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COI finds inadequate on-site casualty management and delayed evacuation of CFC Dave Lee as factors to his death

Defence Minister Ng Eng Hen said in Parliament on Monday (6 Aug) that inadequate on-site casualty management and delayed evacuation to the medical centre were the likely reasons for CFC Dave Lee succumbing to this heat stroke injuries.

The Minister was presenting the report from the Committee of Inquiry (COI).

CFC Lee Han Xuan Dave was a Guardsman from the 1st Battalion Singapore Guards, who passed away on Monday (30 April) at 5.32 pm at Changi General Hospital (CGH) at the age of 19 years old.

He was found to display signs of heat injury at about 08.35 am on 18 Apr 2018, after just completed an 8km fast march in Bedok Camp. He was evacuated to the camp's Medical Centre and then transferred to Changi General Hospital (CGH), where he was warded in the Intensive Care Unit (ICU) since 18 Apr 2018. His condition did not improve in the ICU and worsened during the hospitalisation. CFC Dave Lee was pronounced dead at 5.32 pm on 30 Apr 2018 at CGH.

Lapses on the day before his heat-stroke

A day before his heat stroke, CFC Lee was taking part in a group exercise where soldiers had to run six 400m laps at a common pace. Between each lap, the rest timing was 1 minute, which was 45 seconds shorter than what was stipulated in the training plan.

"These deviations were a breach of training safety regulations," noted the COI.

Later that night, the entire platoon was given out collective punishment as they had used their mobile phones after lights-out despite repeated warnings. At around 9.40pm, the entire platoon was told to assemble in their Number 4 uniform and assault bags.

Punishment given out to them came in the form of physical exercises. This included bear crawls, sprints, leopard crawls, push-ups and crunches. Commanders had also poured water over the troopers from their water bottles and jerry cans.

The entire punishment session lasted for about 30 to 45 minutes and ended with the trainees reciting the Guards Creed a few times while in a high kneel position. Minister Ng said that "the commanders did not seek prior approval for the conduct of this informal punishment or inform their superiors after the punishment".

Eventually, at about 10.25pm, the trainees were sent back to wash-up and lights were turned off at 10.45pm. Such punishment contributed to the trainees having 6 hours and 15 minutes of sleep, which is less than the stipulated 7 hours.

Dr. Ng acknowledged that "less sleep could be one of the factors which caused CFC Lee to have more fatigue before participating in the fast march."

Lapses on the day of heat-stroke

On the day of CFC Dave Lee’s heat stroke, there were also several lapses on how CFC Dave Lee’s medical response was administered.

At the onset of symptoms, his actual temperature was not taken even as his skin felt cold to the touch. Instead, his equipment and uniform were removed while water and oxygen were given to him.

Dr Ng said 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".

"Full body cooling should have been instituted as soon as possible, and within 30 minutes of presentation of signs and symptoms."

More importantly, there was a “significant gap” of time between the onset of symptoms and his arrival at the medical centre. This was because "the persons attending to CFC Lee mistook his signs and symptoms as due to physical exhaustion".

Dr. Ng added that there were several calls for CFC Lee to be evacuated, but these calls were either "not heard or not heeded".

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 noted that the persons involved in this incident have been removed from command. MINDEF will await the results from the police investigation and the coroner's inquiry, also the Attorney General's Chamber's whether any criminal charges will be filed against any persons. If there is no criminal charge, MINDEF will charge the persons involved for any lapses in military court.

According to the earlier Facebook post by CFC Lee's aunt, a fellow camp mate wrote that the sergeants were just surrounding him, "talking cock and laughing and cracking jokes around him, obviously thinking the soldier is trying to keng".

The person also wrote, "if anything happens to him, I believe its the fault of the commanders who did not know even how to administer the proper procedure for Heat Stroke, wasting vital time before his temperature reached 42deg. As well as commanders who don't understand the seriousness of the uninterrupted rest that is required as per training safety regulation, especially for high key activities."