Findings and Follow-up Actions on National Service Training Death

The Minister for Defence (Dr Ng Eng Hen): Mr Speaker, thank you for allowing me to make this Statement. In May this year, I informed the House that a Committee of Inquiry (COI) would be convened to investigate the death of full-time National Serviceman Corporal (First Class) (CFC) Dave Lee that occurred on 30 April 2018. The COI has submitted its preliminary findings to the Armed Forces Council on 16 July this year and I would like to update this House on their findings, as well as follow-up actions taken by the Singapore Armed Forces (SAF) since May.

Under the SAF Act, the COI is structured primarily to investigate and determine facts related to the incident and to identify causation, lapses and systemic problems, if any, which resulted in the incident. The COI does not deal with culpability of individuals. Specifically, to encourage disclosure and cooperation by all involved in the incident, section 8C of the SAF Act provides that no statements made to the COI shall be admissible as evidence in a Court Martial or for disciplinary proceedings. To keep to this remit, I will, therefore, use no names nor designations in this Statement but instead use a generic term – commander/s or person/s, as appropriate.

As I mentioned in May to this House, Police investigations are ongoing and the Coroner may hold an inquiry. Their procedures and evidence uncovered are part of the judicial process to determine if any criminal offence has been committed in this incident and are separate from the COI.

In May, I had also informed this House that the COI would submit its report to the External Review Panel on SAF Safety (ERPSS). The COI has done so for their preliminary assessment and I will also be sharing the ERPSS' responses and recommendations.

Let me start with events that occurred the day before the heat stroke occurred. On 17 April this year, CFC Dave Lee and the troopers from the Support Company participated in two physical training sessions in Bedok Camp, namely, Combat Circuit 4 from 6.30 am to 7.30 am at the hockey pitch, and Cardiovascular 6, followed by Balance, Flexibility and Mobility 6 from 3.30 pm to 5.30 pm at the running track. This was a day before the heat stroke.

The COI found the training for Combat Circuit 4 to be compliant with regulations or guidelines.

However, the COI did discover breaches of the Army's Training Safety Regulations (TSR) for Cardiovascular 6 and breaches of the Army's directive for another subsequent event that took place later that day.

Let me, first, deal with Cardiovascular 6. In this lesson, soldiers had to run six laps of 400 metres each, a total of 2.4 kilometres (km). They have to run according to the lesson plan, grouped according to their running ability. However, the entire company was asked to run at a common pace. This meant that, for the first three laps, CFC Lee was asked to run at a slightly faster pace than required, of about 10 seconds faster per lap. For the next three laps, CFC Lee was allowed to run at his own pace. The rest timing in between each lap was noted to be reduced to one minute, which is 45 seconds shorter than what was stipulated in the lesson plan. These deviations were a breach of Training Safety Regulations. The reason given was that the commanders wanted to enhance fitness and foster greater cohesion by keeping the platoon intact, and the soldiers running at the same pace, not in groups.

Later that night, before the fast march the next day, the collective punishment that was meted out to CFC Lee's platoon was also not authorised.

At about 9.40 pm, the entire Scout Platoon, including CFC Lee, were told to fall-in in their No 4 uniforms and assault bags. The commander/s had wanted to punish the platoon collectively for the perceived lack of teamwork and the use of mobile phones after Lights Out, in particular, by two troopers, despite repeated warnings. At 9.45 pm, the commander/s meted out the informal punishment. This was in the form of physical exercises, which comprised Bear Crawls, Sprints, Leopard Crawls, as well as Push-Ups and Crunches. In total, it was from 30 to 35 minutes. They also had water poured over the troopers from their water bottles and subsequently from the jerry can. The session ended with the troopers reciting the Guards Creed a few times in a high kneel position. As I have said, the entire session lasted for about 30 to 35 minutes. The platoon was eventually sent back to their bunks at about 10.25 pm to wash up and had Lights Out by 10.45 pm. The troopers were also instructed by commanders not to switch on the lights in their bunks. The COI noted that the commanders did not seek prior approval for the conduct of this informal punishment or inform their superiors after the punishment.

