D'Conceicao Jeanie Doris (administratrix of the estate of Milakov Steven, deceased) v Tong Ming Chuan

• Jurisdiction: Singapore
• Judge: Tay Yong Kwang J
• Judgment Date: 22 August 2011
• Neutral Citation: [2011] SGHC 193
• Court: High Court (Singapore)
• Docket Number: Suit No 270 of 2010
• Year: 2011
• Published date: 24 August 2011
• Hearing Date: 14 April 2011,18 April 2011,07 April 2011,12 April 2011,20 April 2011,19 April 2011,11 April 2011,06 April 2011
• Plaintiff Counsel: Mr Palaniappan S (Straits Law Practice)
• Defendant Counsel: Mr Edwin Tong, Ms Mak Wei Munn and Mr Tham Hsu Hsien (Allen& Gledhill)
• Subject Matter: Tort,Negligence,Medical Negligence
• Citation: [2011] SGHC 193

Tay Yong Kwang J: Introduction

The plaintiff is the administratrix of the estate of the late Milakov Steven (“MS”). Dr Tong Ming Chuan (“Dr Tong”) is a cardiothoracic surgeon who performed a redo coronary artery bypass graft surgery (“the redo-CABG”) on MS on 12 March 2007. On 23 April 2007, 6 weeks after the redo-CABG, MS passed away from post-operative complications. The plaintiff brought a claim in tort and contract against Dr Tong, alleging that Dr Tong was negligent and/or in breach of contract in relation to the medical advice, care and treatment that he rendered to MS between 9 March 2007 and 23 April 2007.

The trial before me was confined to the issue of liability.

The parties

The plaintiff and MS were married in 1989. Letters of Administration of the estate of MS were granted to the plaintiff on 22 March 2010 and the grant was extracted on 15 April 2010. The plaintiff brought this action against Dr Tong for damages for the benefit of the dependants of MS under ss 20 and 21 of the Civil Law Act (Cap 43, 1999 Rev Ed) (“the Civil Law Act”) and for the benefit of the estate of MS under s 10 of the Civil Law Act. The dependants of MS are: i. The plaintiff, the lawful widow and next-of-kin, born on 19 July 1951 and presently 60 years of age; ii. Stacey Anne Moody, the lawful daughter and next-of-kin, a citizen of USA, a married woman, born on 24 November 1972 and presently 39 years old; and iii. Tim Milakov, the lawful son and next-of-kin, citizen of USA, a married man, born on 10 April 1976 and presently 35 years old.

Dr Tong is a Consultant Cardiothoracic Surgeon in private practice with over 28 years of experience in cardiothoracic surgery. He practises at a clinic in Mount Elizabeth Medical Centre. MS was referred to and first saw Dr Tong on 9 March 2007. Dr Tong performed the redo-CABG on MS on 12 March 2007. From 12 March 2007 to 23 April 2007 (“the post-surgery period”), MS was cared for in the Coronary Care Unit at Mount Elizabeth Hospital. Dr Tong was MS’s primary physician during the post-surgery period.

MS was 65 years of age at the time of his death. He was an American citizen and held Permanent Residence status in Singapore. Prior to his death, MS was engaged on a contractual basis by M/s Chevron Inc, a multinational company based in the United States of America (“USA”), as a consultant on matters relating to communication skills, brand management and public relations. He was also an author of a number of books and articles. His average monthly earnings were around $16,250 per month when he passed away. MS had a history of borderline diabetes and hypertension. Notwithstanding these conditions, before suffering his first major adverse cardiac event (“MACE”) on 17 January 2007, MS had been in good health. The plaintiff testified that MS led an active lifestyle and was accustomed to exercising five or six times a week regularly.

The background

For the purposes of determining liability, it is necessary to understand the events leading up to this claim. The key medical terms will be defined where necessary to facilitate understanding. The facts and definitions are undisputed unless the contrary is indicated.

The first MACE suffered by MS and the treatment he received at St Joseph Medical Centre, Houston (“SJMC”)

On 17 January 2007, when MS was in Houston, USA, he experienced left-side back tightness accompanied by some nausea while doing his normal routine physical exercise. This exercise routine comprised of a walk which usually lasted about 45 minutes to an hour. After MS felt unwell during the course of the walk, the plaintiff, who was walking with him, accompanied him home to rest. As MS continued to feel unwell, the plaintiff brought him to SJMC on the same day to seek medical attention. MS was diagnosed as suffering from ischaemia (insufficient blood supply to the heart muscles),¹ and angina pectoris (chest pain, a symptom of ischaemia). These conditions are distinct from an acute myocardial infarction (“AMI”) (more commonly known as a heart attack). MS did not suffer an AMI on 17 January 2007. This was the first time he suffered a MACE.

