Noor Azlin Bte Abdul Rahman v Changi General Hospital Pte Ltd and others

JurisdictionSingapore
JudgeBelinda Ang Saw Ean J
Judgment Date14 February 2018
Neutral Citation[2018] SGHC 35
Plaintiff CounselVijay Kumar Rai (Engelin Teh Practice LLC)
Date14 February 2018
Docket NumberSuit No 59 of 2015
Hearing Date10 February 2017,27 April 2017,09 February 2017,08 February 2017,20 January 2017,24 January 2017,08 March 2017,22 March 2017,19 October 2017,26 January 2017,19 January 2017,24 April 2017,07 March 2017,27 January 2017,18 January 2017,09 March 2017,07 February 2017,03 February 2017,25 April 2017,31 March 2017,26 April 2017,11 July 2017,28 April 2017,17 January 2017,01 February 2017,10 July 2017,25 January 2017,02 February 2017
Subject MatterBreach of duty,Negligence,Causation,Tort
Year2018
Defendant CounselLek Siang Pheng, Vanessa Lim, Yvonne Ong and Audrey Sim (Dentons Rodyk & Davison LLP),Kuah Boon Theng, SC, Karen Yong and Samantha Oei (Legal Clinic LLC)
CourtHigh Court (Singapore)
Citation[2018] SGHC 35
Published date01 March 2019
Belinda Ang Saw Ean J: Introduction

The plaintiff is a 38 year-old female suffering from lung cancer. She is suing Changi General Hospital Pte Ltd (“the Hospital”) and three doctors for their negligent failure to diagnose and treat a nodule in her right lung during her respective consultations with them in the five years before she was clinically diagnosed with cancer after a biopsy performed in 2012.

The first defendant is the Hospital. The second defendant is Dr Imran bin Mohamed Noor (“Dr Imran”), a respiratory specialist, who was an associate consultant in the Hospital’s department of respiratory medicine and who saw the plaintiff on 15 November 2007. The third defendant is Dr Yap Hsiang (“Dr Yap”), who attended to the plaintiff at the Hospital’s accident and emergency (“A&E”) department on 29 April 2010 as a medical officer. The fourth defendant, Dr Soh Wei Wen Jason (“Dr Soh”), also a medical officer, attended to the plaintiff in the same A&E department over a year later, on 31 July 2011. The second to fourth defendants are collectively referred to as “the defendant-doctors”.

The plaintiff argues that the presence of the singular pulmonary nodule on her chest x-rays taken at different time points warranted follow-up actions which the defendants failed to carry out. Had the nodule (at the mid-zone of the right lung) been investigated and assessed sooner than 16 February 2012, when a biopsy of the nodule was performed, her cancer would have been treated and her medical outcome would be different today. The plaintiff maintains that the delays in the discovery of the nodule’s malignancy caused her injury for which she claims substantial damages in this action. The defendants deny that they are liable to the plaintiff.

In this judgment, I will start by discussing the cause and development of the plaintiff’s cancer. I will make findings on whether the nodule was malignant since October 2007, as the plaintiff claims, or whether it was benign but turned malignant after 31 July 2011. These findings are relevant to the question of causation and loss. I will comment on the plaintiff’s treatment and medical management of the nodule as it featured heavily in the evidence and the plaintiff’s case. The plaintiff’s assertions essentially require pre-symptomatic detection and treatment of a young person under 35 years of age, with no symptoms of lung cancer, and who had declared herself as a non-smoker. I will examine the defendant-doctors’ alleged breaches in relation to their individual consultations with the plaintiff in the light of her assertions on the one hand, and the defendant-doctors’ evidence-based assessment and management of the nodule on the other hand. For the defendants, their argument is that there was a low index of suspicion for malignancy on the occasions each of the defendant-doctors saw the plaintiff. This judgment will also examine the plaintiff’s claim that her cancer could have been slow-growing and the validity of the defendants’ case that the knowledge that slow-growing lung cancers existed and were more common than previously thought only began to gain traction in the medical community from around 2013. The defendants say they cannot be faulted for not assessing the plaintiff’s nodule based on medical knowledge that was not available to them at the material time, ie, from 2007 to 2011.

