14 May 2012: Official MoD Replies to Parliamentary Questions

NG QIBO AARON AUBREY SG

Ms Irene Ng Phek Hoong: What is the outcome of MINDEF's investigations into the deaths of full-time National Serviceman Private (PTE) Lee Rui Feng Dominique Sarron, and Private (PTE) Amirul Syahmi Bin Kamal; (b) what are the measures in place to ensure the safety of our servicemen, especially those with medical conditions, as they undergo training; (c) whether the investigations revealed any deficiencies in systems and procedures or human lapses; and (d) whether remedial measures would be taken to prevent similar incidents in the future.

Minister for Defence Dr Ng Eng Hen: Mr Speaker, Sir, I want to again offer my deepest condolences to the families of Amirul Syahmi Bin Kamal and Lee Rui Feng Dominique Sarron. MINDEF is committed to assist these families during these difficult times.

Sir, in every case involving the death of a National Serviceman, a number of investigations have been activated and are proceeding concurrently to specifically address the same queries which the Member has posed. First, in MINDEF, the Armed Forces Council has convened an independent Committee of Inquiry or COI to thoroughly examine the circumstances surrounding each of the two incidents. The COI is to ascertain fully the facts leading to the death and determine the contributory cause or causes of death. The COI is also tasked to determine if measures taken to treat, resuscitate and evacuate the affected NSmen were adequate and prompt, and recommend measures to rectify shortcomings, if any. It shall also determine whether there were any breaches of relevant instructions, directives, orders and safety regulations. The COI shall ascertain whether the incident could have been prevented or avoided, and recommend appropriate measures to prevent future occurrence. This four-man COI is chaired by a senior civil servant from outside of MINDEF, with a senior doctor from the public sector as one of its members. The Committee is empowered to call any witness and hear his or her testimony, as well as receive any evidence regardless of its admissibility in civil or criminal proceedings in court.

Second, the Police will submit their independent report to the State Coroner who shall ascertain the cause of and circumstances connected with the death. The Coroner’s inquiry is held in an open court. As part of this process, the Police will report to the Public Prosecutor if their investigations conclude that a person or persons may be arrested and charged in connection with the death.

Third, the State Coroner will review findings from post-mortem examinations to establish the manner and cause of death. The period to complete full post-mortem examinations by the Health Sciences Authority varies depending on the need for supplementary laboratory tests. For some complex cases, it can take as long as 3 months. As a matter of routine, MINDEF does receive the findings of these post-mortem examinations, to aid us in our investigations.

As these investigations are on-going and MINDEF has not received the finalised reports of post-mortem examinations of these two cases, I can only reveal some facts at hand in response to the MP’s question.

First, on PTE Amirul. On 15 March this year, PTE Amirul did not turn up for a routine roll-call. A search was initiated and PTE Amirul was found unconscious in a locked toilet cubicle, with a rope tied around his neck and hanging from the shower beam.

Resuscitative procedures were immediately activated on site and continued en-route and at Changi General Hospital. Unfortunately, the resuscitation failed and PTE Amirul was pronounced dead at Changi General Hospital.

Second, on PTE Lee Rui Feng Dominique Sarron. PTE Lee was noted to have breathing difficulties while participating in a platoon exercise involving the use of smoke grenades at a training facility at Lim Chu Kang on 17 Apr 2012. The unit Chief Safety Officer immediately accompanied him to exit the building. Outside the building, PTE Lee lost consciousness and received Cardio Pulmonary Resuscitation on the spot. He was given supplemental oxygen and evacuated in the safety vehicle to the Medical Centre. Resuscitation efforts by a SAF medical officer continued at the medical centre as well as en-route to the National University Hospital in an SAF ambulance. Unfortunately, the efforts were not successful, and PTE Lee was pronounced dead at NUH.

PTE Lee was noted to have a history of asthma during pre-enlistment screening on 4 Jan 2011 with his last reported asthma attack more than 3 years prior to enlistment. Based on the SAF medical classification system which is devised in consultation with leading senior medical specialists from the public and private healthcare sectors, NSmen with well-controlled asthma are given a PES grading of A or B and certified fit for military training. Based on SAF’s medical records, PTE Lee did not report sick for any asthmatic attacks in the five-month period after enlistment until this incident.

