CORRECTION: An earlier version of this article stated that Defence Minister Ng Eng Hen said the collective punishment meted out by commanders to CFC Dave Lee’s platoon consisted of physical exercises that were repeated 30-35 times. This is incorrect. The minister said that the exercises lasted 30-35 minutes.
The Committee of Inquiry (COI) has found breaches of training safety and discipline rules in relation to the death of Corporal First Class (CFC) Lee Han Xuan Dave based on its preliminary findings, said Minister for Defence Ng Eng Hen in Parliament on Monday (6 August).
Ng, who was reading his Ministerial Statement, was referring to the events that occurred on 17 April this year before the full-time national serviceman from the 1st Battalion Singapore Guards suffered a heat stroke the following day. The 19-year-old Guardsman, who was taking part in an 8-kilometre fast march in Bedok Camp on 18 April, succumbed to his heat injuries and died on 30 April.
The COI discovered breaches of the Army’s Training Safety Regulations (TSR) for Cardiovascular 6 and breaches of the Army’s directive for another subsequent event on 17 April.
For Cardiovascular 6, the soldiers ran six laps of 400m each and were grouped according to their running ability. CFC Lee was asked to run at a slightly faster pace than required for the first three laps – or about 10 seconds faster per lap. For the next three laps, he ran at his own pace. The rest time between each lap was cut to 1 minute, or 45 seconds shorter than the lesson plan.
The deviations from the plan were a breach of TSR, Ng said. The reason given was that the commander/s wanted to foster greater group cohesion with soldiers running at the same pace, he added.
Later that night before the fast march, the collective punishment that was meted out to
CFC Lee’s platoon was also not authorised, Ng told the House.
The commanders had wanted to punish the platoon for their perceived lack of teamwork and use of mobile phones after Lights Out. Among the punishment that the platoon had to undergo were physical exercises including Bear Crawls, Sprints, Leopard Crawls, as well as push-ups and crunches, for 30 to 35 minutes.
“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,” said Ng.
As a result of the informal punishment, the trainees had 6 hours 15 minutes instead of seven hours of uninterrupted rest. Less sleep could have been one of the factors that caused CFC Lee to feel more tired before taking part in the fast march, Ng pointed out.
Inadequate casualty management
Moving on to recount the events of the following day, Ng said CFC Lee’s temperature was normal at 36.3 degrees Celsius and he had drunk water before the fast march.
While he was moving off for the last 2km, CFC Lee indicated to commander/s that he had cramps in his calf muscles. CFC Lee was observed to be disoriented after ending last in the march and was immediately attended to.
The persons attending to CFC Lee thought he was suffering from physical exhaustion. CFC Lee’s skin felt cold to touch and his temperature wasn’t taken.
The COI noted that the on-site cooling measures administered to CFC Lee were inadequate, including the failure to administer an IV drip, the improper placement of ice packs, and the improper use of a ground sheet.
CFC Lee was subsequently evacuated to the Bedok Camp Medical Centre. However, the COI noted there was a “significant gap” between the onset of symptoms and his arrival at the medical centre.
On arrival at the medical centre, CFC Lee was semi-conscious and his temperature was measured at 42.7 degrees Celsius. As he was not responding to treatment, he was evacuated to the Changi General Hospital (CGH). His condition worsened and he died 12 days later on 30 April.
Ng said that the COI found that CFC Lee’s death was the result of heat stroke leading to multiple organ injury. It didn’t find any physical injury sustained 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 contributory 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,” Ng added.
SAF’s new training safety protocols
The minister also highlighted the comments made by The External Review Panel on SAF Safety (ERPSS) following CFC Lee’s death. The ERPSS had emphasised that it is essential for personnel to comply with safety rules in operating manuals and breaches such as those found by the COI should not be condoned, the minister said.
The ERPSS had also flagged three areas for improvement following the COI’s findings including strengthening commanders’ knowledge on heat injuries, allowing medics to exercise their professional authority when dealing with medical issues, and ensuring that commanders watch out for soldiers who feel unwell and pull them out of training before they get injured.
On its part, the Singapore Armed Forces has enhanced its training safety processes including adopting a simplified protocol to lower the bar for immediate evacuation and additional methods to cool servicemen during training. Portable cooling methods, such as purpose-built cooling pads, will soon replace less effective ice packs to be used on the spot.
In conclusion, Ng noted that CFC Lee was an exemplary soldier who served with commitment and was well-respected by his peers.
“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,” Ng said.
“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.”