SINGAPORE: Full-time national serviceman Dave Lee succumbed to heat stroke likely because of inadequate on-site casualty management and delayed evacuation following his collapse after a fast march, Defence Minister Ng Eng Hen said on Monday (Aug 6) in a ministerial statement to Parliament.
Dr Ng told Parliament that if no criminal charges are filed against those responsible for lapses leading to the NSF's death, the Ministry of Defence (MINDEF) would prosecute them in a military court.
He added that the Singapore Armed Forces (SAF) will implement several measures to fine-tune its management of heat injuries, following an external review of its processes.
Dr Ng's ministerial statement is reproduced in full below:
Mr Speaker, thank you for allowing me to make this statement. In May this year, I informed the House that a Committee of Inquiry (COI) would be convened to investigate the death of Full-time National Serviceman Corporal (First Class) Dave Lee that occurred on 30 Apr 2018. The COI has submitted its preliminary findings to the Armed Forces Council on 16 July this year and I would like to update this House on their findings as well as follow-up actions taken by the Singapore Armed Forces (SAF) since May.
Under the SAF Act, the COI is structured primarily to investigate and determine facts related to the incident and to identify causation, lapses and systemic problems, if any, which resulted in the incident. The COI does not deal with culpability of individuals. Specifically, to encourage disclosure and cooperation by all involved in the incident, section 8C of the SAF Act provides that no statements made to the COI shall be admissible as evidence in the court martial or for disciplinary proceedings. To keep to this remit, I will therefore use no names nor designations in this statement but instead use a generic term – commander/s or person/s, as appropriate.
As I mentioned in May to this House, Police investigations are on-going and the Coroner may hold an inquiry. Their procedures and evidence uncovered are part of the judicial process to determine if any criminal offence has been committed in this incident and separate from the COI.
In May, I had also informed this House that the COI would submit its report to the External Review Panel on SAF Safety (ERPSS). The COI has done so for their preliminary assessment and I will also be sharing the ERPSS’ responses and recommendations.
Breaches of Training Safety and Discipline Regulations the Day Before
Let me start with events that occurred the day before the heat stroke occurred. On 17 Apr this year, CFC Dave Lee and troopers from the Support Company participated in two physical training sessions in Bedok camp, namely Combat Circuit 4 from 6.30am to 7.30am in the morning at the hockey pitch, and Cardiovascular 6 followed by Balance, Flexibility and Mobility 6 from 3.30pm to 5.30pm at the running track. This was the day before the heat stroke.
The COI found the training for Combat Circuit 4 to be compliant with regulations or guidelines.
However, the COI did discover breaches of the Army’s Training Safety Regulations (TSR) for Cardiovascular 6 and breaches of the Army’s directive for another subsequent event that took place later in that day.
Let me first deal with Cardiovasular 6. In this lesson, soldiers had to run 6 laps of 400m each, a total of 2.4km. They had to run according to this lesson plan, grouped according to their running ability. However, the entire company was asked to run at a common pace. This meant that for the first three laps, CFC Lee was asked to run at a slightly faster pace than required – of about 10 seconds faster per lap. For the next three laps, CFC Lee was allowed to run at his own pace. The rest timing in between each lap was noted to be reduced to 1 minute, which is 45 seconds shorter than what was stipulated in the lesson plan. These deviations were a breach of TSR. The reason given was that the commander/s wanted to enhance fitness and foster greater cohesion by keeping the platoon intact, and the soldiers running at the same pace, not in groups.
Later that night before the fast march the next day, the collective punishment that was meted out to CFC Lee’s platoon was also not authorised.
At about 2140hrs, the entire Scout Platoon, including CFC Lee, were told to fall-in in No.4 uniforms and assault bags. The commander/s had wanted to punish the platoon collectively for the perceived lack of teamwork and the use of mobile phones after Lights Out; in particular by two troopers despite repeated warnings. At 9.45pm, the commander/s meted out the informal punishment, this was in the form of physical exercises, which comprised Bear Crawls, Sprints, Leopard Crawls, as well as Push-Ups and Crunches (in total it was for about 30-35 minutes). They also had water poured over the troopers from their water bottles and subsequently from the jerry can. The session ended with the troopers reciting the Guards Creed a few times in a high kneel position. As I said, the entire session lasted for about 30 to 35 minutes. The platoon was eventually sent back to their bunks at about 10.25pm to wash up and had Lights Out by 10.45pm. The troopers were also instructed by commanders not to switch on the lights in their bunks. The COI noted that the commander/s did not seek prior approval for the conduct of this informal punishment or inform their superiors after the punishment.
While the majority of the troopers interviewed opined that the commanders were good commanders who demanded high standards, this punishment was unauthorised.
The COI found that the conduct of the unauthorised informal punishment compromised the seven hours of uninterrupted rest as the trainees had about 6 hrs 15 mins instead. Less sleep could be one of the factors which caused CFC Lee to have more fatigue before participating in the fast march.
