Officer rejected suggestions to evacuate NSF Dave Lee, who died of heat stroke: Coroner's court

SINGAPORE: The supervising officer of an 8km fast march for national service trainees repeatedly turned down suggestions to immediately evacuate national serviceman Dave Lee Han Xuan, who was unable to walk properly and was drooling at the end of the march.

The details of the incident, as well as the supervising officer's multiple breaches of protocol, came to light on Wednesday (Jan 13) at the opening of a coroner's inquiry into CFC Lee's death.

According to an investigation report by the police, Captain Tan Baoshu assessed that Corporal First Class (CFC) Lee was suffering from physical exertion rather than heat injury and rejected a suggestion to evacuate him to the medical centre, asking them to wait.

He also rejected a suggestion to administer an intravenous drip on CFC Lee, who was disoriented, unable to swallow liquids and breathing heavily.

CFC Lee was evacuated only 40 minutes later, which a medical expert testified was "really too long", and later died of heat stroke with multiple organ failure, aged 19.

The court heard that CFC Lee had started the march along with the other servicemen at 6.45am on Apr 18, 2018. He appeared well and could talk to his superiors in the last few kilometres.

During the final two kilometres, he informed a First Sergeant that he had a cramp in his calf and was allowed to stop to stretch. He continued to take breaks in the course of the final stretch.

CPT Tan, 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.

CFC Lee crossed the finish line at 8.25am, within the required 84 minutes after accounting for the mandatory rest period, and dropped to his knees.

FELL TO HIS KNEES AT COMPLETION OF MARCH

He had his timing recorded and was helped to a rest area, but was swaying as he walked there and his speech was slurred, the court heard.

He was observed to be incoherent, unresponsive, drooling from the mouth and breathing heavily. His equipment was removed and his uniform unbuttoned. On CPT Tan's instruction, ice packs were applied on his neck, armpits and groin and water poured on his face.

CFC Lee was also sprayed with water from a mobile cooling unit, but he was unable to swallow isotonic water administered to him, with the liquid flowing out from his mouth.

CPT Tan observed that CFC Lee was disoriented, unresponsive, breathing heavily and unable to follow instructions. However, he assessed that he was suffering from physical exertion rather than heat injury.

When someone suggested to evacuate him to the medical centre, CPT Tan told him to wait as CFC Lee was suffering from physical exertion and would recover. He failed to order CFC Lee's immediate evacuation, breaking protocol that states soldiers suspected to be suffering from heat injury should be immediately evacuated.

CPT Tan also rejected another suggestion to administer an intravenous drip, which is also stipulated in guidelines for unconscious casualties or those who are unable to drink water.

HE DIRECTED THAT CFC LEE BE COVERED WITH GROUND SHEET

Instead, CPT Tan directed that CFC Lee should be covered with ground sheets, as his arm felt cold. He was covered from the neck down with the ground sheet, and later from the pelvis down.

Fifteen minutes after CFC Lee first collapsed, CPT Tan gave his approval to dismiss the safety vehicle, saying that CFC Lee could be evacuated via a stretcher. He did not check CFC Lee's condition before doing so.

The dismissal of the safety vehicle was contrary to guidelines for the fast march, which stipulate that the vehicle must remain on site for responsive evacuation.

At about 8.45am, an off-duty medic who was walking past the parade square came across CFC Lee and attended to him. He assessed him and told CPT Tan that he should be evacuated to the medical centre immediately.

CPT Tan told him that they should wait for another five to 10 minutes to see if his condition improved. The medic applied an oxygen mask to CFC Lee, as he was wheezing. 

At 8.50am, another person urged CPT Tan to evacuate CFC Lee without further delay, but CPT Tan responded that they should wait for another five minutes. 

CFC Lee was finally placed on a stretcher at about 9am and taken by foot to the medical centre, arriving at 9.05am. His temperature had not been taken at any time between his collapse and his arrival at the medical centre.

ARRIVAL AT MEDICAL CENTRE

He had a temperature of about 42 degrees Celsius at the centre and was attended to by three doctors who treated him with two cycles of a body cooling unit and applied ice packs.

