F v Chan Tanny

• Jurisdiction: Singapore
• Judge: Lai Kew Chai J
• Judgment Date: 29 August 2003
• Neutral Citation: [2003] SGHC 192
• Docket Number: Suit No 1554 of 2001
• Date: 29 August 2003
• Published date: 23 December 2003
• Year: 2003
• Plaintiff Counsel: Kwok-Chern Yew Tee and Mak Moo Theng (Lawrence Chua and Partners)
• Citation: [2003] SGHC 192
• Defendant Counsel: Edwin Tong and Karen Eu (Allen and Gledhill)
• Court: High Court (Singapore)
• Subject Matter: Tort,Breach of duty,Negligence,Whether the injury suffered caused or materially contributed to by any breach of care,Gynaecologist's duties to competently manage pregnancy of mother and delivery of baby,Whether gynaecologist on a balance of probabilities breached duty of care,Whether applicable,Applicable standard of care,Duty of care,Res ipsa loquitur maxim,Causation

Introduction

1 The plaintiff, F, was born on 12 December 1998 and was diagnosed with subarachnoid haemorrhage (bleeding in the brain), intrauterine pneumonia, and a ventricular septa defect (hole in the heart). As a result, F is suffering from various other complications. The defendant (“Dr Chan”) is a consultant obstetrician and gynaecologist, practising at Gleneagles Hospital. She managed the mother’s pregnancy and delivered the baby. She worked closely with her partner and husband, Dr Sng Soo Pheow (“Dr Sng”), to whom she referred her patients for obstetrical and gynaecological ultrasound scanning.

2 F, suing by her mother (“Mdm C”) and next friend, is claiming against Dr Chan for damages for pain and suffering, loss of amenities, and consequential losses arising from the alleged medical negligence of Dr Chan
in the monitoring and management of the gestation and the eventual delivery of F. There were numerous allegations directed to support the allegation that a Caesarean section should have been performed.

3 Dr Chan wholly disputes the allegations. She says there was no reasonable basis, at any stage throughout the pregnancy, for her to have intervened by ordering a Caesarean section or taken any other step.

Findings of Facts

Antenatal management

4 Mdm C, a teacher, first consulted Dr Chan on 15 April 1998 when she was five weeks pregnant. She was expecting her first child. Dr Chan took note of the medical history of Mdm C and of her husband, Mr D, a self-employed businessman. Mr D had a history of asthma. Apart from that, there was no other medical matter of note. Dr Chan’s general and abdominal examination of Mdm C did not disclose any abnormality. Pelvic examination showed a normal cervix. Her expected date of delivery was assessed to be 13 December 1998. Mdm C was seen by Dr Chan regularly, with a total of
16 antenatal visits. I shall recite them as they were not in controversy, unless otherwise stated in this judgment.

5 Dr Chan next saw Mdm C – on 9 May 1998. She was nine weeks pregnant. She was well and had no complaints. The foetal heart beats were heard and were regular. Mdm C’s weight was 43.7kg.

6 On 13 May 1998, Mdm C telephoned Dr Chan complaining that she was experiencing lower abdominal pain and slight breathlessness. There was no bleeding per vagina. Dr Chan explained to her that in early pregnancies, slight pain in lower abdomen was usually of no significance in the absence of bleeding. She was advised to see Dr Chan for consultation if the symptoms persisted. She did not.

7 Mdm C next saw Dr Chan on her scheduled appointment on 30 May 1998. She was then 12 weeks pregnant. She was well and had no complaints. She had no further complaints of lower abdominal pain or breathlessness. Mdm C’s weight was 44.7kg. The foetal heart rate was found to be 176 beats per minute, which was regular.

8 The ultrasound scan performed by Dr Sng showed a single foetus with
a crown-rump length of 54mm, biparietal diameter of 21mm, head circumference of 70mm and femur length of 7mm. It was not in controversy that these readings were normal for her period of pregnancy. Dr Chan also noted that the nuchal fold was normal at 2.4mm thickness, which indicated a low risk of the foetus suffering from Down’s syndrome. In addition, there was a normal amount of liquor (amniotic fluid). The placenta was in the posterior position, as shown by the ultrasound scan, which was exhibited.

9 Dr Chan again gave Mdm C supplementary iron, minerals, vitamins and calcium. She explained to Mdm C that, as a precaution, she should undergo an antenatal blood screening during her next consultation. Dr Chan further explained that she would further screen her for Toxoplasma infection, which could damage the foetal brain and the eyes, even though this was and is a rare condition. If detected, early treatment could prevent the damage.

10 Dr Chan next reviewed Mdm C on 27 June 1998. She was well with
no complaints. She was 16 weeks pregnant and the uterine size was about 16 weeks. Her blood pressure was 120/70mm Hg. Dr Chan once again discerned that the foetal heart beats were regular. Her weight was 46.7kg. As the results of Mdm C’s urine test showed a trace of albumin and 3+ glucose, Dr Chan arranged for Mdm C to, and she did, undergo a glucose tolerance test on 29 June 1998 to exclude diabetes. She was given supplementary iron, minerals, vitamins and calcium.

