SINGAPORE - Preliminary findings from a Committee of Inquiry (COI) revealed an unauthorised punishment that took place the night before Corporal First Class (CFC) Dave Lee's heatstroke as well as a delayed evacuation of CFC Lee to the medical centre.

The findings were presented by Defence Minister Ng Eng Hen in Parliament on Monday (Aug 6).

The COI was convened after CFC Lee died on April 30.

CFC Lee, who was a guardsman from the 1st Battalion Singapore Guards, died about two weeks after being admitted to Changi General Hospital for heatstroke.

He had completed an 8km fast march at Bedok Camp on April 18 before he showed signs of heat injury and had to be hospitalised.

Here are the COI's key findings:

1. Training safety breach

A safety breach during one of the two physical training sessions the day before CFC Lee's heatstroke meant he had to run faster than required.

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For a cardiovascular exercise, soldiers were supposed to be grouped according to their running ability.

However, for the first three laps of 400m each, the entire company was asked to run at a common pace, meaning CFC Lee had to run about 10sec faster per lap than his own pace.

The rest time between each lap was also reduced to a minute, which is 45sec less than stipulated in the lesson plan.

2. Unauthorised punishment

CFC Lee's platoon was given informal punishment for about 30 minutes the night before the 8km fast march, compromising the soldiers' required seven hours of uninterrupted rest.

The commander was punishing them for a perceived lack of teamwork and using mobile phones after lights out despite repeated warnings.

The punishment started with the platoon being told to assemble in their No.4 uniform and assault bags, and included bear crawls, sprints, leopard crawls and push-ups.

3. Severity of CFC Lee's heat injury condition likely misjudged, leading to inadequate casualty management

After the fast march, CFC Lee was initially thought to be suffering from physical exhaustion and his temperature was not taken. His pulse was assessed to be normal and his skin felt cold to the touch.

This led to inadequate on-site cooling measures, said the COI. Even though the first aid given included CFC Lee's equipment being removed, his uniform unbuttoned and ice packs applied at his vital points, the COI noted that an on-site IV drip was not administered, the ice packs were improperly placed and a ground sheet was improperly used.

4. Delayed evacuation

Due to the mistaking of CFC Lee's condition as physical exhaustion, there was a significant delay between the onset of symptoms and his evacuation, according to the COI, which could have escalated the heat injury to heatstroke.

5. CFC Lee's state of health before the fast march

The investigation also revealed that CFC Lee had been taking medication in the weeks before the fast march for acute upper respiratory tract infection. He visited a polyclinic on March 31 for the infection, more than two weeks before the fast march.