While the majority of the troopers interviewed opined that the commanders were good commanders who demanded high standards, this punishment was unauthorised.

The COI found that the conduct of unauthorised informal punishment compromised the seven hours of uninterrupted rest as the trainees had about six hours 15 minutes instead. Less sleep could be one of the factors which caused CFC Lee to have more fatigue before participating in the fast march.

Let me move on to the day of the heat stroke. The COI's assessment was that the conduct of the fast march was in line with the lesson plan and relevant regulations. CFC Lee had undergone the requisite build-up training prior to the eight-km fast march, and all measures to prevent heat injuries according to the TSR had been complied with – which are temperature-taking regime, hydration regime, water supply where soldiers must carry water and have resupply points planned for, work-rest cycle based on the Wet Bulb Globe Temperature, and rest management, except that CFC Lee and his platoon did not have the requisite seven hours of sleep that I have just mentioned.

Before the fast march, CFC Lee had taken his temperature, which was normal at 36.3°C, and had drunk water. This was witnessed by his buddy, who also observed him to be looking well and seemed to be his usual self. CFC Lee and his fellow scout troopers then consumed their Recommended Dietary Allowance, which consisted of an oatmeal cracker and chrysanthemum drink.

Thereafter, the safety brief was conducted by the Conducting Officer. Troopers were asked if they had completed their six-km fast march build-up training, completed their water parade, and had seven hours of uninterrupted rest, and taken their body temperature during the declaration. The troops were asked to declare if they had. The Conducting Officer had checked if there was anyone who was not feeling well. Three troopers stood out as they had not completed their six-km fast march and were subsequently deployed as marshals. No one else sounded off any other concerns when the checks were made. This was followed by the conduct of warm-up exercises to get the troopers ready for the eight-km fast march.

After the conduct of warm-up exercises, the fast march commenced just before sunrise with the troopers despatched in four waves, at five-minute intervals. Each wave included a commander as a rear sweeper. CFC Lee was in the fourth wave – the last wave.

After CFC Lee completed the first six km, he had a mandated 20-minute rest. After the 20-minute rest period, as CFC Lee was moving off for the last two km, he sounded off to the commanders that he had cramps in his calf muscles. They advised him to stretch his calf muscles, which he did, and encouraged him to complete the march.

CFC Lee was the last one to complete the eight-km fast march in around 100 minutes, including the 20-minute break. Shortly after the fast march, as CFC Lee was walking from the end point of the fast march to the Support Company line, he was observed to be disoriented and immediately attended to by the commander/s and the cover medic/s.

Let me now state the findings at the completion of the eight-km fast march.

After the fast march, the persons attending to CFC Lee thought that he was suffering from physical exhaustion. His pulse was assessed to be normal and his skin felt cold to touch. His temperature was not taken. The first aid that was administered comprised the removal of CFC Lee’s equipment, unbuttoning his uniform, applying ice packs at his vital points, pouring water on him and giving him water. He was also given oxygen. However, the COI noted that the onsite cooling measures administered were inadequate, including the failure to administer an onsite intravenous (IV) drip, the improper placement of ice packs and the improper use of a ground sheet. When his condition did not improve, CFC Lee was subsequently evacuated to the medical centre. However, there was a significant gap between the onset of symptoms and his arrival at the medical centre.

On arrival at the Bedok Camp Medical Centre, CFC Lee was semi-conscious. His temperature taken measured 42.7^o Celsius (C). Two bags of fast IV drip were administered and he was also placed in the Body Cooling Unit, for two cycles. Seeing that CFC Lee was not responding to the treatment, the Medical Officer decided to evacuate him to the Changi General Hospital.

The Medical Officer accompanied CFC Lee in the SAF ambulance to Changi General Hospital’s Accident and Emergency (A&E) department where he was handed over and admitted to the Intensive Care Unit. Unfortunately, his condition deteriorated and he passed away on 30 April 2018. This was 12 days later.

