An inquiry into the death of a Kiwi teenager in India on a military cadet trip has criticised the NZ Defence Force for not connecting its health experts with those escorting her as her symptoms worsened.
Chief Petty Officer cadet Sacha Wallace Piper, 18, died of a suspected brain aneurysm in New Delhi on February 2 2023 while on a hastily arranged NZ Cadet Force trip to India to celebrate the country’s 75 years of independence.
A NZDF Court of Inquiry identified a number of flaws in organising the trip, including poor system links between NZDF and the cadet forces, which deprived Piper of support from the military’s expert health division.
The high-achieving teenager was selected as one of those attending the celebrations in India after an invitation for New Zealand to contribute a cadet force cadre to join others from around the world.
The invitation for 10 cadets to attend arrived in October and was passed to the cadet force in November, leaving just three weeks to meet the deadline for responding to the expenses-paid trip to India.
The short deadline saw the cadet force bypassing usual selection processes and hand-picking 10 cadets aged 18-22 years on the basis of consistent high performance along with two supervising adult cadet force officers.
The two-week trip — from January 15-30 — was a showcase of Indian cultural and historical highlights in regions around Delhi.
The inquiry said several witnesses spoke to the “intensity” of a busy schedule requiring exhausting four-hour journeys with cadets told to reduce water intake because of the lack of toilet stops. It created a perception the cadets needed to “keep going” with fatigue also impacting on the two cadet force officers escorting the group.
In the first half of the trip, the group and one of the officers also wrestled with illness believed to be due to a change in environment, food and long-haul travel.
Long travel times, poor health, and a late night contributed to “irritability” across the group. The inquiry report said that “when Sacha complained” of issues “the CF Officers considered that it was a direct result of fatigue”.
The inquiry found the symptoms experienced by Piper were not linked to the illness in the first half of the trip and were “more serious” from January 26. It said “Sacha was still displaying symptoms which only intensified until her hospitalisation”.
“Despite the symptoms that she was experiencing, the nature and seriousness of the illness was not yet clear.”
By January 28 — two days before the trip was to end — Piper was admitted to hospital with one of the two cadet force officers supporting her. At 10pm that day, she was taken by ambulance to another hospital for a CT scan.
At that stage, cadet force leaders in New Zealand were told, along with Piper’s family and the High Commission in New Delhi. The inquiry said that cadet force leaders were told “Sacha’s medical condition was treatable” at that stage.
Overnight, concern escalated as Piper was admitted to the Intensive Care Unit and, by early morning, a decision had been made to operate. The escalation in condition led to news of her plight being communicated to NZDF senior ranks.
Piper died on February 2, by which time family were with her in Delhi. By then, her fellow cadets were back in New Zealand and were told on a group video call she had died.
The inquiry was critical of the support provided to the cadets.
Although counselling was offered, it was done so to the group and without professional support at hand. While the inquiry said the offer was genuine, it was “not taken up due to a number of factors, including a lack of representation from experts, coming after extensive long haul travel and as it was too public for many of those affected”.
The inquiry found “a high degree of emotion and stress remains for some cadets” and the group had not come together again since the trip back from India. It recommended the group be brought together “as part of a follow-up decompression”.
In its report, the inquiry found cadet force processes lacking when compared to NZDF’s systems, largely geared towards domestic incidents and notification of cadet force leadership. In contrast, NZDF’s process in the case of a serious illness offshore would have escalated reporting including bringing in its health division and its expertise.
The health division would liaise with health providers looking after the ill or injured person, seek advice from experts in New Zealand and elsewhere, organise medical flights if needed and keep a record of all medical information.
In the inquiry report, it noted it did not have access to Piper’s medical records and was required to extrapolate her symptoms with experts who did not treat her. While the cadet force reported Piper had died of a brain aneurysm, the inquiry was unable to establish that.
“The Court finds that it would have been preferable for [cadet force staff] to access [defence headquarters] staff support during the exchange.
“Had the [cadet force] officers been able to seek medical advice from [NZDF Health] particularly in the days leading up to Sacha’s admission as more severe symptoms presented, this may have better supported the [cadet force] officers and assisted them obtaining medical attention for Sacha.”
The inquiry report also found that the pre-trip risk assessment lacked a plan for a number of events, including illness. A misunderstanding appeared behind the assignment of just two cadet officers, reduced to one when the other also fell ill.
“Greater attention in planning may have led to an increased ratio of staff to cadets in order to deal with common illness, but also stronger means of distinguishing common illness symptoms from others,” the inquiry report said.
The inquiry recommended better processes for the cadet forces, easier and stronger links to support from NZDF and for those who went on the trip to be brought together again.
The inquiry was told “Sacha was an outgoing individual who was extremely proud of being a Sea Cadet” and “she was described by various witnesses as a ‘bubbly’ individual”. The inquiry process was completed in March this year and the report released through the Official Information Act.
Piper was awarded most promising cadet in 2022 and promoted to Chief Petty Officer in November of that year after taking on a leadership role and completing the required non-commissioned officer course.
Training Ship Amokura — where her cadet unit was based — has commemorated Piper’s memory with the newly-created Sacha Wallace Piper Memorial Prize for Most Steadfast First Year Cadet.
The Herald has approached Piper’s family. NZDF was approached for comment and declined.
David Fisher is based in Northland and has worked as a journalist for 35 years, winning multiple journalism awards including being twice named Reporter of the Year and being selected as one of a small number of Wolfson Press Fellows to Wolfson College, Cambridge. He joined the Herald in 2004.
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