Despite the treatment, CFC Lee's temperature remained at 42 degrees Celsius and when he started to foam at the mouth, he was evacuated to Changi General Hospital.

He arrived there at about 9.50am with a temperature of 41.6 degrees Celsius. He was intubated and treated with two pints of ice-cold IV drips, but found to have organ damage from heat stroke.

He was transferred to the Intensive Care Unit, but his condition continued to deteriorate, and he later showed brain dysfunctions and his prognosis was subsequently deemed terminal and irreversible with likely brain damage.

He was pronounced dead on Apr 30, a few weeks after the march, with the cause of death being multiple organ failure from heat stroke. The police said in their report read out in court that they do not suspect any foul play in the death of CFC Lee.

The delay of his evacuation was a contributing factor to his death, said the police.

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.

READ: SAF captain accused of causing NSF Dave Lee’s death granted discharge not amounting to acquittal

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.

Medical expert Kenneth Heng from the emergency department at Tan Tock Seng Hospital, who was hired to provide an independent expert opinion on the case, testified that the first aid rendered to CFC Lee at the scene could have been improved.

He could have been moved to a shady area, had his shirt removed completely and fanned to help sweat evaporation, said Dr Heng. An IV drip could have been administered, and covering him with a ground sheet was "counter-productive" as he would not have been able to sweat.

EXPERT EXPLAINS HEAT STROKE

Explaining heat stroke, Dr Heng said it is the most severe heat stress of all with temperatures elevated beyond 40 degrees Celsius and mental or neurological deficits.

CFC Lee had been subject to physical exertion from the fast march and demonstrated neurological problems such as drooling, disorientation and slurring of speech, said Dr Heng.

His elevated temperature was due to heat produced by his muscles during the march, with the environment, humidity and temperature contributing to this. He was not able to lose enough heat to keep up with his heat generation.

"Heat stroke leads to multi-organ failure," explained Dr Heng. "There are three main mechanisms. First - direct damage to the cells because of heat - the cells of every organ are affected. Second - because of dehydration and low blood pressure, blood to organs ... is also affected. The final thing is that because of cell damage, there's toxins released, and this causes an inflammatory cascade. So it's a vicious cycle that worsens multi-organ failure."

Dr Heng said the priority in heat stroke is to reduce temperatures as quickly as possible. Guidelines state that it should be reduced to below 39 degrees Celsius within 30 minutes.

"There's limited things you can do at the scene, so evacuation to a medical centre with a body cooling unit should be the priority," he said. "It was 40 minutes to evacuate (CFC Lee), which was really too long."

He said a 10 to 15-minute delay would have been reasonable. He was unable to comment on CFC Lee's "survivability in terms of delay", but said research has shown that if blood pressure is corrected, mortality decreases from 33 per cent to about 10 per cent.

Responding to the coroner's questions, Dr Heng said there did not seem to be anything in CFC Lee's medical records that would have predisposed him to this sort of injury.

Other circumstances that could have contributed to the heat stroke include CFC Lee's exertion the night before as well as his reduced rest. The night before, instead of having seven hours of rest as required, CFC Lee and his fellow servicemen were punished for various infractions and made to do activities including bear crawls, sprints and push-ups without the knowledge or sanction of supervisors.

However, Dr Heng said CFC Lee did not appear to be sick before the march and was not on any medication. He said it is difficult to identify any precursor symptoms that might have identified the condition, adding that the cramp CFC Lee suffered was fairly non-specific.

The coroner said she would consider the evidence and deliver her findings on Jan 27.

SUBSEQUENT STEPS TO IMPROVE HEAT INJURY MANAGEMENT

In the wake of CFC Lee's death, a Committee of Inquiry was convened to investigate the incident, and several recommendations were proposed to minimise recurrences. 

These include reinforcing heat injury management, highlighting to commanders the need to adhere to regulations and guidelines and strengthening the decision-making process on evacuation.

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. 

First aid should be rendered and casualties evacuated as soon as possible, with commanders and medics erring on the side of caution as it is difficult to accurately determine the degree of heat injury. When in doubt, all suspected heat injury cases should be transferred to a medical facility, said the panel.