The COI opined that the significant delay from the time of symptoms to evacuation could have escalated the heat injury to a heat stroke. Full body cooling should have been instituted as soon as possible and within 30 minutes of presentation of signs and symptoms.

The delay in evacuation resulted as the persons attending to CFC Lee mistook his signs and symptoms as being due to physical exhaustion. Though trained, they had never encountered any previous case of heat injury themselves.

There were several suggestions for CFC Lee to be evacuated, but these calls were either not heard or not heeded.

For completeness, let me share the COI’s finding on one other aspect, which is CFC Lee’s state of health prior to the fast march. While CFC Lee had no significant medical history, it was established that he had been taking some medication in the weeks prior to the fast march following a visit to the Jurong Polyclinic on 31 March 2018 for acute upper respiratory tract infection. This was more than two weeks before the fast march on 18 April.

Let me conclude with the COI’s preliminary assessment on the cause of death. The COI found that CFC Lee’s death was the result of heat stroke leading to multiple organ injury. Other than this, the COI did not find any physical injury sustained, as verified by the autopsy, nor any evidence indicating any foul play or medical negligence that caused his death. While the COI was unable to ascertain the direct causes which led CFC Lee to suffer from his heat stroke, it noted that possible contributing causes were accumulated fatigue, insufficient rest, CFC Lee’s less than optimal state of health and his potential use of medication. However, the COI’s preliminary assessment was that the likely reasons for CFC Lee succumbing to the heat stroke were inadequate onsite casualty management and delayed evacuation to the medical centre.

The Ministry of Defence (MINDEF) will await the outcome of the Police investigations and Coroner’s Inquiry, as well as the Attorney-General’s Chambers' decision whether to prosecute any persons in the criminal Court. If no criminal charges are filed, MINDEF will prosecute persons responsible for lapses in this incident in our military Court. In the meantime, the relevant persons in this incident had been removed from command.

Let me share the findings of the External Review Panel. With your permission, Mr Speaker, may I ask the Clerks to distribute a copy of the ERPSS’ statement?

Mr Speaker: Please do. [Handouts were distributed to hon Members.]

Dr Ng Eng Hen: First, the ERPSS agreed with the COI’s preliminary assessment on the cause of death, as earlier stated.

Second, the panel emphasised that it is essential for personnel to comply with safety rules promulgated in the approved operating manuals. Breaches, such as those found by the COI in this case, should not be condoned.

Third, the ERPSS highlighted the value of strengthening the safety culture in Army units. They felt that if each soldier takes greater personal ownership and responsibility for safety, it would bring about desirable behaviours, such as (a) having a strong respect for safety rules and guidelines; (b) being willing to speak out when there are safety concerns; (c) taking care of one another; and (d) open-reporting, so as to share lessons and prevent future accidents. Such behaviours would substantially strengthen the Army’s efforts to ensure safe training.

Finally, the ERPSS flagged out three areas for further emphasis based on the COI’s findings. First, the need to strengthen commanders’ knowledge on heat injuries and improve their decision-making processes. Second, for medics to be able to exercise their professional authority when dealing with medical issues. This includes being able to communicate effectively with commanders who are much more senior than them. Third, for commanders to watch out for soldiers who are feeling unwell or are unable to cope and proactively pull them out of training before they get injured.

The COI will submit its final report after completion of the Police investigations and Coroner’s Inquiry, if held.

Let me now focus on what the SAF has done or will put in place to reduce the risks of heat injuries so that we can achieve zero training fatalities. Training and safety protocols were reviewed and advised by an External Review Panel on Heat Injury Management (ERPHIM). This was chaired by Assoc Prof Mark Leong, who is a senior consultant at the Department of Emergency Medicine at the Singapore General Hospital (SGH). The following changes will be put into place.

First, a simplified protocol to lower the bar for immediate evacuation. Under this protocol, all commanders and medics across the SAF will evacuate every trainee that cannot respond to simple questions on time, place and identity. The intent is obvious. This takes the guesswork out of the assessment and what the reason is, as this case showed, and imposes early evacuation as the default, as a strict Training Safety Regulation to be followed. This Training Safety Regulation is effective immediately.