Conduct of Fast March
Let me move on to the day of the heat stroke. The COI’s assessment was that the conduct of the fast march was in line with the lesson plan and relevant regulations. CFC Lee had undergone the requisite build-up training prior to the 8km fast march, and all measures to prevent heat injuries according to the TSR had been complied with, which are temperature-taking regime, hydration regime, water supply where soldiers must carry water, and have re-supply points must be planned for, the work-rest cycle based on the Wet Bulb Globe Temperature, and rest management, except that CFC Lee and his platoon did not have the requisite seven hours of sleep that I’ve just mentioned.
Before the fast march, CFC Lee had taken his temperature, which was normal at 36.3oC, and had drunk water. This was witnessed by his buddy, who also observed him to be looking well and seemed to be his usual self. CFC Lee and his fellow scout troopers then consumed their Recommended Dietary Allowance, which consisted of an oatmeal cracker and chrysanthemum drink.
Thereafter, the safety brief was conducted by the Conducting Officer. Troopers were asked if they had completed their 6km fast march build-up training, completed their water parade, and had seven hours of uninterrupted rest, and taken their body temperature during the declaration. The troops were asked to declare if they had. The Conducting Officer had checked if there was anyone who was not feeling well. Three troopers stood out as they had not completed their 6km fast march and were subsequently deployed as marshals. No one else sounded off any other concerns when the checks were made. This was followed by the conduct of warm-up exercises to get the troopers ready for the 8km fast march.
After the conduct of warm-up exercises, the fast march commenced just before sunrise with the troopers despatched in four waves, at five minute intervals. Each wave included a commander as a rear sweeper. CFC Lee was in the fourth wave, the last wave.
After CFC Lee completed the first 6km, he had a mandated 20-minute rest. After the 20 minutes rest period, as CFC Lee was moving off for the last 2km, he sounded off to the commander/s that he had cramps in his calf muscles. They advised him to stretch his calf muscles (which he did), and encouraged him to complete the march.
CFC Lee was the last one to complete the 8km fast march in around 100 minutes, including the 20-minute break. Shortly after the fast march, as CFC Lee was walking from the end point of the fast march to the Support Company line, he was observed to be disoriented and immediately attended to by the commander/s and the cover medic/s.
Management of CFC Lee after Completion of Fast March
Let me now state the findings at the completion of the 8km fast march.
After the fast march, the persons attending to CFC Lee thought that he was suffering from physical exhaustion. His pulse was assessed to be normal and his skin felt cold to touch. His temperature was not taken. The first-aid that was administered comprised the removal of CFC Lee’s equipment, unbuttoning his uniform, applying ice packs at his vital points, pouring water on him, and giving him water. He was also given oxygen. However, the COI noted that the on-site cooling measures administered were inadequate, including the failure to administer an on-site intravenous (IV) drip, the improper placement of ice packs, and the improper use of a ground sheet. When his condition did not improve, CFC Lee was subsequently evacuated to the medical centre. However, there was a significant gap between the onset of symptoms and his arrival at the medical centre.
On arrival at the Bedok Camp Medical Centre, CFC Lee was semi-conscious. His temperature taken measured 42.7oC. Two bags of fast IV drip were administered, and he was also placed in the Body Cooling Unit, for two cycles. Seeing that CFC Lee was not responding to the treatment, the Medical Officer (MO) decided to evacuate him to the Changi General Hospital (CGH).
The MO accompanied CFC Lee in the SAF ambulance to CGH’s Accident and Emergency department where he was handed over and admitted to the Intensive Care Unit (ICU). Unfortunately, his condition deteriorated and he passed away on 30 Apr 2018, this is 12 days later.
The COI opined that the significant delay from time of symptoms to evacuation could have escalated the heat injury to a heat stroke. Full body cooling should have been instituted as soon as possible, and within 30 minutes of presentation of signs and symptoms.
The delay in evacuation resulted as the persons attending to CFC Lee mistook his signs and symptoms as being due to physical exhaustion. Though trained, they had never encountered any previous case of heat injury themselves.
There were several suggestions for CFC Lee to be evacuated, but these calls were either not heard or not heeded.
For completeness, let me share the COI’s findings on one other aspect, which is CFC Lee’s state of health prior to the fast march. While CFC Lee had no significant medical history, it was established that he had been taking some medication in the weeks prior to the fast march following a visit to the Jurong Polyclinic on 31 March 2018 for acute upper respiratory tract infection. This was more than two weeks before the fast march on 18 April.
COI’s Preliminary Assessment – Inadequate Casualty Management and Delayed Evacuation Identified
Let me conclude with the COI’s preliminary assessment on the cause of death. The COI found that CFC Lee’s death was the result of heat stroke leading to multiple organ injury. Other than this, the COI did not find any physical injury sustained, as verified by the autopsy, nor any evidence indicating any foul play or medical negligence that caused his death. While the COI was unable to ascertain the direct causes which led CFC Lee to suffer from his heat stroke, it noted that possible contributing causes were accumulated fatigue, insufficient rest, CFC Lee’s less than optimal state of health and his potential use of medication. However, the COI’s preliminary assessment was that the likely reasons for CFC Lee succumbing to the heat stroke were inadequate on-site casualty management and delayed evacuation to the medical centre.
