Chia Foong Lin v Singapore Medical Council

JurisdictionSingapore
JudgeChao Hick Tin JA,Andrew Phang Boon Leong JA,Judith Prakash JA
Judgment Date27 June 2017
CourtHigh Court (Singapore)
Docket NumberOriginating Summons No 10 of 2016
Date27 June 2017
Chia Foong Lin
and
Singapore Medical Council

[2017] SGHC 139

Chao Hick Tin JA, Andrew Phang Boon Leong JA and Judith Prakash JA

Originating Summons No 10 of 2016

High Court

Professions — Medical profession and practice — Professional conduct — Paediatrician failed to discuss or advise patient's parents about possibility of patient being infected with disease — Whether doctor breached standard of care reasonably expected of paediatrician — Whether this amounted to professional misconduct by reason of gross negligence

Professions — Medical profession and practice — Professional conduct — Patient presented more than five days of persistent and remittent fever and more than two classic features of disease — Paediatrician failed to diagnose disease and/or order supportive tests to verify symptoms — Whether doctor breached standard of care reasonably expected of paediatrician — Whether this amounted to professional misconduct by reason of gross negligence

Professions — Medical profession and practice — Professional conduct — Sentencing — Three months' suspension imposed by Disciplinary Tribunal appointed by Singapore Medical Council — Whether sentence fell outside reasonable range of sanctions available to tribunal

Dr Chia Foong Lin (“Dr Chia”), a paediatrician, was convicted by a Disciplinary Tribunal (“DT”) appointed by the Singapore Medical Council (“SMC”) of one charge of professional misconduct under s 53(1)(d) of the Medical Registration Act (Cap 174, 2004 Rev Ed), in relation to her management of one [A] (“the Patient”), a one-year-old boy, during his hospital admission from 25 February 2013 to 1 March 2013 and during a clinic review on 3 March 2013 (“the Relevant Period”).

Dr Chia first saw the Patient when the latter was admitted to the Accident and Emergency Department of Gleneagles Hospital (“GH”) and Dr Chia was on call. The Patient had suffered from high fever for the previous three days. Dr Chia's diagnosis was that of a viral infection. Over the next three days, from 26 to 28 February 2013, Dr Chia noted that the Patient displayed spikes of fever each day. The Patient also displayed other symptoms such as red lips and maculopapular rash. Nonetheless, Dr Chia's clinical impression remained that of a viral infection and she noted there were “no full features of [Kawasaki Disease]” (“KD”). This was despite the fact that a patient could also be diagnosed with the incomplete variant of KD (“Incomplete KD”) if he does not display the complete features of KD.

On 1 March 2013, Dr Chia noted that the Patient's fever had settled. Her diagnosis remained that of a viral infection, with no evidence of KD. She discharged the Patient as she thought that he would benefit from symptomatic treatment at home.

On 3 March 2013, Dr Chia reviewed the Patient at her clinic. She recorded from the Patient's mother that the Patient had a fever during the two nights after discharge, but that he had been afebrile during the day. According to Dr Chia, the Patient was also afebrile on examination. Dr Chia's diagnosis was once again viral fever as she found that not all of the criteria for the diagnosis of KD were present. She sent the Patient home with a review scheduled on 5 March 2013.

On 4 March 2013, the Patient had a high fever. His parents took him to see Dr Lee Bee Wah (“Dr Lee”), a consultant paediatrician at Mount Elizabeth Hospital (“MEH”), for a second opinion. Dr Lee suspected that the Patient had KD and conducted some supportive tests. The tests confirmed that the Patient was suffering from KD. The Patient was therefore admitted to MEH from 4 to 6 March 2013 and treated for the disease.

The SMC brought charges against Dr Chia after the Patient's mother lodged a complaint. The DT convicted Dr Chia of the charge and imposed three months' suspension on Dr Chia. Although the DT recognised that the diagnosis of KD was not straightforward, it held that it should be reasonably expected of a paediatrician to be able to diagnose KD competently and to provide the treatment effectively, especially one with Dr Chia's experience (of 23 years in practice) and credentials. The DT doubted if Dr Chia had truly appreciated or considered a diagnosis of Incomplete KD. The DT found it wholly unacceptable that Dr Chia did not conduct supportive tests to rule out KD and made repeated diagnoses of viral fever despite the Patient's prolonged fever.

By Originating Summons No 10 of 2016 (“OS 10/2016”), Dr Chia appealed against her conviction and sentence.

Held, dismissing the appeal in OS 10/2016:

(1) The court would be slow to interfere with findings of the DT and to overturn an order made by the DT unless they were unsafe, unreasonable, or contrary to evidence. Whilst deference would be paid to the views of the DT, it would not give undue deference in a way which will effectively render nugatory the appellate powers granted by the MRA. Nonetheless, where all material evidence has been placed before the DT and it had given due consideration to the relevant factors, the court should place weight on the expertise brought to bear by the members of the DT in evaluating how best the needs of the public and the profession should be protected: at [34] to [36].

