Ang Pek San Lawrence v Singapore Medical Council

• Jurisdiction: Singapore
• Judge: Sundaresh Menon CJ
• Judgment Date: 19 November 2014
• Neutral Citation: [2014] SGHC 241
• Plaintiff Counsel: Lek Siang Pheng, Mar Seow Hwei, Lim Yew Kuan Calvin and Aw Jansen (Rodyk & Davidson LLP)
• Docket Number: Originating Summons No 1219 of 2013
• Date: 19 November 2014
• Hearing Date: 08 July 2014
• Subject Matter: Professions,Professional conduct,Medical profession and practice
• Year: 2014
• Citation: [2014] SGHC 241
• Defendant Counsel: Ho Pei Shien Melanie, Chang Man Phing Jenny and Ng Shu Ping (WongPartnership LLP)
• Court: High Court (Singapore)
• Published date: 20 November 2014

Sundaresh Menon CJ (delivering the judgment of the court): Introduction

This is an appeal by Dr Ang Pek San Lawrence (“the appellant”) against the decision of a Disciplinary Committee (“the DC”) constituted by the Singapore Medical Council (“the respondent”). The DC convicted the appellant of professional misconduct under s 45 of the Medical Registration Act (Cap 174, 2004 Rev Ed) (“the Medical Registration Act”) for his failure to make arrangements to ensure that a neonatologist would be present at or placed on standby for the delivery of a patient’s baby on 23 September 2009 despite the fact that there were certain clinical indicators which, in the DC’s view, suggested the need for such arrangements to be made. The DC’s orders included one that suspended the appellant from practice for three months. In this appeal, the appellant seeks to set aside his conviction; in the alternative, he seeks to set aside or reduce the period of suspension from practice as well as the costs ordered against him. For the purposes of this appeal, the applicable version of the Medical Registration Act is that which was in force as at 23 September 2009 (the date of the incident complained of), and we shall hereafter refer to that version of the Medical Registration Act as “the MRA”.

Background facts

The appellant is a registered medical practitioner and a registered obstetrician and gynaecologist. A complaint was brought by a patient of the appellant (“the complainant”) in respect of his management of her labour and the delivery of her second child on 23 September 2009.

The appellant had managed the complainant’s first pregnancy in 2007. The baby on that occasion had been delivered pursuant to an emergency Caesarean section operation. There were no other complications. The complainant returned to the appellant when she became pregnant with her second child, requesting that he manage her second pregnancy. She wished to have a natural delivery for this second delivery. This is referred to as a vaginal birth after Caesarean (“VBAC”) procedure. The appellant discussed the risks of the procedure with the complainant and offered her a delivery by Caesarean section instead. However, the complainant was firm in her wish to proceed with the attempted VBAC procedure.

The complainant went into labour on 23 September 2009 and was admitted to Thomson Medical Centre at 2.38pm. The appellant attended to the complainant and performed an amniotomy at around 3.40pm. The amniotomy revealed moderate meconium-stained liquor. The appellant again offered the complainant a delivery by Caesarean section, but the complainant maintained her wish for a VBAC procedure.

The appellant left Thomson Medical Centre at around 4.00pm and attended to some other patients. At 6.30pm, one of the ward nurses contacted the appellant and updated him on the complainant’s condition. Specifically, the appellant was informed that the cardiotocography (“CTG”) trace of the baseline foetal heart rate was around 160bpm to 165bpm, and that the complainant had a temperature of 37.3°C. Between 6.30pm and 8.15pm, the CTG trace showed an increase in the baseline foetal heart rate to 165bpm, but this was not specifically communicated to the appellant during that period.

