Officer rejected suggestions to evacuate NSF Dave Lee, who died of heatstroke: Coroner’s Court


SINGAPORE: The supervising officer of an 8 km brisk march for national service trainees repeatedly refused suggestions to immediately evacuate National Serviceman Dave Lee Han Xuan, who was unable to walk properly and drooled in the end of the walk.

Details of the incident, as well as multiple violations of the supervising officer’s protocol, were revealed Wednesday (January 13) at the opening of a coroner’s inquest into the death of CFC Lee.

According to a police investigation report, Captain Tan Baoshu felt that Corporal 1st Class (CFC) Lee was suffering from physical strain rather than heat injuries and rejected a suggestion to evacuate him to the medical center, asking them to wait.

He also rejected a suggestion to give an intravenous drip on CFC Lee, who was disoriented, unable to swallow fluids and breathing heavily.

CFC Lee was evacuated only 40 minutes later, which one medical expert said was “way too long”, and later died of heat stroke with multiple organ failure at the age of. 19 years old.

The court heard that CFC Lee started the march with the other soldiers at 6:45 a.m. on April 18, 2018. He looked fine and could talk to his superiors in the last few miles.

During the last two kilometers, he informed a first sergeant that he had a calf cramp and that he had been cleared to stop to stretch. He continued to take breaks on the home stretch.

CPT Tan, the officer commanding the support company, 1st guard battalion and the supervising officer of the march, joined CFC Lee in the last 300 meters of the march.

CFC Lee crossed the finish line at 8:25 am, within the required 84 minutes after allowing for the mandatory rest period, and knelt.


He had his time recorded and was helped to a rest stop, but swayed as he walked there and his speech was scrambled, the court heard.

He has been observed to be inconsistent, unresponsive, drooling from the mouth and breathing heavily. His equipment was removed and his uniform unbuttoned. On instructions from CPT Tan, ice packs were applied to his neck, armpits and groin and water was poured on his face.

CFC Lee was also sprayed with water from a mobile cooling unit, but was unable to swallow the isotonic water given to him as the fluid leaked out of his mouth.

CPT Tan observed that CFC Lee was disoriented, unresponsive, breathing heavily and unable to follow instructions. However, he felt that he was suffering from physical exertion rather than a heat injury.

When someone suggested that he evacuate him to the medical center, CPT Tan told him to wait as CFC Lee was suffering from physical strain and would recover. He did not order the immediate evacuation of CFC Lee, violating protocol that soldiers suspected of heat injury should be immediately evacuated.

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CPT Tan also rejected another suggestion to give an intravenous drip, which is also stipulated in the guidelines for victims who are unconscious or those who cannot drink water.


Instead, CPT Tan ordered CFC Lee to be covered with groundsheets, as his arm was cold. He was covered from the neck down with the groundsheet, and later from the pelvis down.

Fifteen minutes after the collapse of CFC Lee, CPT Tan agreed to return the security vehicle, claiming that CFC Lee could be evacuated via a stretcher. He did not check CFC Lee’s condition before doing so.

The return of the safety vehicle was contrary to the guidelines for brisk walking, which state that the vehicle must remain in place for a reactive evacuation.

At approximately 8:45 a.m., a nurse on leave walking past the parade ground encountered CFC Lee and attended to him. He assessed him and told CPT Tan that he had to be evacuated immediately to the medical center.

CPT Tan told her that they would have to wait another five to ten minutes to see if her condition improved. The doctor applied an oxygen mask to CFC Lee because he was wheezing.

At 8.50 am, another person urged CPT Tan to evacuate CFC Lee without further delay, but CPT Tan replied that he would have to wait another five minutes.

CFC Lee was eventually placed on a stretcher at around 9 a.m. and walked to the medical center to arrive at 9:05 a.m. His temperature had not been taken at any time between his collapse and his arrival at the medical center.


He had a temperature of about 42 degrees Celsius in the center and was treated by three doctors who treated him with two cycles of a body cooling unit and applied ice packs.

Despite the treatment, CFC Lee’s temperature remained at 42 degrees Celsius, and when he began to foam in his mouth, he was evacuated to Changi General Hospital.

He got there around 9:50 a.m. with a temperature of 41.6 degrees Celsius. He was intubated and treated with two pints of ice cold intravenous drops, but was discovered to have organ damage from heat stroke.