(2) Paediatricians were required to maintain a high index of suspicion when a patient presented with features of KD due to the possible dire consequences if no timely proper treatment is given: at [46].

(3) The AHA Scientific Statement set out the applicable standard of care, stating that KD should be considered in the differential diagnosis of a young child with unexplained fever for at least five days that was associated with any of the principal clinical features of this disease. Incomplete KD, on the other hand, should be considered in all children in whom such fever takes place for at least five days and is associated with two or three of the principal clinical features of KD. Once characteristics consistent with KD appear, supportive tests should be conducted: at [48] to [49].

(4) Dr Chia failed to seriously consider or appreciate the possibility of Incomplete KD throughout the Relevant Period. By 28 February 2013, the Patient had presented more than five days of persistent and remittent fever, as well as more than two of the five classic features of KD. Yet, on 28 February 2013, Dr Chia documented that there were “no full features of [KD]” when quite clearly a diagnosis of Incomplete KD should have been considered. Dr Chia was unduly fixated on her diagnosis of viral fever and therefore failed to consider a diagnosis of Incomplete KD even though its symptoms were clearly present: at [53].

(5) In view of the Patient's symptoms during the Relevant Period, the applicable standard of care required Dr Chia to order the supportive tests to determine if Incomplete KD or KD could have been excluded. Because she failed to order these tests on 28 February 2013, and even up till 3 March 2013, when she ought to, she was in breach of the applicable standard of care. This was especially given the severe consequences a late diagnosis could have for the Patient and the fact that non-invasive and non-prohibitive measures could have been taken to prevent such consequences: at [56].

(6) The logical conclusion was that Dr Chia also breached her duty to inform the Patient's parents about the possibility of Incomplete KD so that they could make an informed decision on treatment choice or to suggest a plan of management, including the ordering of supportive tests to rule out KD: at [56].

(7) The DT found that Dr Chia's conduct amounted to professional misconduct by reason of gross negligence. There was nothing on the facts to suggest that the DT's decision was unsafe, unreasonable, or contrary to evidence: at [61].

(8) The line between an error of judgment and gross negligence had been crossed in the present case due to a number of factors. First, the consequences of a delayed or missed diagnosis of KD, a disease which was not uncommon among infants, could be severe. Second, the Patient presented persistent fever throughout the Relevant Period and at least two characteristics of classic KD. Yet, Dr Chia was fixated on her diagnosis of viral fever. Third, Dr Chia, as an experienced paediatrician of 23 years' standing, was expected to be aware of the possibility of Incomplete KD and to conduct the supportive tests to exclude the disease. Finally, Dr Chia had multiple opportunities to rule out KD by ordering supportive tests but failed to do so. She also did not seek the advice of her colleagues who were present at GH during the Relevant Period: at [61].

(9) In order to determine whether the punishment imposed by the DT is appropriate, the court would need to consider whether the punishment imposed falls outside the reasonable range of sanctions available to the tribunal in the circumstances: at [64].

(10) There was no existing benchmark that a fine should be preferred over a term of suspension when a medical practitioner is convicted of one charge. Taking into consideration precedents as well as the facts of the present case, the three-month suspension imposed by the DT was within the acceptable range: at [66] and [68].

Ang Pek San Lawrence v Singapore Medical Council [2015] 1 SLR 436 (distd)

Chia Yang Pong v Singapore Medical Council [2004] 3 SLR(R) 151; [2004] 3 SLR 151 (refd)

Council for the Regulation of Health Care Professionals v General Medical Council [2004] 1 WLR 2432, QBD (Eng) (folld)

Council for the Regulation of Health Care Professionals v General Medical Council [2005] 1 WLR 717, CA (Eng) (folld)

Gobinathan Devathasan v Singapore Medical Council [2010] 2 SLR 926 (folld)

Julius Libman v General Medical Council [1972] AC 217 (folld)

Low Cze Hong v Singapore Medical Council [2008] 3 SLR(R) 612; [2008] 3 SLR 612 (folld)

Pillai v Messiter (No 2) (1989) 16 NSWLR 197 (folld)

Singapore Medical Council v Kwan Kah Yee [2015] 5 SLR 201 (folld)

Singapore Medical Council v Wong Him...

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3 cases
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    • High Court (Singapore)
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    ...when such further assessment was warranted in the circumstances: at [61]–[62]. Similarly, in Chia Foong Lin v Singapore Medical Council [2017] 5 SLR 334, we reiterated that the threshold to be crossed before misconduct may be found is a high one. Misconduct entails more than mere negligence......
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