Inadequate on-site measures, delay in evacuation ‘likely why late NSF succumbed to heat stroke’

SINGAPORE — A significant delay in evacuating the late full-time National Serviceman Dave Lee to Bedok Camp Medical Centre and inadequate measures given on-site after his 8km fast march were likely why he succumbed to heat stroke.

This was the preliminary assessment by a Committee of Inquiry (COI) set up to look into the training death.

Corporal First Class (CFC) Lee, 19, died on April 30 from heat stroke leading to multiple organ injury, 12 days after he needed help after the fast march. Earlier, the Ministry of Defence had said CFC Lee showed signs of heat injury after an 8km fast march in Bedok Camp at 8.35am on April 18. After a Singapore Armed Forces (SAF) medic tried to bring down his core temperature, he was sent to Bedok Camp's medical centre where a SAF medical team continued "body cooling measures and treatment". He was sent to the Changi General Hospital's Intensive Care Unit (ICU) at about 9.50am that day.

Lapses before the march could have resulted in accumulated fatigue and insufficient rest, which may have contributed to the heat stroke, the COI found. Other possible contributory causes were his less-than-optimal state of health and potential use of medication for an acute upper respiratory tract infection more than two weeks before the event.

On April 17, the day before the march, the conduct of an afternoon training session deviated from the lesson plan, resulting in CFC Lee running faster and having less rest than stipulated. His platoon was also turned out that night for not observing "lights out" and were punished with physical exercises, among other things. This resulted in the soldiers having six hours and 15 minutes of uninterrupted rest instead of the stipulated seven hours.

While the COI found no evidence of foul play, Defence Minister Ng Eng Hen said in Parliament on Monday (Aug 6) that those responsible for the lapses will be punished after the conclusion of police investigations.

Dr Ng said his ministry will wait for the outcome of police investigations and coroner's inquiry, as well as the Attorney-General's Chambers' decision on whether to press criminal charges. If no criminal charges are filed, the Ministry of Defence (Mindef) will prosecute those responsible for lapses in the military court, he said. The relevant persons in this incident have been removed from command in the meantime.

No names were disclosed on Monday because the COI does not deal with the culpability of individuals and no statements made to the COI are admissible as evidence in a court martial or for disciplinary proceedings.

And although there were no systemic lapses, the Singapore Armed Forces (SAF) has implemented several measures to improve the management of heat injury, including lowering the bar for medical evacuation.

RUNNING LAPS, UNAUTHORISED COLLECTIVE PUNISHMENT

CFC Lee, a Guardsman from the 1st Battalion Singapore Guards, died after spending more than a week in intensive care at Changi General Hospital.

Mindef said previously he had first shown signs of heat injury after an 8km fast march in Bedok Camp at 8.35am on April 18 and arrived at the hospital at about 9.50am.

Taking the House through the findings on Monday, Dr Ng said there were several lapses and breaches of training regulations, which started from the day before the fast march.

On the afternoon of April 17, soldiers including CFC Lee had to run six laps of 400m each, grouped according to their running ability.

In a deviation from the lesson plan, the commanders asked the entire company to run at a common pace, as they wanted to "enhance fitness and foster greater cohesion by keeping the platoon intact".

This meant that CFC Lee had to run at a slightly faster pace than required — about 10 seconds faster per lap — for the first three laps, before being allowed to run at his own pace for the remaining laps.

The time to rest in between laps was also reduced to one minute, which was 45 seconds less than what was stipulated in the lesson plan.

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

CFC Lee's platoon also received "collective punishment", which Dr Ng stressed was not authorised, later that night for the "perceived lack of teamwork and the use of mobile phones after lights out".

They were told to fall in at 9.40pm in their Number 4 uniforms and assault bags, and were asked to perform exercises comprising of bear crawls, sprints, leopard crawls, as well as push-ups and crunches.

Troopers also had water poured over them from water bottles and jerry cans. The session ended with the troopers reciting the Guards Creed a few times in a high kneel position. The entire session lasted for about 30 to 35 minutes.