He was transferred to the intensive care unit, but his condition continued to deteriorate, and he subsequently showed brain dysfunctions and his prognosis was subsequently deemed terminal and irreversible with probable brain damage.

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He was pronounced dead on April 30, a few weeks after the march, with the cause of death being multiple organ failure from heat stroke. Police said in their report read to court that they did not suspect any foul play in the death of CFC Lee.

The delay in his evacuation was a contributing factor in his death, police said.

After the incident, six SAF soldiers were fined by a military court for the case. CPT Tan was indicted in state courts in October 2018 for causing the death of CFC Lee by a reckless act not constituting culpable homicide.

READ: SAF captain accused of causing NSF death Dave Lee secured release not constituting acquittal

However, CPT Tan received a discharge that did not amount to an acquittal in early February last year. A spokesperson for the Attorney-General’s Chambers (AGC) said CPT Tan was diagnosed with stage 4 cancer. He died a few weeks later in February 2020, aged 31.

Medical expert Kenneth Heng from the emergency department at Tan Tock Seng Hospital, who was hired to provide an independent expert opinion on the case, said first aid to CFC Lee at the scene could have be improved.

He could have been moved to a shaded area, had his shirt completely removed, and ventilated to help the sweat evaporate, Dr Heng said. An intravenous drip could have been given and covering him with a ground sheet was “counterproductive” as he could not have sweated.


Explaining heat stroke, Dr Heng said it was the most severe heat stress of all with high temperatures over 40 degrees Celsius and mental or neurological deficits.

CFC Lee had been subjected to the physical exertion of brisk walking and demonstrated neurological problems such as drooling, disorientation and speech, Dr Heng said.

His high temperature was due to the heat produced by his muscles while walking, with the environment, humidity and temperature contributing to it. He couldn’t lose enough heat to keep up with his heat generation.

“Heat stroke causes multiple organ failure,” said Dr Heng. “There are three main mechanisms. First – direct damage to cells from heat – cells in every organ are affected. Second – due to dehydration and low blood pressure, blood to organs. . is also affected. The last thing is that because of the cell damage, there are toxins released, and this causes an inflammatory cascade. So it’s a vicious cycle that worsens multi-organ failure. “

Dr Heng said the priority in heatstroke is to reduce temperatures as quickly as possible. The guidelines say it should be reduced to below 39 degrees Celsius within 30 minutes.

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“There is not much you can do at the scene, so evacuation to a medical center with a body cooling unit should be the priority,” he said. “It took 40 minutes to evacuate (CFC Lee), which was really too long.”

He said 10 to 15 minutes would have been reasonable. He was not able to comment on CFC Lee’s “survival in terms of delay”, but said research has shown that if blood pressure is corrected, mortality drops from 33 percent to about 10 percent. .

In response to the coroner’s questions, Dr Heng said nothing in CFC Lee’s medical records predisposed him to this type of injury.

Other circumstances that could have contributed to the heat stroke included CFC Lee’s strain the night before as well as his reduced rest. The night before, instead of having seven hours off as needed, CFC Lee and his military comrades were punished for various offenses and made to do activities such as bear ramps, sprints and push-ups. without the knowledge or sanction of supervisors.

However, Dr Heng said CFC Lee did not appear ill before the walk and was not taking any medication. He said it was difficult to identify the warning symptoms that could have identified the disease, adding that the cramp suffered by CFC Lee was quite non-specific.

The coroner said she would review the evidence and present her findings on January 27.


Following the death of CFC Lee, a commission of inquiry was convened to investigate the incident and several recommendations were offered to minimize recurrence.

These include strengthening the management of heat injuries, emphasizing to commanders the need to adhere to regulations and guidelines, and strengthening evacuation decision-making.

An external review panel commissioned by the Department of Defense in May 2018 found that SAF’s heat management measures were generally strong and aligned with industry practice.

READ: NSF Dave Lee dies: FAS to improve prevention, management of heat injuries after exam

The committee suggested several additional measures such as adjusting the work-rest cycle, improving awareness of heat injuries, and removing barriers to self-report that might discourage soldiers from speaking out when ‘they don’t feel well.

The committee also stressed that early recognition of heat injuries was the most important of their recommendations, and said all had a key role to play in recognizing signs and symptoms in other soldiers.

First aid should be provided and the injured evacuated as soon as possible, with commanders and medics exercising caution as it is difficult to accurately determine the degree of heat. When in doubt, all suspected heat injury cases should be transferred to a medical facility, the panel said.



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