SAF officer delayed evacuating CFC Dave Lee despite NSF's heat injury symptoms: Coroner's court

Wan Ting Koh
·Senior Reporter
·7-min read
Committee of Inquiry convened to investigate death of NSF Dave Lee
Committee of Inquiry convened to investigate death of NSF Dave Lee

SINGAPORE — The Singapore Armed Forces (SAF) officer overseeing a fast march had repeatedly delayed evacuating a full-time national serviceman (NSF) suffering from heat injuries to a medical centre until some 40 minutes after the NSF had collapsed, the Coroner’s court heard on Wednesday (13 January).

Captain (CPT) Tan Baoshu had turned down several suggestions by fellow officers and a medic for Corporal First Class (CFC) Dave Lee to be conveyed to the medical centre, a Singapore police investigation officer told the court during a Coroner’s Inquiry into CFC Lee’s death.

CPT Tan had gone against military protocol in the lead-up to CFC Lee’s death and had repeatedly told officers to wait five or 10 more minutes so that CFC Lee’s condition might improve.

CFC Lee, 19, a Guardsman from the 1st Battalion Singapore Guards, had collapsed and showed signs of heat injury following an 8km fast march on 18 April 2018. He died from his injuries at Changi General Hospital on 30 April 2018, with the delay in evacuation determined to be a factor in his death.

A day before the fast march, on 17 April 2018, CFC Lee’s platoon was punished for various infractions, including a perceived lack of teamwork and using their mobile phones after lights out on previous nights. They were made to do various exercises, including crunches and pushups, between 9.45pm and 10pm. The punishment was carried out without the sanction of supervisors.

The next day, before the fast march began, none of the soldiers indicated feeling unwell. The fast march commenced at 6.30am in four waves, with CFC Lee being dispatched in the last wave.

CFC Lee appeared normal and was still speaking and joking with others even until the 6km mandatory rest point. During his last 2km of the stretch, CFC Lee experienced cramping in his calf and was allowed to stretch it.

For the last 300m of the fast march, CFC Lee was urged to run to the finish line and he did so, crossing it at 8.25am and then dropping to his knees at the table where he had his timing recorded.

He was then helped to a rest area, where he was observed swaying and slurring in speech. He was also unresponsive, drooling and breathing heavily.

He then had his equipment removed and uniform unbuttoned, with officers placing ice packs on his neck, armpit, and groin. He also had water sprayed on him. A commander attempted to give him isotonic water but CFC Lee was unable to swallow, with the liquid flowing out from his mouth.

CPT Tan had observed Lee’s symptoms. However, he felt that Lee had been suffering from physical exertion rather than a heat injury and rejected the suggestions made by fellow officers to convey him to a medical centre, preferring to wait and see if CFC Lee recovered with rest.

He failed to order immediate evacuation according to safety regulations, which stipulated that those suspected to be suffering from heat injuries should be evacuated with continuous cooling measures, the IO told the court.

CPT Tan also rejected an officer’s offer to administer an intravenous (IV) drip to CFC Lee, which was also contrary to regulations, which state that an IV drip should be administered if the casualty was unconscious and unable to drink water.

Instead, CPT Tan said that CFC Lee should be covered with a ground sheet, as his arms felt cold. Around 8.40am, CPT Tan approved a decision to dismiss the safety vehicle, as he felt that a stretcher was sufficient. He did not check CFC Lee’s condition before approving the decision. This was also in breach of regulations, which stated that the the vehicle was to remain on site for evacuation.

At around 8.45am, an off-duty medic came across CFC lee and informed that the NSF ought to be evacuated to the medical centre immediately. However, CPT Tan demurred, saying that there should be a wait of another five to 10 minutes to see if his condition improved.

CPT Tan again rejected another officer’s suggestion to convey CFC Lee to the medical centre without further delay, suggesting to wait another five minutes.

The officer finally ordered for CFC Lee to be evacuated at around 9am. CFC Lee was then placed on a stretcher and conveyed on foot to the medical centre some 230m away.

In five minutes, CFC Lee arrived at the medical centre, where his temperature was ascertained to be 42.7 degree celsius. IV drips were inserted into both of his arms and CFC Lee was later conveyed to Changi General Hospital via ambulance. By then, he was foaming at the mouth.

Despite further treatment, CFC Lee’s condition deteriorated and he died on 30 April 2018. His cause of death was multiple organ failure from heat stroke, to which a delay in evacuation was a contributing factor.

A second witness to testify on Wednesday was Dr Kenneth Heng, who is a senior consultant at the emergency department at Tan Tock Seng Hospital. He was appointed to provide an independent expert opinion for the case.

Dr Heng said that the priority in treating patients with heat stroke was to reduce the body temperature as quickly as possible, with guidelines stating that temperatures should be reduced to below 39 degree celsius within half an hour.

Asked by a State Counsel what the maximum delay should have been, Dr Heng said a 10 to 15 minutes delay would have been “reasonable”.

He added that a continual high body temperature would have set in place an “inflammatory cascade”, which would have been difficult to reverse.

While unable to give a figure on survivability, Dr Heng said that with the correct blood pressure restored to a patient, research showed that the mortality rate would have decreased from 33 per cent to 10 per cent.

Commenting on the appropriateness of the measures applied to CFC Lee, Dr Heng said that the personnel on site could have moved CFC Lee to a shady area when he first collapsed and removed his shirt completely. He stated that it was counter productive to use a ground sheet on CFC Lee as he would not have been able to sweat, and an IV drip would have been able to replace the fluids he lost by sweating.

The findings into the coroner’s hearing will be delivered by State Coroner Kamala Ponnampalam on 27 January.

CFC Lee’s parents and older sister were in court during the hearing.


Following Lee’s death, Minister for Defence Ng Eng Hen said in a ministerial statement on 6 August 2018 that a Committee of Inquiry had found breaches of training safety and discipline rules in the events leading to CFC Lee’s death, based on its preliminary findings.

After CPT Tan was charged on 31 October 2018 with committing a rash act causing his death, he had claimed trial to the charge.

However, the 31-year-old 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 a month later, on 13 February last year.

Six other servicemen were referred to the SAF for internal investigations on 31 October 2018. The Ministry of Defence deferred internal proceedings pending the conclusion of CPT Tan’s criminal proceedings. The six servicemen were charged in 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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