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NSF Dave Lee’s death: SAF captain delayed evacuation despite heat stroke symptoms, coroner’s court hears

SINGAPORE — When full-time national serviceman Dave Lee Han Xuan grew incoherent and unresponsive after completing an 8km fast march, his superior rejected suggestions to evacuate him to the medical centre and administer an intravenous drip.

NSF Dave Lee’s death: SAF captain delayed evacuation despite heat stroke symptoms, coroner’s court hears

Corporal First Class Dave Lee collapsed after an 8km fast march on April 18, 2018 and died 12 days later.

  • Corporal First Class Dave Lee collapsed after an 8km fast march on April 18, 2018
  • His officer commanding, Captain Tan Baoshu, rejected suggestions to evacuate him immediately and infuse intravenous fluids
  • Lee was evacuated to the Bedok Camp Medical Centre about 40 minutes after showing symptoms
  • An independent medical expert said that this was “really too long”
  • The state coroner will give her inquiry findings on Jan 27

 

SINGAPORE — When full-time national serviceman Dave Lee Han Xuan grew incoherent and unresponsive after completing an 8km fast march, his superior rejected suggestions to evacuate him to the medical centre and administer an intravenous drip.

Singapore Armed Forces (SAF) captain Tan Baoshu, who was the supervising officer of the fast march, told others to wait, saying that the 19-year-old appeared to be suffering from physical exertion rather than heat injury.

Lee was only evacuated to the Bedok Camp Medical Centre about 40 minutes after collapsing. 

He was later taken to Changi General Hospital, where he spent more than a week in the intensive care unit before dying of heat stroke.

Details of Tan’s actions on April 18, 2018 emerged on Wednesday (Jan 13) — the sole day of a coroner’s inquiry into Lee’s death. 

State Coroner Kamala Ponnampalam will deliver her findings on Jan 27.

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But the charge was withdrawn early last year when he was diagnosed with stage 4 cancer.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 age 31 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.

Singapore Armed Forces Captain Tan Baoshu, in a photo taken in November 2018. TODAY file photo

APPEARED NORMAL IN FIRST 6KM

On Wednesday, State Counsel Andre Chong called two witnesses to testify in the coroner’s court.

They were an investigation officer who gave his detailed investigative findings into Lee’s death, as well as Dr Kenneth Heng from Tan Tock Seng Hospital’s emergency department, who served as an independent medical expert.

The court heard that on April 17, 2018, the day before the fast march, Lee’s platoon received unauthorised “collective punishment”, such as physical exercises, that night for perceived lack of teamwork and using mobile phones after lights out.

The next morning, they were asked if they had had seven hours of uninterrupted rest and if anyone felt unwell. No one indicated otherwise.

Lee also 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 session before resuming. He was still able to joke and talk, and was observed to be walking normally.

Shortly after leaving the rest point, he told a conducting officer that he had a cramp in his calf. The other man allowed him to stop for a minute to stretch.

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. He finished the march within 80 minutes, which was under the passing time.

WAS DISORIENTATED, DROOLING

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.

According to the investigation officer, 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 directed for Lee to be covered with a ground sheet as his skin felt cold to the touch.

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 evacuate 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.

Since Lee’s death, the SAF has made changes to its heat injury measures. This includes immediately evacuating trainees for heat injury if they cannot respond to simple questions on time, place and identity.

DR HENG’S TESTIMONY

Dr Heng, the independent medical expert, told the court that a 10- to 15-minute delay in evacuation would have been “reasonable”.

“The priority in heat stroke is to reduce heat as soon as possible… Forty minutes to evacuation was really too long,” he said.

While he could not give a figure, Dr Heng said research has shown that if a person’s blood pressure and temperature are corrected, the mortality rate decreases from 30 per cent to 10 per cent.

Lee had demonstrated the classic signs of heat stroke, such as mental and neurological problems and a high temperature, the doctor said.

When State Counsel Chong asked if the first aid Lee got at the scene was appropriate, Dr Heng said it generally was, but that he should also have been moved to a shady area and his shirt should have been completely removed. 

An IV drip and intravenous fluids could also have been administered with the right experts around, Dr Heng added. Covering him with a ground sheet was “counterproductive” as he would not have been able to sweat.

Dr Heng noted that apart from the fast march, exertion from the night before and reduced rest could have contributed to Lee’s state.

Lee’s parents and sister, who were in court, did not raise any questions.

His mother, Mrs Jasmine Lee, previously told TODAY that she has forgiven Tan and was “truly sad” for him.

Lee’s death was among three in the SAF in a span of 14 months. Another NSF, 21-year-old Gavin Chan, was killed in a vehicular accident during an overseas military exercise in Australia on Sept 15, 2017.

A third NSF — Liu Kai, 22 — perished in a field training exercise near Lim Chu Kang on Nov 3, 2018.

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Dave Lee NSF death coroner's inquiry

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