The events that took place between 8.15pm and just after 9.03pm, when the complainant’s baby was delivered, are of particular significance in this appeal for reasons that will become evident. From the record of proceedings and the DC’s written decision dated 22 November 2013 (“the GD”), we set out below the relevant chronology and the accompanying clinical indicators: After 8.15pm, the CTG trace of the baseline foetal heart rate increased to more than 180bpm. The appellant returned to Thomson Medical Centre at about 8.15pm. The appellant could not immediately attend to the complainant as he had a patient in the next delivery room. The appellant was updated on the complainant’s condition while he was attending to the other patient. At about 8.30pm, the appellant attended to the complainant. At that time, the complainant’s temperature had risen to 37.8°C and the CTG trace of the baseline foetal heart rate remained above 180bpm. The appellant ordered that intravenous antibiotics be administered to the complainant at around 8.30pm. He then attended to his other patient and delivered her baby at about 8.43pm. At that time, the appellant requested that Dr Keoy Soo Hin (“Dr Keoy”), a neonatologist, be called to attend to the baby he had just delivered. The appellant was not aware then that Dr Keoy was unavailable and that the latter had made arrangements for Dr Adeline Wong (“Dr Wong”), a paediatrician, to cover his cases. After 8.40pm, the CTG trace of the baseline foetal heart rate of the complainant’s baby reached nearly 220bpm, this being the maximum heart rate that a CTG trace was capable of measuring. The appellant returned to attend to the complainant and made the decision to commence the delivery of the complainant’s baby at about 8.50pm as the complainant was fully dilated. The appellant annotated “NRFS” for non-reassuring foetal status in the delivery notes before commencing the delivery. The complainant’s baby was successfully delivered at 9.03pm with the assistance of forceps. From the time the appellant commenced the delivery until the time the complainant’s baby was delivered, the appellant did not ask for a neonatologist to be present. In his testimony, the appellant said that it had slipped his mind to specifically ask that a neonatologist be present at the delivery suite. However, he also explained that he was conscious of the fact that he had requested that Dr Keoy be called to attend to the baby in the next delivery room, and he thought that this would be the quickest and, in the circumstances, a suitable way to ensure that the complainant’s baby received the appropriate specialist care at the earliest opportunity. Shortly after the delivery, the complainant’s baby cried once and then stopped crying. Dr Wong, who was then in the adjoining delivery room, was called by a nurse to attend to the complainant’s baby. She did so within one to two minutes of the delivery and successfully resuscitated the baby.

In the event, and most unfortunately, the complainant’s baby developed congenital E. coli septicaemia and congenital pneumonia, and required emergency care. The baby was initially warded at Thomson Medical Centre, and was subsequently transferred to KK Women’s and Children’s Hospital. He was hospitalised for about five months. It must be noted that based on the evidence, the baby’s condition was causally unconnected to anything which the appellant had done or had omitted to do.

The complainant filed a complaint against the appellant. The complaint was reviewed by the respondent’s Complaints Committee, which dismissed the complaint and concluded that a formal inquiry was not required. The Complaints Committee, after considering “all the circumstances of the complaint and the information submitted”, including the expert opinion of Prof Sir S Arulkumaran (“Prof Arulkumaran”), Head of Obstetrics and Gynaecology at St George’s Hospital, London, concluded (among other things) that:¹ the poor outcome of the baby’s birth and the baby’s eventual diagnosis were unrelated to the appellant’s management of the complainant’s pregnancy; the fact that the baby had passed moderate meconium-stained liquor did not warrant changing the delivery management plan by embarking on an emergency Caesarean section operation; the actions taken by the appellant based on the clinical indicators and the CTG trace were appropriate; and it was not necessary to have a neonatologist placed on standby in the circumstances.

The Complaints Committee did, however, advise the appellant to communicate better with his patients.

The complainant appealed to the Minister for Health for a formal inquiry to be conducted. This eventually led to the DC issuing a notice of inquiry to the appellant to answer four charges, although it is not known on what grounds the complainant’s appeal was acceded to. The four charges against the appellant were as follows: The first charge (“the First Charge”) alleged the gross mismanagement of the complainant, in that the appellant failed to carry out a proper assessment of her within a reasonable time during her labour. The second charge (“the Second Charge”) alleged that the appellant failed to inform the complainant of and/or failed to sufficiently explain to her the possible risks and clinical indicators associated with the meconium-stained liquor revealed during the amniotomy, and thereby failed to provide adequate information for the complainant to make informed choices about her further medical management. The third charge (“the Third Charge”) alleged that the appellant failed to act in the best interests of the complainant by failing to arrange for another obstetrician to take over the management of the complainant “when [he was] not available to do so”. The fourth charge (“the Fourth Charge”) alleged that the appellant failed to act in the best interests of the complainant by failing to arrange for a neonatologist to be present at or placed on standby for the delivery of the complainant’s baby despite the presence of meconium-stained liquor accompanied by suspected foetal compromise.

The appellant contested all four charges.

The following experts were called to give evidence at the inquiry: Dr Annapoorna Venkat (“Dr Venkat”), the respondent’s obstetrics and gynaecology (“O&G”) expert; Prof Ho Lai Yun (“Prof Ho”), the respondent’s neonatology expert; Assoc Prof Mary Rauff (“Assoc Prof Rauff”), the appellant’s O&G expert; Prof Arulkumaran, the appellant’s O&G expert; Assoc Prof John Tee (“Assoc Prof Tee”), the appellant’s O&G expert; Assoc Prof Lee Jiun (“Assoc Prof Lee”), the appellant’s neonatology expert;...