The concurrent investigations will examine all the facts to determine the cause of death, and if the asthma or smoke grenades were contributory factors. Smoke grenades have been commonly used for many years during military training and the SAF has not had any similar incident in the past. Sir, we will have to await the conclusive findings of these investigations to determine the cause and measures to be taken arising for these two specific cases.

Allow me to share general aspects on the existing system, which have incorporated lessons learnt from previous incidents. The on-going investigations are conducted so that we can continue to improve our system to ensure the highest standards of training safety for our NSmen. This is our top priority and the SAF will do its utmost to implement all recommendations. This includes appropriate disciplinary action against any SAF personnel whose negligent actions have contributed to the death.

For NSmen, the SAF stands guided by leading medical specialists drawn from the public and private sectors to formulate both medical screening protocols as well as a classification system based on known medical conditions to ensure the safe training and appropriate deployment of our servicemen. For this purpose, all NSmen are subjected to a compulsory and detailed pre-enlistment medical screening to detect anomalies and diseases. Additional screening is also conducted prior to onerous training activities such as overseas exercises. We have and we will continue to review our medical screening procedures on a regular basis, to make sure that they stay in line with international and national standards of clinical practice. After medical screening, NSmen are deployed to suitable vocations to undergo military training. This Physical Employment Status or PES system has been in use since 1971, and NSmen with a history of well-controlled asthma have been graded PES A or B and suitable for military training for more than 20 years.

In addition, ground commanders know that they have a responsibility for the safety of their servicemen during training. They have to keep a keen eye on the safety and condition of their servicemen before, during and after the training is completed. They have the prerogative to stop training for any serviceman at anytime if they sense something is amiss.

The SAF also reminds individual servicemen to ensure their own safety and that of their NS buddies. Servicemen who are unwell at any time during training are required to highlight their condition to their commanders. They are asked proactively before exercises and given the opportunity to excuse themselves. If in the course of their national service, they develop a new medical condition or injury, they have ready access to SAF Medical Officers or the public health care system. If need be, they would then be excused from certain types of training or redeployed to a role more suited to their medical condition.

Sir, safety is top priority for MINDEF and the SAF. We know that we have the responsibility to keep sons of Singapore safe while training. Every incident resulting in injury or death is painful to us and gets top management priority, to make it right. We will spare no effort to investigate every incident thoroughly. We will also incorporate findings and recommendations from independent investigations by the Police and Coroner. Where there are mistakes, we will own up to them, learn, rectify and continuously improve. That way, we can put in place a robust safety system that will prevent all avoidable injuries and deaths. Once again, MINDEF and the SAF extend our deepest condolences to the families of the late PTE Amirul and PTE Lee.

Supplementary Questions

Ms Irene Ng Phek Hoong: I would like to thank the Minister for his useful replies. I would like to focus my supplementary questions on PTE Dominique Lee who was my resident and also suffered from asthma. Sir, asthma attacks can kill quite quickly if the sufferer doesn't receive emergency treatment. Yet despite the seriousness of his condition, PTE Lee was exposed to the asthma triggers such as smoke grenades during the training exercise. Can I ask the Minister that given the fact that NSF medics are not trained or equipped to give emergency treatment for asthma, why does MINDEF not exempt soldiers with asthma from such training which puts their lives at undue risk. Can I also ask the Minister, given the fact that acute asthma attacks can lead to death, and can be triggered by exposure to smoky and dusty environments, will the Minister agree that there is a need to confront the recruitment of asthmatic recruits, given that the militaries in US and UK have also reviewed their processes, and tightened the rules, and in fact also discharged soldiers with asthma. Can the Minister review the SAF medical classification system and screening test, and improve the safety culture to ensure that our military system identifies and disqualifies recruits with chronic diseases such as asthma that could be exacerbated by combat training? And I urge the Minister to expedite the Committee of Inquiry, so that things can be put right quickly to prevent such unnecessary deaths and to assure parents that indeed MINDEF does take the safety of our NSmen seriously, and that deaths which can be prevented and eliminated, will have the utmost seriousness of MINDEF and will be eliminated.

