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Coroner finds no basis to suspect foul play in NSF Dave Lee’s death; mother calls lapses ‘unforgivable’

SINGAPORE — There is no basis to suspect foul play in the death of full-time national serviceman (NSF) Dave Lee Han Xuan, though lapses by Singapore Armed Forces (SAF) personnel had contributed to his death, the state coroner said on Wednesday (Jan 27).

Coroner finds no basis to suspect foul play in NSF Dave Lee’s death; mother calls lapses ‘unforgivable’

A photo of Corporal First Class Dave Lee at his funeral wake in 2018.

  • A state coroner has ruled that there was no foul play in the death of Corporal First Class Dave Lee
  • He collapsed after an 8km fast march in 2018 and died later of heat stroke
  • The coroner noted that Lee had no medical history that predisposed him to heat stroke
  • His exertion during an unauthorised exercise the night before may have made him more prone to it, she said
  • Lee’s mother said after the verdict that the lapses that led to his death were unacceptable

 

SINGAPORE — There is no basis to suspect foul play in the death of full-time national serviceman (NSF) Dave Lee Han Xuan, though lapses by Singapore Armed Forces (SAF) personnel had contributed to his death, the state coroner said on Wednesday (Jan 27).

Lee, who was 19 when he died in 2018, collapsed after an 8km fast march at Bedok Camp. He died from heat stroke after spending more than a week in Changi General Hospital.

During the sole day of the coroner’s inquiry hearing two weeks ago, the court heard that Captain Tan Baoshu, the supervising officer of the fast march, had rejected several suggestions to immediately evacuate Lee and administer an IV drip. 

This was despite Lee displaying symptoms of heat stroke. He was evacuated to the Bedok Camp Medical Centre about 40 minutes after collapsing.

On Wednesday, State Coroner Kamala Ponnampalam noted in her inquiry findings that SAF has since adopted several recommendations made by an external review panel on heat injury management. The panel was convened by the Ministry of Defence.

Lee had no medical history that predisposed him to heat stroke, though his exertion during an unauthorised “collective punishment” the night before could have made him more prone to it, the coroner said.

“The ensuing on-site management was abysmal. The first-aid rendered was suboptimal, and there was inordinate delay in evacuating Lee to the medical centre,” she added.

She noted that Lee was a good soldier by all accounts who had given his best during training. “His death is truly a sad loss to the family and nation.”

Lee’s mother, Madam Jasmine Lee, as well his father and older sister were present in court. Mdm Lee told reporters after the hearing that the lapses were “totally unforgivable” and that they “only have sadness left”.

When asked if they will take any civil action against the SAF, she replied that they are not ready for that as the coroner’s verdict had just been released.

She added: “Obviously we are not okay with the lapses. It’s really outrageous… it’s totally unacceptable that this kind of thing can happen in camp.

“Any parent that lost a child will never have any closure. It will only be sadness till the day they meet their child.”

She had previously told TODAY that she has forgiven Tan and was “truly sad” for him. 

A family photo of Corporal First Class Dave Lee being screened at his funeral wake in 2018. TODAY file photo

THOSE PUNISHED

Tan, who was also Lee’s officer commanding at the support company of the 1st Guards Battalion, was charged in civilian court in October 2018 with committing a rash act causing Lee’s death, and claimed trial. 

But the charge was withdrawn early last year when he was diagnosed with stage 4 cancer.

He died at the age of 33 on Feb 13 last year.

Six other servicemen, including the safety officer of the fast march and the conducting officer who made unauthorised deviations to a lesson plan the day before the march, were fined between S$1,800 and S$4,500 each in military court. 

Following his death, Lee was posthumously promoted from the rank of private to corporal first class.

WHAT HAPPENED

On April 17, 2018, the day before the fast march, Lee’s platoon was mobilised that night for perceived lack of teamwork and using mobile phones after lights out. 

They received unauthorised “collective punishment”, including physical exercises such as bear crawls, leopard crawls, push-ups and abdominal crunches. Because of this, they had just six hours and 15 minutes of uninterrupted rest, rather than the stipulated seven hours.

Lee took his temperature, which registered at 36.3°C. He appeared normal and could still talk when he reached the 6km rest point, where he had a mandatory 20-minute rest before resuming. 

In the final 2km stretch, he took several 10-second breaks and was urged to run to the finish line upon entering the parade square.

After crossing the finish line at about 8.30am, Lee dropped to his knees. Others saw that he was swaying, his speech was slurred, and he was drooling from his mouth and breathing heavily.

Among other measures, his load bearing equipment was removed and his shirt was unbuttoned, with ice packs applied to his neck, armpit and groin. He was unable to swallow isotonic water offered to him.

Tan personally observed Lee to be in a disoriented state and unable to follow instructions. The captain assessed him to be suffering from physical exertion rather than heat injury.

Tan then went against the SAF’s Training Safety Regulations in telling his subordinates to not evacuate him first, and rejected suggestions to infuse fluids through an IV drip. 

Instead, he gave instructions for Lee to be covered with a ground sheet because Lee said that he felt cold.

At 8.40am, when someone else sought approval from Tan to dismiss a safety vehicle, he did not check on Lee before authorising it. This was also against protocol.

An off-duty medic walking past the parade square checked on Lee at 8.45am, telling Tan to evaluate the NSF immediately. Tan said to wait another five to 10 minutes to see if his condition improved.

Tan rejected another suggestion for evacuation shortly afterwards, before finally ordering it at about 9am. Lee was taken on a stretcher to the medical centre where medical officers treated him.

However, his temperature remained at 42°C and he began foaming at the mouth. 

He was taken to Changi General Hospital, where his condition deteriorated. He was pronounced brain dead on April 30, 2018.

A forensic pathologist from the Health Sciences Authority certified his cause of death as multiple organ failure from heat stroke, with contributing factors being a delay in evacuation and inadequate casualty management.

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Dave Lee NSF death coroner's inquiry

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