. He had CFC Lee covered with a ground sheet and did not move him to a shady area away from the parade square.
About 15 minutes after CFC Lee collapsed, CPT Tan gave permission for the safety officer to dismiss the safety vehicle, a breach of protocol. When an off-duty medic walked by, he was asked to attend to CFC Lee, and said he should be evacuated without delay.
However, CPT Tan said they should wait for another five minutes. He was finally evacuated by foot to the medical centre, arriving at about 9.05am with a delay of about 40 minutes.
He did not respond well to body-cooling measures at the centre, with a recorded temperature of 42.7 degrees Celsius when he first arrived, and was taken to hospital.
His condition continued to deteriorate and he eventually died of heat stroke with multiple organ failure on Apr 30, 2018.
After the incident, six SAF servicemen were fined by a military court over the case. CPT Tan was charged in the State Courts in October 2018 for causing CFC Lee's death by a rash act not amounting to culpable homicide.
However, CPT Tan was given a discharge not amounting to an acquittal in early February last year. A spokesperson for the Attorney-General's Chambers (AGC) said CPT Tan had been diagnosed with Stage 4 cancer. He died a few weeks later in February 2020, aged 31.
After CFC Lee's death, a Committee of Inquiry was convened to investigate the incident and recommendations were proposed to minimise recurrences. An external review panel commissioned by the Ministry of Defence in May 2018 found that SAF's heat management measures were generally sound and aligned with prevailing industry practices.
READ: Death of NSF Dave Lee: SAF to enhance prevention, management of heat injuries following review
The panel suggested several additional measures such as fine-tuning the work-rest cycle, improving heat injury awareness and addressing impediments to self-reporting that might discourage soldiers from speaking up when they feel unwell.
The panel also emphasised that early recognition of heat injuries was the most important of their recommendations, and said all have key roles to play in recognising signs and symptoms in fellow soldiers.
The coroner noted "with satisfaction" that SAF has since adopted several recommendations and instituted changes.
Asked by the media if the family is taking any civil action, CFC Lee's mother said they were "not ready for it" yet as the verdict was just given, but added that they were obviously "not okay with the lapses".
"It's just unbelievable that such a thing can happen in such a big organisation, when we hand our boys to them.
"It's totally unacceptable that this kind of thing can happen in camp," she said.
"Every son is very precious. We only have sadness left."