11 On 4 July 1998, Dr Chan telephoned Mdm C and informed her of the results of her blood test. Apart from being mildly anaemic, the blood test results were normal. Her Thalassaeimia screen was normal, on the basis of which Dr Chan concluded that her anaemia was due to nutritional deficiency (as opposed to genetic anaemia). In addition, she was screen negative for Toxoplasma IGM. Her screen for Syphillis and HIV (AIDS) were negative. Her random blood-sugar level was well within normal range and her glucose tolerance test showed she was not diabetic. Her urine test did not show any urine infection.

12 The blood test results also indicated that Mdm C was screen negative for Down’s syndrome, Edward’s Trisomy and neural tube defects. In this context, Dr Chan informed Mdm C that the blood test for Down’s syndrome and Edward’s Trisomy were not 100% accurate, and that she would have to do an amniocentesis in order to exclude completely these conditions.

13 However, Dr Chan advised Mdm C against undergoing amniocentesis for the following reasons. The test carries a risk of inducing a miscarriage. Secondly, Mdm C’s age at 30 was not in the high risk group for Down’s syndrome and Edward’s Trisomy. Finally, Mdm C’s blood test was screen negative. Dr Chan asked Mdm C to discuss with her husband and to let Dr Chan know whether she wished to undergo amniocentesis. As usual, Dr Chan advised her on a proper diet, which was mainly to consume iron-rich food and reduce the intake of sugar food.

14 Mdm C attended her next medical review on 18 July 1998. She was well and had no complaints. At 19 weeks pregnancy, her uterine size corresponded to her period of pregnancy. Her blood pressure was 120/80mm Hg. The foetal heart beats were regular. Mdm C’s weight was 47.2kg. Her urine test showed positive for albumin and negative for glucose. In the absence of hypertension, Dr Chan was of the view that the slight albumin in the urine was of no clinical significance. Dr Chan also gave Mdm C a copy of all her blood tests and explained to her again the interpretation of all the tests. Mdm C then informed Dr Chan of her decision to follow the latter’s advice not to perform amniocentesis. Mdm C was given supplementary iron, minerals, vitamins and calcium and was told her next review was 3 weeks later on 8 August 1998.

15 On 8 August 1998, Dr Chan reviewed Mdm C, who was 22 weeks pregnant. She informed Dr Chan that she had recovered from a slight flu but was otherwise well. The uterine size was about 22 weeks. Her blood pressure was 120/80mm Hg. The foetal heart beats were heard and were regular. Her weight was 48.5kg.

16 Dr Chan ordered an ultrasound to be done on the same day as this was the appropriate time for a foetal anomaly scan. The ultrasound anomaly scan performed by Dr Sng showed a normal single foetus presenting by its breech. The biparietal diameter was 56mm, the head circumference was 208mm, the abdominal circumference was 175mm and the femur length was 38mm. Dr Chan was of the view that these measurements were normal for Mdm C’s period of pregnancy. There was no abnormality detected in the foetal head, brain, spine, eyes, lips, mouth, nose, neck, heart, aorta, pulmonary artery, lungs, stomach, intestines, kidneys, bladder, umbilicus, liver, diaphragm, upper limbs and lower limbs. Head Circumference/Abdominal Circumference at 1.19 and Femur Length/Biparietal Diameter at 0.67 were both normal readings. The placenta was posterior in the normal position and the liquor was normal in amount. Dr Chan observed that the foetus was growing well, which indicated good placental function.

17 At her review on 29 August 1998, when she was 25 weeks pregnant, Mdm C was found to be well and had no complaints. The uterine size was about 25 weeks. The foetus was presenting by its breech and the foetal heart beats were heard and were regular. Her blood pressure was 120/80 mm Hg. Her weight was 49.8kg. She was given the usual nutritional supplements.

18 At her next consultation on 19 September 1998, Mdm C was 28 weeks pregnant. Her uterine size was about 28 weeks. The foetus was presenting by its breech. Mdm C’s blood pressure was 120/80mm Hg and her weight was 50.7kg. She was well except for some mild and painless contractions.

19 Dr Chan conducted a vaginal examination, and noted that the cervical os was closed and that there was no bleeding. Dr Chan explained to Mdm C that she was experiencing Braxton-Hick’s contractions and they were normally experienced in the later half of pregnancy. This was physiological, and in the absence of painful contractions and cervical dilation or show, she was not in labour. However, Dr Chan told Mdm C that if she experienced painful contractions, she should take a tablet, Ventolin (which Dr Chan prescribed to prevent premature labour), and to contact Dr Chan immediately. In addition, Mdm C was given the usual nutritional supplements and was told to return for consultations every fortnight instead of once every three weeks.

20 Her next follow-up consultation was on 3 October 1998 when Mdm C was 30 weeks pregnant. Dr Chan noted that the uterine size was about 30 weeks. Mdm C was well and had no complaints. She informed Dr Chan that the painless contractions had subsided. The foetus was presenting by its breech. Her blood pressure was 120/80mm Hg and her weight was 52.3kg. She was again given the usual nutritional supplements.

21 Mdm C was next reviewed on 17 October 1998. She was into her 32nd week of pregnancy. She was well with no complaints. The...