They were sent back to their bunks at about 10.25pm to wash up, and had to observe "lights out" by 10.45pm.

Ironically, the unauthorised punishment resulted in them having less sleep. This could have been a contributing factor to CFC Lee experiencing greater fatigue before his fast march the next day, the COI noted.

MISTAKEN FOR PHYSICAL EXHAUSTION

Dr Ng said CFC Lee was the last one to complete the 8km fast march the next day. He took about 100 minutes, including a 20-minute break.

He had "sounded off" to his commanders that he had cramps in his calf muscles as he was moving off for the last 2km of the march.

At the end of his march, he was observed to be "disoriented" and was immediately attended to by the commanders and the cover medic.

CFC Lee's pulse was normal but his skin felt cold to the touch. His temperature was not taken.

At the site, others removed his equipment, unbuttoned his uniform and applied ice packs at his vital points. They poured water on him and gave him water. CFC Lee was also given oxygen.

The COI said the on-site cooling measures administered were "inadequate" and noted the "failure to administer an on-site IV drip, the improper placement of ice packs, and the improper use of a ground sheet".

The persons attending to him also mistook his condition for physical exhaustion. Several suggestions were made for him to be evacuated, but they were either not heard or heeded, Dr Ng said.

"Though trained, they had never encountered any previous case of heat injury themselves," the minister added.

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

It was only when CFC Lee's condition did not improve, that he was evacuated to the medical centre.

He was semi-conscious when he arrived at the Bedok Camp Medical Centre and had a temperature of 42.7°C. His temperature was normal at 36.3°C before the fast march.

Two bags of fast IV drip were administered and CFC Lee was placed in the Body Cooling Unit for two cycles. Seeing that CFC Lee was not responding to the treatment, the Medical Officer then decided to evacuate him to the Changi General Hospital's intensive care unit.

‘NOT EASY’ TO GET SOLDIERS TO FLAG CONCERNS

Six Members of Parliament (MPs) raised clarifications after Dr Ng’s ministerial statement.

Bukit Batok MP Murali Pillai and Nominated MP Kok Heng Leun asked if the COI had looked into why platoon members had not reported getting less than seven hours of rest to the conducting officer, especially since the COI findings revealed that the officer had asked the troopers if they had had sufficient rest.

Dr Ng said some soldiers, in their “zeal” to carry on with training, may choose not to alert conducting officers. “There is not going to be an easy answer… How do we ensure that (soldiers) in their zeal, perhaps… take training safety regulations seriously? I presume some who didn’t have seven hours (of rest) felt that they could go on,” said Dr Ng.

To make it “second nature” for trainees to report insufficient rest, the Army will give soldiers more opportunities for make-up training.

Dr Ng said: “(When soldiers) know that they have time to make up and will not fail the course, (then) there will be more incentive to declare (that they did not get sufficient rest).”

“Where we have regulations, but we are not sure if everybody follows it, we will need everybody to play their part to achieve zero training fatalities,” he said.

On the use of wearables, Dr Ng said that there is currently no “technology” that allows the wearables to measure core temperature well.

“We had an expert panel of doctors… they concluded that wearables on the market don’t measure core temperature that well. For heat strokes, you need to measure core temperature. In this case, (CFC Lee’s) skin was actually cooler than normal, so if you have wearables that measure skin temperature then it doesn’t quite work, (unfortunately) the technology just isn’t there yet,” said Dr Ng.

Nee Soon MP Henry Kwek asked if conducting officers could be given the “discretionary power” to pare down training in extreme heat conditions. Dr Ng said “discretionary power” is not given to commanders. Instead, conducting officers currently use the Wet Bulb Globe Temperature (WBGT) test – a measure for heat stress – to determine whether to conduct trainings and mandate “work-rest cycles”.

Mindef is currently studying and comparing the rigour of military training in the SAF compared to other militaries, Dr Ng said.

Said Dr Ng: “We looked around to other militaries to see if we’re more or less stringent and we’ve learnt from it. Different militaries use different work-rest cycles depending on what the temperature and humidity is, so we’re reviewing it.”