Minister for Defence Dr Ng Eng Hen: Sir, before I reply member Irene Ng's question which I share her concern, I just want to state a caveat that we don’t know the cause of death and we should await the investigations of the COI. As I said, the terms of the COI will determine if the cause of death was contributed by the asthma and the smoke grenade, so until then, we should not make that conclusion, and it is better for a panel of medical experts and the COI to determine that. So the questions that I am answering specific to asthma doesn’t mean that the SAF and MINDEF have pre-judged that it was indeed related. We’ll have to await the findings of the COI.

With that caveat, the member's concerns are similar to ours. We are careful to ensure that the medical classification system that we have developed is safe enough for our NSmen to train. As I have said, the SAF stands guided by our medical experts who are drawn from the public and private sectors, and they tell us which diseases, or if a particular case of asthma, whether mild, moderate or severe asthmas, where they can be deployed. As I have said in my reply, mild asthmas have been PES A or B for the last 20 over years, and this is the first such incident that we had in the presence of a smoke grenade. I don’t know whether it has been caused, and the COI will determine, by the presence of a smoke grenade.

Just in terms of frequency, asthmatics are quite prevalent among our servicemen and they follow the general population. The prevalence of asthma is around 20 percent of our servicemen are found to have some form of asthma, of which majority are mild. Many of them have been put through training without adverse effects. The member asked if our medics are trained to deal with asthma attacks and the answer is yes. They are trained to administer substances like ventolin through metered dose inhaler if the patient is already prescribed with one. In this particular case, supplemental oxygen was administered.

I take the member's suggestion that we should review our medical classification system if the COI does recommend it. We will try to expedite it, but we have to wait for a number of investigations to be completed, including the forensic reports and lab tests, but I share the concern that we should do this as quickly as possible without compromising full fact-finding.

Dr Lim Wee Kiak: Mr Speaker Sir, I would like to thank the Minister for his reassurance that the SAF takes safety as paramount, especially in training. Certainly it has been the concern of many mothers after hearing the mishaps that has happened recently, especially over last weekend, Mothers' Day. I have received much feedback on that. I’ll like to ask Minister as to what is the estimated duration of the COI. Is there a time limit given for the COI? You can’t be dragging on forever. When does SAF declare a timeout, for example in the earlier case, why wasn’t a timeout declared? In the recent incident, why was a five day timeout declared? What is the purpose of the timeout? Would the safety review of the timeout be made public after it is done? Last of all, will the SAF review its medical response for severe injury, whether the evacuation to the medical centre is the most appropriate, or should they be evacuated directly to the hospital if there is a nearby hospital, because the hospital’s capability is definitely higher as compared to medical centres. Thank you, Minister.

Minister for Defence Dr Ng Eng Hen: Sir, the first question on whether there is a timeline for COIs to be completed, obviously the SAF and MINDEF is also keen to have the COI concluded, so that we can improve our system if there are any recommendations. As I have said, sometimes it depends on laboratory tests which can take up to 3 months, so it varies. From experience, it usually takes around a few months, not forever, but a few months. We will expedite it as much as we can.

On when does SAF take a timeout, that's a command decision that our commanders on the ground have to assess, and in this particular instance they felt it was necessary, and I backed them. What was done during the timeout, basically there was a stop to all field training. The Chief of Army called all Commanders, all Warrant Officers who were in command positions to emphasise to them, to give them the facts. Independently, the safety inspectorate will also review our SOPs, our processes to make sure that our safety guidelines were adhered to.

Another question related to our evacuation and resuscitative norms; apart the COI examining this, we are not going to wait for that. Obviously our HQ Medical Corps within the SAF is also reviewing these to see whether the steps taken, and whether the facilities and expertise are up to par. So I want to assure members that every incident does cause us to re-examine the system. As I said, we want to do this deliberately, but we are giving the top management priority and we will learn the right lessons to make our system stronger.

