Death of NSF Dave Lee: COI highlights inadequate casualty management, delayed evacuation as factors
SINGAPORE: The Committee of Inquiry (COI) investigating the death of full-time national serviceman Corporal First Class (CFC) Dave Lee has found that inadequate on-site casualty management and delayed evacuation were "likely reasons" for him succumbing to heat stroke.
CFC Lee died on Apr 30, nearly two weeks after "displaying signs of heat injury" in Bedok Camp following the completion of an 8km fast march, the Ministry of Defence (MINDEF) said.
"The COI found that CFC Lee’s death was the result of heat stroke leading to multiple organ injury," Defence Minister Ng Eng Hen said in a ministerial statement in Parliament on Monday (Aug 6), citing preliminary findings.
"Other than this, the COI did not find any physical injury sustained, as verified by the autopsy report, 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 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 heat stroke were inadequate on-site casualty management and delayed evacuation to the medical centre."
IMPROPER MANAGEMENT OF CFC LEE AFTER FAST MARCH
After the fast march on Apr 18, the persons attending to CFC Lee thought that he was suffering from physical exhaustion, Dr Ng said, citing the COI's findings.
His pulse was assessed to be normal and his skin felt cold to the touch, but his temperature was not taken, the COI found.
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 IV drip, the improper placement of ice packs, and the improper use of a ground sheet," Dr Ng said.
"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, the COI found that CFC Lee was semi-conscious, with his temperature at 42.7 degrees Celsius.
Two bags of fast intravenous (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 COI's findings stated.
The MO accompanied CFC Lee in a Singapore Armed Forces ambulance to CGH’s Accident and Emergency department, where he was handed over and admitted to the Intensive Care Unit. His condition deteriorated and he died 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," Dr Ng said. "Full body cooling should have been instituted as soon as possible, and within 30 minutes of presentation of signs and symptoms."
It is not clear how long before body cooling was started after CFC Lee presented heat injury symptoms.
"The delay in evacuation resulted as the persons attending to CFC Lee mistook his signs and symptoms as due to physical exhaustion," Dr Ng continued. "Though trained, they had never encountered any previous case of heat injury themselves."
Dr Ng added that there were several calls for CFC Lee to be evacuated, but these calls were either "not heard or not heeded".
TRAINING SAFETY AND DISCIPLINE REGULATIONS BREACHES DAY BEFORE FAST MARCH
The COI also found breaches of training safety and discipline regulations on Apr 17, the day before the heat stroke occurred.
It discovered breaches of the Army’s Training Safety Regulations (TSR) for a cardiovascular physical exercise that CFC Lee took part in.
For this exercise, soldiers had to run six laps of 400m each 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," Dr Ng said.
"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 commanders wanted to enhance fitness and foster greater cohesion by keeping the platoon intact, and the soldiers running at the same pace, not in groups."
As for discipline regulations, the collective punishment that was meted out to CFC Lee’s platoon later that night was also not authorised, the COI discovered.
READ: MINDEF to prosecute those responsible for lapses leading to death of NSF Dave Lee if no criminal charges filed
At about 9.40pm, the COI found that CFC Lee's platoon was told to fall in in their Number 4 uniform and assault bag.
"The commanders 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," Dr Ng said.
Five minutes later, the commanders meted out the informal punishment in the form of physical exercises, which comprised bear crawls, sprints, leopard crawls, as well as push-ups and crunches.
The commanders also had water poured over the troopers from their water bottles and jerry can. The session ended with the troopers reciting the Guards Creed a few times in a high kneel position.
The entire session lasted for about 30 to 35 minutes, and 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 commanders did not seek prior approval for the conduct of this informal punishment or inform their superiors after the punishment," Dr Ng said.
"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 6 hours, 15 minutes 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 IN LINE WITH LESSON PLAN AND REGULATIONS
The COI also found that conduct of the fast march was in line with the lesson plan and relevant regulations, Dr Ng said.
"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," he added.
These measures include the temperature-taking regime, hydration regime, water supply, 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".
When asked follow-up questions on whether the COI had determined why the soldiers did not admit to having fewer than seven hours of sleep, Dr Ng said "from what I can recollect, they didn't give specific reasons".
"One surmises that they wanted to do it because they wanted to carry on with their training," he added.
"You've got to make it second nature for the trainees to say this is for my own self-protection or my buddy. I'm going to tell on you if you didn't do it because I'm going to protect you.
"We will require at this stage of ours, where we have the regulations but we're not sure everybody follows it, that we need everybody to play their part to achieve zero training fatalities."
Before the fast march, CFC Lee had his temperature taken, which was normal at 36.3 degrees Celsius, and had drunk water, the COI found. This was witnessed by his buddy, who also observed him "to be looking well and seemed to be his usual self".
CFC Lee did not inform the Conducting Officer when the latter asked if anybody was not feeling well. This was followed by the conduct of warm-up exercises to get troopers ready for the 8km fast march.
After the 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.
After CFC Lee completed the first 6km, he had a mandated 20-minute rest. Following that, as CFC Lee was moving off for the last 2km, he informed the commanders 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," Dr Ng said.
CFC Lee was the last 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 commanders and the cover medics," Dr Ng added.
OTHER FINDINGS AND PROSECUTION
Besides these findings, the COI also looked into CFC Lee’s state of health prior to the fast march.
While CFC Lee had no significant medical history, the COI established that he had been taking medication in the weeks prior to the fast march for acute upper respiratory tract infection.
This was after he visited a polyclinic on Mar 31, more than two weeks before the fast march.
"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 person in the criminal courts," Dr Ng stated.
He added that those responsible for lapses leading to the death of CFC Lee will be prosecuted in a military court if no criminal charges are filed.