Second, additional methods to cool servicemen during training. For example, the Army will implement what is called the Arm Immersion Cooling System – you immerse your arms – and this has been used in the United States (US) and Australian militaries to reduce heat injury for all fast marches and route marches that are 12 km and longer. Portable cooling methods, such as purpose-built cooling pads, will now replace less effective ice packs, to be used on the spot. These will be implemented in phases, starting from this month.

Third, there had been suggestions for wearables. The expert opinion of this Expert Review Panel on Heat Injuries is that those currently available in the market are not effective for measuring core temperature.

Fourth, the Army will ensure that our commanders and soldiers can better recognise the signs and symptoms of heat injuries. Lesson plans on safety will be improved and the annual Training Safety Regulation test will also include mandatory questions on heat injury prevention and management.

Fifth, the importance of open reporting will be emphasised. Soldiers will be encouraged to use the Hotline to report any unauthorised activities or violations of rules, especially during Basic Military Training phase and reinforced during In-Camp Training.

Sixth, more opportunities for make-up training. The Army will encourage our soldiers not to push themselves beyond safety limits. If a soldier feels that he is unwell during any training activity, or if the buddy notices it, soldiers will be reminded to err on the side of caution, to stop and make up training another day.

Seventh, more clinical exposure and patient contacts for medics to upgrade their skills in resuscitation and handling of emergencies. This may include periodic attachments to hospitals, A&E departments or to run in ambulances.

Mr Speaker, we need a strong SAF that can defend Singapore, but it must and can be built up without compromising the safety and well-being of Singapore’s precious sons serving their National Service. CFC Lee was an exemplary soldier who served with commitment, and was well-respected by his peers for his positive attitude. The loss of such a good soldier like CFC Lee is deeply grievous to us. It will take collective effort to achieve zero training fatalities. Each serviceman must take care of himself or sound the alert when his buddy is not well, or if regulations are not complied with during training. Commanders must be alert and pull out early those who are not coping and use another occasion to train.

Zero training deaths must be the norm and any mishap should be vigorously attended to by commanders to achieve this norm. Let me conclude by expressing this House’s deep condolences to the late CFC Lee’s family. The SAF has updated the family of the COI’s findings and the actions that the SAF is taking to prevent recurrences of the lapses found. I assure all Members that MINDEF and the SAF will do all it can to help the family through this difficult period.

4.55 pm

Mr Speaker: Mr Murali Pillai.

Mr Murali Pillai (Bukit Batok): Mr Speaker, Sir, may I ask the hon Minister for Defence, on 18 April 2018, before the fast march started, when CFC Lee and the other platoon mates were asked whether or not they had seven hours of uninterrupted sleep, what was the response of his platoon mates and himself? And if they did not respond that they did not have seven hours of uninterrupted sleep, how do we, in future, make sure that the soldiers would state the truth of the matter?

Dr Ng Eng Hen: Mr Speaker, the facts are what I have recounted. The findings were recounted by the COI and that three troopers stood out, declared that they did not fulfil all the conditions of the conducting officer, and they were deployed as marshals and were not put on the eight-km fast march. How do we ensure that, in their zeal, perhaps, soldiers take cognisance and take training safety regulations seriously? I presume that some of them who did not have seven hours uninterrupted sleep, for instance, still said, "I can go on". As I have said, this was the external safety review panel's comment, too, that you have got to make it second nature for the trainees to say, "Look, this is for my own self-protection or my buddy. I am going to tell on you because you did not do it, because I am going to protect you." We thought that one crucial factor was to give more opportunities for make-up training. So, if they know they have time to make up and they would not fail the course, there will be more incentives for them to declare that they did not have it. And if commanders know now that if the conditions are not met, they will ensure that the conditions are met.

There is not going to be an easy answer. At this stage of ours where we have the regulations but we are not sure everybody follows these, we need everybody to play their part to achieve zero training fatalities.

Mr Speaker: Mr Dennis Tan.