MS underwent a coronary angiography on 18 January 2007. A coronary angiography is a procedure to visualise the coronary arteries. To conduct an angiography, the catheter is inserted into a large artery in the groin or the wrist (in MS’s case, the femoral artery was selected), ² then advanced to the heart and positioned at the mouths of the coronary arteries before injection is performed. To see the coronary arteries, a special dye or contrast medium is injected through the catheter. The dye will “opacify” the vessels and thus makes them visible on the angiogram. Coronary angiography may be said to be an invasive procedure. This procedure is carried out to determine whether there is any significant narrowing or blockage (“stenosis”) in the coronary arteries. Stenosis of the vessels may be caused by coronary artery disease. Where there is stenosis, the blood flow to the heart muscles becomes restricted, which in turn may cause ischaemia, angina pectoris and AMI.³

The coronary angiography revealed that MS had coronary artery disease and that the following blood vessels had become stenosed: (i) the left main coronary artery (“LMCA”); (ii) the left anterior descending arterial system (“LAD”); (iii) the circumflex artery (“Cx”); and (iv) the right coronary arterial system (“RCA”).

MS was advised by his doctors in SJMC to undergo a coronary artery bypass graft surgery (“CABG”). A CABG is a surgery which allows for coronary revascularisation. Revascularisation refers to intervention to restore or improve blood supply to the heart. If coronary revascularisation is desired, there are two procedures that may be performed, namely, a CABG or a percutaneous coronary intervention (“PCI”). The suitability of each procedure is dependent on the particular patient. The aim of a CABG is to insert one or more grafts to the coronary arteries to bypass the stenosed areas.⁴ This revascularisation will help to ensure that an adequate supply of blood continues to reach the heart muscles. This is important as oxygen and nutrients, which are vital for muscle survival, are transported through the blood. To perform a CABG, the patient is first put under general anaesthesia. The surgeon then makes an incision down the middle of the patient’s chest and saws through his breastbone. The blood vessels which are to be used as grafts will be harvested. The two types of vessels commonly used as grafts are saphenous veins and internal mammary arteries. The heart will then be stopped, and the patient placed on a cardiopulmonary bypass machine. A cross clamp will be placed across the aorta to prevent blood returning to the heart and a cardioplegia solution administered to prevent cell death within the heart. The grafts will then be inserted. Following this, the patient will be removed from the bypass machine. To complete the surgery, the surgeon will stop any bleeding, wire the breastbone together, and close the incision. As can be seen from this brief description of a CABG, the surgery is a major one.

On his doctors’ advice, MS underwent a triple CABG on 19 January 2007 (“the initial CABG”). The initial CABG performed at SJMC involved the insertion of three grafts: (i) A saphenous vein graft (“SVG”) from the aorta to a marginal branch of the Cx (“Graft 1”). There was a dispute at trial about the position of Graft 1, but both sides accepted that this was inconsequential. (ii) A SVG from the aorta to another marginal branch of the Cx (“Graft 2”). (iii) A left internal mammary artery (“LIMA”) graft to the LAD (“the LIMA-LAD graft”).

Recovery after the initial CABG

Following the initial CABG, MS made good recovery, and returned to Singapore in February 2007. Upon his return to Singapore, MS consulted his regular general practitioner, one Dr Michael Chua, as his doctors in SJMC had suggested routine medical reviews. Dr Michael Chua in turn opined that MS would benefit from regular check-ups by a cardiologist and recommended one Dr Christopher Chew, an interventional cardiologist at Mount Elizabeth Medical Centre.

On 23 February 2007, MS consulted Dr Christopher Chew at his clinic. Dr Christopher Chew conducted some tests on MS. MS performed within the acceptable range of results for the tests. Dr Christopher Chew thus advised MS that he was recovering well and that he could continue with his usual exercises and lifestyle. Even so, MS adopted a more sedentary lifestyle and rested at home as he was on medical leave after the initial CABG.

The second MACE suffered by MS and the treatment he received at Mount Elizabeth Hospital (“MEH”)

At around 5.00am on 9 March 2007, MS experienced some chest pain. He presented himself at the Accident and Emergency Department of MEH for a consultation at around 6.00am and requested to see Dr Christopher Chew. It is not disputed that on 9 March 2007, MS suffered an AMI. This was the first AMI that MS suffered.

Dr Christopher Chew examined MS and performed a coronary angiography on him at or about 8.45am on 9 March 2007. It is not disputed that the angiogram suggested that Graft 1 and Graft 2 were completely occluded. The Cardiac Catheterization Report stated that a “total block” had occurred in Graft 1 and Graft 2. ⁵ The occlusion would mean that no blood could flow through those grafts, thus cutting off the supply of oxygen and nutrients to areas of heart muscle downstream of the grafts. Dr Christopher Chew opined that the AMI had been caused by the occlusion of Graft 1 and Graft 2. With regard to the LIMA-LAD graft, there was a substantial dispute at trial as to its patency. The significance of this dispute will be seen in the discussion on whether the redo-CABG was an indicated and/or appropriate treatment.

Dr Christopher Chew then recommended that MS obtain a surgical...