Private (Pte) Ganesh Pillay Magindren's supervising officer was "completely out of her depth" in dealing with his mental condition, the coroner said on Tuesday.
That was because Captain (Capt) Jessie Goh, then a lieutenant, did not try to find out how to manage the full-time national serviceman (NSF), who had schizophrenia.
Pte Ganesh, 23, was found dead at the foot of his Sengkang condominium last July.
In an inquiry into the NSF's death, State Coroner Imran Abdul Hamid said he died from multiple injuries sustained from a deliberate fall from height, and that he had known it would lead to his death.
The day before his death, Capt Goh had given him 14 days of extra duties for not signing a logbook, reporting late for work and unsatisfactory work performance.
Mr Imran said: "(The punishment) is a daunting prospect even for soldiers without any mental issues.
"I agree with a previous witness who said Ganesh probably found it difficult to stomach the fact that he was given 14 days of extra duties after being at the receiving end of so many."
A stone-faced Capt Goh sat in the public gallery as the findings were read out in the State Courts.
She was the manpower officer at 24th Battalion Singapore Artillery and was directly in charge of Pte Ganesh when he was posted to the unit in November two years ago.
Pte Ganesh was assigned to clerical work as an administrative support assistant.
When he was posted there, Capt Goh interviewed him and found out that he was depressed and had been seeing a private doctor. When she asked what kind of doctor he was seeing, he did not tell her and she did not probe further.
In fact, Pte Ganesh was seeing a psychiatrist regularly for schizophrenia.
She knew only that he had been given the Physical Employment Status (PES) E9L9, the second-lowest medical classification given to servicemen.
Her computer system did not state why he had been given that PES status and she did not try to find out.
She testified earlier that she had treated him just like any other soldier.
She found out about his schizophrenia only after his private psychiatrist, Dr Paul Ngui, informed her in a letter last April, five months after he was posted to the unit at Khatib Camp.
The letter said Pte Ganesh had "a vulnerable personality and should not be exposed to severe stress conditions".
But Capt Goh did not know what schizophrenia meant and testified that the letter was "too generic and did not specify what should be done to manage Ganesh".
Said Mr Imran: "She was not even slightly curious about how well she could have managed the deceased. A simple phone call to his psychiatrist or the unit's medical officer would have cleared up matters."
He noted that she was out of her depth and "severely lacked the curiosity in the only PES E soldier she was in charge of".
Capt Goh was also supervising five other clerks at the time, but none of them had the PES E classification.
She told the inquiry earlier that while she was strict, she had given Pte Ganesh plenty of leeway and only the lightest punishment of extra duties.
She described their relationship as "friends", and would compliment his Facebook posts and teach him how to iron and clean his clothes.
Mr Imran was also critical of the way information about Pte Ganesh's schizophrenia was handled.
According to an army directive, camps are supposed to keep a medical register of servicemen with psychiatric illnesses. But Khatib Camp did not, the coroner said.
Unit commanders who are in charge of servicemen with psychiatric problems would need to be informed by a letter from the Personnel Management Centre. But Pte Ganesh's unit did not receive any such letter until a day before his death.
An earlier letter from Dr Ngui was given to the Medical Classification Centre at the Central Manpower Base in January last year. But it was not handed over to his unit.
Said Mr Imran: "This reveals the ignorance the unit had regarding the deceased's schizophrenia... Capt Goh was disadvantaged from the start by not being informed of his condition."
When contacted, the Defence Ministry said that it will study the State Coroner's findings "carefully to improve and tighten its procedures to ensure better compliance by SAF units in dealing with soldiers with mental problems".
This article by The New Paper was published in MyPaper, a free, bilingual newspaper published by Singapore Press Holdings.
Get The New Paper for more stories.