The Ministry of Defence (MINDEF) will await the outcome of the Police investigations and Coroner’s Inquiry, as well as the Attorney-General’s Chambers’ decision whether to prosecute any persons in the criminal courts. If no criminal charges are filed, MINDEF will prosecute persons responsible for lapses in this incident in our military court. In the meantime, the relevant persons in this incident have been removed from command.
ERPSS and ERPHIM Findings
Let me share findings of the External Review Panel (for SAF Safety) (ERPSS). With your permission Mr Speaker, may I ask the clerks to distribute a copy of the ERPSS’ statement. First, the ERPSS agreed with the COI’s preliminary assessment on the cause of death, as earlier stated.
Second, the panel emphasised that it is essential for personnel to comply with safety rules promulgated in the approved operating manuals. Breaches such as those found by the COI in this case should not be condoned.
Third, the ERPSS highlighted the value of strengthening the safety culture in Army units. They felt that if each soldier takes greater personal ownership and responsibility for safety, it would bring about desirable behaviours such as (a) having a strong respect for safety rules and guidelines; (b) being willing to speak out when there are safety concerns; (c) taking care of each other; and (d) open-reporting so as to share lessons and prevent future accidents. Such behaviours would substantially strengthen the Army’s efforts to ensure safe training.
Finally, the ERPSS flagged out three areas for further emphasis based on the COI’s findings. First, the need to strengthen commanders’ knowledge on heat injuries and improve their decision-making processes. Second, for medics to be able to exercise their professional authority when dealing with medical issues, and this includes being able to communicate effectively with commanders who are much more senior than them. Third, for commanders to watch out for soldiers who are feeling unwell or are unable to cope and proactively pull them out of training before they get injured.
The COI will submit its final report after completion of the Police investigations and Coroner’s Inquiry, if held.
Measures to Enhance Training Safety Systems and Processes
Let me now focus on what the SAF has done or will put in place to reduce the risks of heat injuries so that we can achieve zero training fatalities. Training and safety protocols were reviewed and advised by an External Review Panel on Heat Injury Management (ERPHIM), this was chaired by Associate Professor Mark Leong who is a senior consultant at the Department of Emergency Medicine at Singapore General Hospital. The following changes will be put into place:
First, a simplified protocol to lower the bar for immediate evacuation. Under this protocol, all commanders and medics across the SAF will evacuate every trainee that cannot respond to simple questions on time, place and identity. The intent is obvious, and this takes the guesswork out of the assessment and what the reason is, as this case showed, and imposes early evacuation as the default, as a strict TSR to be followed. This TSR is effective immediately.
Second, additional methods to cool servicemen during training. For example, the Army will implement what is called the Arm Immersion Cooling System; you immerse your arms (in ice water). And this has been used in United States and Australian militaries to reduce heat injury for all fast marches and route marches that are 12 km and longer. Portable cooling methods, such as purpose-built cooling pads, will now replace less effective ice packs to be used on the spot. These will be implemented in phases, starting from this month.
There had been suggestions for wearables. The expert opinion of the ERPHIM is that those currently available in the market are not effective for measuring core temperature.
Fourth, the Army will ensure that our commanders and soldiers can better recognise the signs and symptoms of heat injuries. Lesson plans on safety will be improved and the annual TSR test will also include mandatory questions on heat injury prevention and management.
Fifth, the importance of open reporting will be emphasised. Soldiers will be encouraged to use the Hotline to report any unauthorised activities or violations of rules, especially during Basic Military training and reinforced during In-Camp Training.
Sixth, more opportunities for make-up training. The Army will encourage our soldiers not to push themselves beyond safety limits. If a soldier feels that he is unwell during any training activity, or if the buddy notices it, soldiers will be reminded to err on the side of caution, to stop and make up training another day.
Seventh, more clinical exposure and patient contact for medics to upgrade their skills in resuscitation and handling of emergencies. This may include periodic attachments to hospitals, A&E departments or ambulances.
Mr Speaker, we need a strong SAF that can defend Singapore but it must and can be built without compromising the safety and well-being of Singapore’s precious sons serving their National Service (NS). CFC Lee was an exemplary soldier who served with commitment, and was well-respected by his peers for his positive attitude. The loss of such a good soldier like CFC Lee is deeply grievous to us. It will take collective effort to achieve zero training fatalities. Each serviceman must take care of himself or sound the alert when his buddy is not well, or if regulations are not complied with during training. Commanders must be alert and pull out early those who are not coping and use another occasion to train.
Zero training deaths must be the norm and any mishap should be vigorously attended to by commanders to achieve this norm. Let me conclude by expressing this House’s deep condolences to the late CFC Lee’s family. The SAF has updated the family of the COI’s findings and the actions that the SAF is taking to prevent recurrence of the lapses found. I assure all members that MINDEF and the SAF will do all it can to help the family through this difficult period. Thank you Mr Speaker.