Goh Guan Sin (by her litigation representative Chiam Yu Zhu) v Yeo Tseng Tsai and another

• Judge: Tan Siong Thye J
• Judgment Date: 27 November 2019
• Neutral Citation: [2019] SGHC 274
• Citation: [2019] SGHC 274
• Defendant Counsel: Lek Siang Pheng, Mar Seow Hwei, Aw Sze Min and Toh Cher Han (Dentons Rodyk & Davidson LLP),Kuah Boon Theng SC, Yong Shuk Lin Vanessa and Chain Xiao Jing, Felicia (Qian Xiaojing) (Legal Clinic LLC)
• Published date: 05 December 2019
• Hearing Date: 26 April 2019,14 May 2019,07 May 2019,17 July 2019,10 May 2019,09 May 2019,03 May 2019,02 May 2019,18 April 2019,23 April 2019,08 October 2019,19 July 2019,13 August 2019,24 April 2019,16 July 2019,06 August 2019,15 May 2019,09 October 2019,12 July 2019,21 May 2019,09 July 2019,10 July 2019,22 May 2019,05 August 2019,30 April 2019,11 July 2019,08 May 2019,08 July 2019,18 July 2019,16 May 2019,17 April 2019,25 April 2019
• Plaintiff Counsel: Abraham Vergis and Bestlyn Loo (instructed) (Providence Law Asia LLC), Seenivasan Lalita, Virginia Quek and Isabel Chew (Virginia Quek Lalita & Partners)
• Date: 27 November 2019
• Court: High Court (Singapore)
• Docket Number: Suit No 463 of 2017
• Subject Matter: Breach of duty,Negligence,Tort

Tan Siong Thye J:

This is a medical negligence case involving a 70-year-old patient, Mdm Goh Guan Sin (“the Plaintiff”), who has been in a persistent vegetative state (“PVS”) since June 2014 after undergoing surgery to remove a brain tumour.¹ The surgery was performed by Dr Yeo Tseng Tsai (“the First Defendant”), a senior consultant and the Head of the Division of Neurosurgery at the National University Hospital (“NUH”). NUH is managed by the National University Hospital (Singapore) Pte Ltd (“the Second Defendant”). The Plaintiff filed this suit through her litigation representative, PW1 Ms Chiam Yu Zhu (“PW1 Ms Chiam”), who is one of her daughters and her deputy. The Plaintiff commenced the suit against the First Defendant and the Second Defendant (collectively referred to as the “Defendants”) on allegations of negligence before, during, and after the surgery. However, when the trial started, the Plaintiff decided not to pursue her claims for negligence during the surgery. At the end of the trial, the Plaintiff further dropped her allegations of negligence at the pre-operative stage. She now focuses her case of negligence against the Defendants for their failure to care and manage her after the surgery. The Second Defendant counterclaims for unpaid hospital bills.

Facts Diagnosis of the tumour

On 24 April 2014, PW1 Ms Chiam brought the Plaintiff to see an orthopaedic doctor at NUH as the Plaintiff had been experiencing frequent falls due to difficulty in balancing herself. The Plaintiff was advised to have a magnetic resonance imaging (“MRI”) scan done.

On 2 May 2014, the Plaintiff, accompanied by another daughter, Ms Chiam Li Ling (“Li Ling”), went for a brain MRI scan at RadLink Diagnostic Imaging (S) Pte Ltd (“the RadLink MRI”). The RadLink MRI showed that the Plaintiff had a large tumour and hydrocephalus.² Hydrocephalus is a condition that involves an increase in intracranial pressure due to excessive cerebrospinal fluid (“CSF”) accumulation in the four ventricles of the brain. The ventricles produce CSF, which is a clear, colourless fluid that circulates in the brain to protect vital brain components from trauma. CSF is also found in the spinal cord.