Dr Lim Wee Kiak: Are National Service enlistees screened medically for specific allergies especially to substances that they may be exposed to during their military training; and (b) if not, whether there are plans to do so.

Minister of State for Defence and Education Mr Lawrence Wong: All national servicemen undergo compulsory medical screening by the SAF before their enlistment. When a medical condition is declared or detected, the SAF will conduct follow-up medical assessment to determine the suitability of the pre-enlistee for NS training.

As part of this medical screening, pre-enlistees are specifically asked whether they have any previously known or suspected allergies. The SAF medical officer will conduct a more detailed clinical assessment of any allergy reported. Depending on the outcome of the clinical assessment, the pre-enlistee could be referred to a specialist doctor to confirm the diagnosis and to determine the underlying substance causing the allergic reaction. The result of the screening will be factored in the deployment and employment of the serviceman. Similarly, if a serviceman reports that he has an allergy during his NS, his case will be assessed using the same procedures.

I think as the Minister has highlighted in his earlier replies, the SAF’s medical screening protocols are developed and reviewed regularly in consultation with leading medical specialists from the public and private sectors. Likewise, our approach to allergy testing is in line with established national and international clinical practice guidelines. We continue to monitor these guidelines, and as these guidelines change, we will also adjust our protocols to enhance the robustness of our medical screening.

Supplementary Questions

Dr Lim Wee Kiak: Sir, let me thank the MOS for his answer. Certainly I believe that the SAF will await the medical review to see whether allergy testing is required. May I ask the Minister that in short, the answer is no, which means that there is no allergy testing at all done in MINDEF currently, unless the serviceman give an answer that he has allergy before. The problem now is that a lot of allergy may go undetected. Since SAF already knows what your NSmen are exposed to, there is a whole range of antigens, and antigen testing is now possible, I would like to urge the SAF to reconsider, to ask the medical community within MINDEF to review this seriously, to see if they can introduce an allergy test for all NSmen.

Minister of State for Defence and Education Mr Lawrence Wong: I thank the member for the supplementary question. The first part of the clarification is indeed the current medical guidelines do not recommend routine allergy testing in individuals who do not show any symptoms of allergy. We go through a process which I have elaborated earlier. As to the question on whether this system is robust enough today and can be reviewed, I think we are reviewing as I have mentioned, on a regular basis. There is also a COI which is ongoing, and if there are observations made within the COI pertaining to this particular aspect, certainly we will improve our system.

Ms Irene Ng Phek Hoong: Sir, given that there are some soldiers who suffer from asthma but they may not have the symptoms at that period of time, or even for several years; can MINDEF explore improving its diagnostic tools and implementing some tolerance test for lungs, so that they are properly assessed before they are sent out for combat training which involves exposure to dust and smoke and allergens.

Minister of State for Defence and Education Mr Lawrence Wong: I thank the member for the supplementary question. I understand where she is coming from and the concerns that she is highlighting on behalf of the soldiers, especially if they develop some medical symptoms along the way. I think that there are processes in place where if the National Serviceman develop something and find difficulties in the course of his training, there are processes where he can approach his commander and get appropriate medical attention at the medical centre. We do have avenues and platforms for the National Servicemen to approach the commander to go to the medical centre and to get attention. If indeed something has developed in the course of his training, which may not have been identified earlier, then the National Servicemen will be redeployed and put to another appropriate level of training. The training will be adjusted according to his medical condition. So we are aware of these concerns. I think we will continuously make sure that the system that we have is adequate, is robust; and will ensure the safety of our National Servicemen during training. As we have highlighted, it is a very serious matter; we take the issue very seriously. We continuously finetune our protocols and guidelines, not just for screening, but also for medical treatment of servicemen through the course of their training, whether they are in schools, or whether they are in their units. We will continue to finetune these guidelines and procedures in consultation with leading medical specialists, both in the private and in the public sector.

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