SINGAPORE - A Coroner's Inquiry into a full-time national serviceman's suicide last July found that his army unit had lapses in managing his schizophrenia.
Presenting his findings on Tuesday, State Coroner Imran Abdul Hamid said that its medical centre was supposed to maintain a psychiatric register of all its soldiers.
But a year after Private Ganesh Pillay Magindren's death, such a register is still not being maintained, he said.
Pte Ganesh, 23, was found dead at the foot of his Sengkang condominium last July and Mr Imran found that he had killed himself by jumping from height.
The coroner highlighted how such lapses in handling mentally ill NSFs may be more widespread than thought.
On Wednesday, The New Paper obtained a copy of his written judgment in which he raised several concerns.
PROTOCOL NOT FOLLOWED
According to an army directive, camps are supposed to keep a medical register of NSFs with psychiatric illnesses.
But Khatib Camp, where Pte Ganesh was posted, did not, said the coroner.
The unit's medical officer at the time, Dr Mogilan Mohan, had claimed that his seniors and the psychiatrist in the SAF told him there was no instruction to maintain the register, Mr Imran added.
The coroner said on Tuesday that he had asked the counsel for the Ministry of Defence, Ms Asanthi, whether the directive has been adhered to since then.
Noting that Ms Asanthi had replied in the negative, he said: "There is still no compliance 'on the ground' despite what had happened. This was a classic case of non-compliance."
LACK OF INFORMATION
Mr Imran was also critical of the way information about Pte Ganesh's schizophrenia was managed.
Unit commanders who are in charge of NSFs with psychiatric problems needed to be informed by a letter from the Personnel Management Centre (PMC).
But Pte Ganesh's unit did not receive any letter from the PMC about his condition until a day before his death in last July. He had been posted to the unit in November 2012.
An earlier letter from his private psychiatrist, Dr Paul Ngui, was given to the Medical Classification Centre at the Central Manpower Base in January last year.
The letter, a copy of which was obtained by The New Paper, contained details about his schizophrenia, but it had not been handed over to his unit either.