It is not disputed that the Plaintiff was correctly diagnosed with a left cerebellopontine angle tumour (vestibular schwannoma (VS), also known as acoustic neuroma). The tumour was benign and slow-growing. Eventually it reached a size of 4.9cm x 3.7cm x 3.5cm as of 2 May 2014.³ The tumour compressed the brainstem (which comprises the midbrain, pons and medulla in descending order in a roughly columnar shape)⁴ at the level of the pons, as well as other parts of the brain. Prolonged compression by the growing tumour had distorted the shape, size and location of the pons significantly, though the precise extent is disputed by the parties. The tumour also pressed against the cerebellum and the fourth ventricle. The tumour developed on the vestibular and cochlear nerves leading from the inner ear to the brain. The location of the tumour is shown in the diagram⁵ below:

The tumour had to be removed to prevent further brain damage. This is a serious and a major surgery that carries other risks, including the risk of death. The Plaintiff and her children wanted a second opinion.

On 10 May 2014, the Plaintiff, accompanied by PW1 Ms Chiam and another daughter, Ms Chiam Yin Mee (“Carol”), consulted Dr Timothy Lee (“Dr Lee”), a neurosurgeon at Gleneagles Hospital. Dr Lee confirmed that the Plaintiff had a tumour which had to be removed.

Consultations at NUH

After consulting Dr Lee, the Plaintiff, accompanied by PW1 Ms Chiam and Li Ling, sought another opinion at NUH on 15 May 2014 (“the 15 May 2014 Consultation”). The doctor who attended to the Plaintiff was DW9 Dr Ho Kee Hang (“DW9 Dr Ho”), a neurosurgeon who is a visiting consultant at NUH.⁶ DW9 Dr Ho also practises neurosurgery at Mount Elizabeth Medical Centre. At this consultation, DW15 Dr Gabriel Lu Yeow Yuen (“DW15 Dr Lu”) and DW6 Dr Ng Zhi Xu (“DW6 Dr Ng”) were in attendance. The parties dispute what transpired at the 15 May 2014 Consultation. In any event, it was on 15 May 2014 that surgery to remove the tumour was scheduled for 2 June 2014 (“the First Surgery”) and a second consultation was scheduled for 29 May 2014 (“the 29 May 2014 Consultation”).

On 22 May 2014, the Plaintiff, accompanied by PW1 Ms Chiam and Carol, sought another opinion from Dr James Khoo (“Dr Khoo”), a neurosurgeon at Mount Elizabeth Medical Centre. The Plaintiff was prescribed with Diamox, as she had complained of headaches. She was also diagnosed with ataxia, which refers to the lack of muscle coordination resulting in, inter alia, gait abnormality.⁷ Also on this day, though unbeknownst to the Plaintiff at that time, the Plaintiff’s case was discussed at the NUH’s Division of Neurosurgery’s weekly peer review pre-operative discussion (“the Department Meeting”). According to the First Defendant, it was at this meeting that he agreed to DW9 Dr Ho’s request to perform the First Surgery.⁸

On 26 May 2014, PW1 Ms Chiam brought the Plaintiff to the Accident and Emergency (“A&E”) department at NUH as the Plaintiff was unwell. Coincidentally, this was also the day when PW1 Ms Chiam received a call from NUH about the Plaintiff’s next appointment at NUH. Following the clarifications made by Carol with NUH, the siblings realised that an appointment was scheduled for the Plaintiff to consult the First Defendant on 27 May 2014. The Plaintiff did not attend this consultation.⁹

On 29 May 2014, the Plaintiff returned to NUH for her appointment and was attended to by DW6 Dr Ng, a resident at NUH at the material time. As with the 15 May 2014 Consultation, the parties’ accounts of what happened during the 29 May 2014 Consultation differ.