Mr Dennis Tan Lip Fong (Non-Constituency Member): I thank the Minister for the Ministerial Statement with many details of the COI Report. I would like to ask the Minister – not sure if I heard correctly – what was the COI's finding with respect to the detection of the physical status of the soldier CFC Dave Lee during the fast march itself. Did any of his colleagues or instructors detect or spot that he was not coping well during the training? My second question is: would the SAF look into the possibility of training commanders for early detection of soldiers who are not coping well during an extreme, strenuous exercise like the fast march so that they can be pulled out before the completion of the fast march?

Dr Ng Eng Hen: Mr Speaker, the findings are, again, as I have given in the Ministerial Statement. For the first six km, there did not seem to be any witness who noticed anything out of the ordinary. He took his 20-minute rest. During the last two km, he complained of cramps, told his commanders and his commanders advised him to stretch, which he did. And he was the last one to complete the fast march. It was only at the end of the fast march as he was walking towards the company line that they noticed that he was disoriented and then, the medics and others gave him immediate attention.

How do we ensure better recognition by commanders and men? That, indeed, is the point. So, as I have said, one of the recommendations is to take the guesswork out of this. In this instance, those attending to him thought he had physical exhaustion, not heat exhaustion. The immediate training safety regulation, effective now, is that we do not really care what the reason is. As soon as anybody is disoriented, we take him out, we send him to the medical centre, where there are facilities, where there is expertise. And we have learnt from this that, you do not guess, you may not be in the best position, err on the side of caution. And we want a simple mechanism where you can determine if someone is disoriented. If he is not oriented to time, place and identity – that is, to either one, not all three – you evacuate him.

Mr Speaker: Mr Henry Kwek.

Mr Kwek Hian Chuan Henry (Nee Soon): I thank the Minister for his comprehensive answer. In the Report, I do not sense that the weather was a factor for this heat injury. But in the face of global warming – and the last few months have been very, very intense weather – I am just curious: are commanders given the discretion to, in extreme weather conditions, extreme heat waves, pare down the training, or is there a Standard Operating Procedure (SOP) to allow them to have flexibility, not during normal times, but extreme heat situations?

Dr Ng Eng Hen: Mr Speaker, Sir, our training requirements are much more serious than that. It is not discretionary, and Members will remember when I updated this House about what the requirements are for fast marches or any training activities, we use special sensors which measure the wet globe temperature and, depending on what the temperature is based on this instrument, you mandate work-rest cycles – you can only work so much and you need to rest so much.

So, yes, indeed, temperature is taken into account. In fact, after this, we looked around other militaries to see whether we were more stringent or less stringent than others. And we have learnt from it. So, different militaries use different work-rest cycles depending on what the temperature or the humidity is. So, we are reviewing that. But it is not a discretion given to commanders. They must follow it. It is part of the TSR.

Mr Speaker: Mr Vikram Nair.

Mr Vikram Nair (Sembawang): I thank the Minister for sharing the Committee of Inquiry's Report. I think the next steps are all quite logical. But one of the things that struck me – this was a trainee who, for all intents and purposes, appeared healthy to everyone, even completed the exercise and then passed out after that. There are many situations where tough training pushes people to the limits. So, are there any thoughts about looking at exercise-specific instructions? For example, if you are doing, say, trench-digging, where you would not sleep for a number of nights, you might be a little bit tired; you might be a little bit disoriented. But does that require the same procedures – what is normal, what is not? And maybe something more attuned to specific exercises, particularly those that are higher, I guess, that test people more, may be useful as well because it will probably be different in different exercises.

Dr Ng Eng Hen: The approach that the Army uses is graduation – in other words, graduated activities that train up. So, if you notice from my Ministerial Statement, one of the prerequisites that the conducting officer had asked was: have all of you done the six-km march? And some did not, alerted themselves and fell out of the march.

So, there was graduation, and not only in terms of just distance but tolerance for heat. So, that is also built into the programme. I would say at our level that we have not had a heat stroke of this magnitude for the last nine years, as I have said. Unfortunately, the commanders, those who dealt with CFC Lee had never encountered one in their own experience and that may have been part of the problem.