Tumour removal surgery at NUH (the First Surgery)

Thereafter, on 1 June 2014 at around 1736 hrs, the Plaintiff was admitted to NUH as a Class B1 private paying patient to prepare for the First Surgery the following day. At around 2100 hrs, DW15 Dr Lu, then a registrar in NUH, attended to the Plaintiff and obtained the Plaintiff’s signature on the consent form for the First Surgery.¹⁰

On 2 June 2014 at around 0800 hrs, the Plaintiff was wheeled into the operating theatre. This was the first time that the Plaintiff was seen by the First Defendant.¹¹ The First Surgery started at 0947 hrs. The First Defendant was assisted by two other consultant neurosurgeons, DW11 Dr Pang Boon Chuan (“DW11 Dr Pang”) and DW12 Dr Low Shiong Wen (“DW12 Dr Low”). In the course of the First Surgery, the superior petrosal vein (“SPV”) was sacrificed in order to access the tumour. The SPV is a vein or venous complex that drains blood from the cerebellum and brainstem into the superior petrosal sinus.¹² A portion of the tumour capsule could not be removed as it was densely adherent to the brainstem. The First Surgery was uneventful and concluded at 1415 hrs.

Post-operative developments

After the First Surgery, the Plaintiff was transferred to the recovery room, also known as the post-acute care unit or PACU, at 1452 hrs. There, it was documented that the Plaintiff had a Glasgow Coma Scale (“GCS”) score of 15, the best possible score, at 1505 hrs, 1510 hrs, 1520 hrs, 1535 hrs, 1550 hrs, 1605 hrs and 1620 hrs.¹³ The GCS is an accepted scoring system for measuring a patient’s consciousness level. It comprises three components that check for the patient’s best eye opening response, best motor response, and best verbal response. The maximum score for each component is 4, 6 and 5 respectively, giving a best possible score of 15 (ie, E4 M6 V5) which indicates that a patient has no apparent neurological deficit. The lowest possible GCS score is 3, which signifies deep coma or brain death.¹⁴ The scoring chart for GCS is as follows.

At 1655 hrs, the Plaintiff was transferred to the High Dependency Unit (“HDU”) Ward 25. It was recorded by a nurse, DW14 Ms Lee Sok Gin (“DW14 Nurse Lee”), that the Plaintiff’s GCS at 1655 hrs was 13 (E4 V3 M6) and that there was a complete lack of motor power over her right limbs (ie, her motor power for both right limbs was 0 out of 5).¹⁵ In other words, the Plaintiff had right hemiplegia, which refers to the paralysis of the right side of the body.¹⁶ I note here that there is no contradiction between scoring M6 for GCS (ie, a perfect motor component score) and right hemiplegia under the motor score. The former assesses the best motor response in terms of whether the patient understands what is being said and obeys commands, while the latter assesses motor movement of each limb. Hence, if a patient is hemiplegic but can use the limbs on the other side of the body to obey commands, that warrants a score of M6 for GCS¹⁷ but will be reflected as zero power on one side of the body for motor score.

The Plaintiff was then reviewed by DW15 Dr Lu together with DW5 Dr Yang Ming (“DW5 Dr Yang”) at 1730 hrs. The Plaintiff’s GCS, as recorded at 1730 hrs, was 15. The Plaintiff was noted to be able to move all four limbs, although there was weakness on the right side. The motor power recorded for the right upper and lower limbs were 3 and 1 respectively.¹⁸ The motor power of her left limbs was normal for her, this being a score of 4 out of 5 due to pre-existing weakness of her left leg.¹⁹ The Plaintiff was observed to be alert.

At about 1805 hrs, the Plaintiff’s GCS declined to 12. The Plaintiff was reviewed again by DW5 Dr Yang at 1820 hrs. It was noted that her level of consciousness had deteriorated rapidly with right-sided weakness in her limbs. Her GCS score was recorded as 10 with motor power of 0 out of 5 for her right upper and lower limbs. The Plaintiff’s blood pressure was 200/90 mmHg, her heart rate was 55 bpm and she was experiencing laboured breathing. In other words, the Plaintiff was exhibiting signs of Cushing reflex, which is a nervous system...