How do we simulate this? How do we teach better? I think it is a challenge. But for every activity, as Mr Vikram Nair pointed out, we want to make sure that the trainees are built up to take higher levels of activity, and that is the prevailing principle and practice.

Mr Speaker: Assoc Prof Randolph Tan.

Assoc Prof Randolph Tan (Nominated Member): Sir, I would like to thank the Minister for all the efforts that have been put in to uncover these details so far. I would like to seek two clarifications.

I am not sure if I understood correctly, is it true to say that the conclusion is that CFC Lee's condition and the six-km march could not be linked to what happened to him subsequently? Did the COI actually give any conclusions about whether there was a link? My second clarification is: I think the Minister said earlier that wearables were considered but have now been ruled out. Would the possible use of wearables continue to be explored?

Dr Ng Eng Hen: Mr Speaker, what the COI did was to investigate in detail, first of all, chronologically, the events leading to the heat stroke. And they started from the day before the fast march. I have related how there were a number of activities, two of which did not comply with Training Safety Regulations – one part of the lesson plan where CFC Lee ran faster than he should have for three laps of 400 metres each. And that night where there was an informal unauthorised punishment which lasted 30-35 minutes which resulted in them not having seven hours of sleep as required – they had about six hours 15 minutes or thereabouts.

The COI concluded, based on all these findings – and I would repeat this because I think it is important – that CFC Dave Lee's death was a result of heat stroke. There is no argument there. Other than this, they did not find any physical injury sustained nor any foul play or medical negligence. The COI was unable to ascertain the direct causes which led CFC Lee to suffer from heat stroke. It noted the possible contributory causes were "accumulated fatigue, insufficient rest and less than optimal state of health and his potential use of medication". These are words that they used. But their preliminary assessment was that the likely reasons for him succumbing to the heat stroke were inadequate onsite casualty management and delayed evacuation to the medical centre. Heat stroke is usually a culmination of events – exposure to heat, your own body's mechanisms cannot cope with the heat produced and it shuts down. The COI opined that they could not find any direct cause but it could have been due to a number of accumulated causes. But they felt that his succumbing to the heat stroke was a result of delay between the symptoms and evacuation.

I think the Member's second question was on wearables. We had an expert panel of doctors – the Chair, who is a senior consultant in the A&E Department in SGH – and they concluded that wearables that are on the market do not measure core temperature that well because, for heat injuries or heat strokes, you need to measure core temperature. In this case, as Members have noticed, when they touched CFC Lee's skin, it was actually cold, cooler than norm – it was not warm. So, if you have wearables that measure surface temperature, it does not quite work. You have to measure core temperature, and the technology just is not there yet.

Mr Speaker: Mr Kok Heng Leun.

Mr Kok Heng Leun (Nominated Member): I thank the Minister for the Report. My condolences to the family. I have one clarification and one question. The first clarification is the part about the conducting officer asking them if they had seven hours of rest. The troop apparently did not respond to that. Did the COI talk about why they did not respond to that? Was there a reason why they did not? That is the first clarification.

The second question is, I wonder if there is a daily log of the activities that the troops go through that would have been recorded every day so that that would include how many hours of rest that they have or any extra activities that have been added on. Is there such a daily log that has been placed so that we could check on it, at least, for the conducting officer?

Dr Ng Eng Hen: Mr Speaker, those are good questions. I would have to go back to the detailed COI Report to see whether they had asked the various platoon members why they did not all say they did not have the seven hours of sleep. From what I can recollect, they did not give specific reasons. And as I have said, one surmises that they wanted to do it because they wanted to carry on with their training.

Was there a log? As I have said earlier in my Statement, the commanders who conducted the informal punishment neither sought permission nor told their superiors of this. So, I think, this was missed – the seven hours – they did not have the requisite seven hours of sleep.

Mr Speaker: Order. Introduction of Government Bills. Minister for Transport.