The plaintiff is represented by Mr Vijay Kumar Rai (“Mr Rai”). Ms Kuan Boon Theng (“Ms Kuah”) acts for the Hospital and Mr Lek Siang Pheng (“Mr Lek”) acts for the second to fourth defendants.

The plaintiff’s medical condition

The plaintiff was diagnosed with non-small cell lung cancer in 2012 by Adjunct Assistant Professor Sridhar Venkateswaran (“A/Prof Sridhar”) in the Hospital, following a biopsy of a nodule in her right lung. It was subsequently determined in December 2014 to be an anaplastic lymphoma kiyenase (“ALK”)-positive non-small cell lung cancer, meaning that the cancer was caused by an abnormal gene fusion in the plaintiff’s body, which was known to be able to transform benign cells to malignant (ie, cancerous) cells. Detailed medical evidence was led in relation to the development of the nodule from 2007 to 2012 and the cause and progress of the cancer.

The nodule in the plaintiff’s lung was first noted by Dr Yeo Cheng Hsun Jonathan (“Dr Yeo”) in October 2007. The plaintiff went to the Hospital’s A&E department at around 4am complaining of lower chest pain and shortness of breath. Dr Yeo recorded that the plaintiff was a non-smoker and ordered a chest X-ray for her (“the October 2007 X-ray”). He reviewed it together with Dr Steven Lim Hoon Chin. Both noted that there was an opacity in the right mid-zone of the plaintiff’s chest. Dr Yeo diagnosed her presenting complaints on that occasion as a possible case of gastritis and prescribed her medication accordingly. The incidental finding of the opacity was unrelated to the plaintiff’s presenting symptoms but Dr Yeo referred her to the Hospital’s department of respiratory medicine to review the opacity for good measure.

Two weeks later, in November 2007, the plaintiff went to the Hospital’s specialist outpatient clinic for respiratory medicine and consulted the second defendant, Dr Imran, a respiratory physician. Dr Imran noted that the plaintiff had already seen A&E for chest pain, had no other respiratory problems, no weight loss, no loss of appetite, no fever or cough, and clear lungs. He reviewed the plaintiff’s October 2007 X-ray, noted an opacity on her right lung, and ordered a repeat chest X-ray in an erect view and a right lateral view (“the November 2007 X-ray”). He reviewed the wet films on a light box, concluded that no obvious nodule was noted on the November 2007 X-ray, and gave the plaintiff an open date for follow-up. This meant that the plaintiff could return to him for a follow-up if she felt unwell.

The plaintiff made a few other visits to the Hospital’s A&E department in the next few years, although she claims only against two doctors who attended to her during her visits in 2010 and 2011. She consulted with Dr Yap, the third defendant, in April 2010, with complaints of right lower chest pain with shortness of breath. Dr Yap ordered a chest X-ray (“April 2010 X-ray”) and spotted the nodule in her right lung as an incidental finding. He retrieved the October and November 2007 X-rays and assessed that the nodule was stable with no clinically significant changes and her presenting symptoms were not related to this incidental finding. After discussing with the senior consultant on duty, Dr Mohan Tiruchittampalam (“Dr Mohan”), he sent the April 2010 X-ray for reporting, discharged the plaintiff and advised her to return if her symptoms persisted or worsened. Around a year later, the plaintiff visited the Hospital’s A&E department with complaints of left lower ribcage pain. Dr Soh, the fourth defendant, attended to her and ordered another chest X-ray (“July 2011 X-ray”) in erect and left oblique views. He missed the nodule in the plaintiff’s right lung, diagnosed her pain as musculoskeletal, and after discussing with the senior doctor on duty, Dr Lim Ghee Hian (“Dr Lim”), he discharged the plaintiff with painkillers, advising her to return if her symptoms persisted or worsened.

In November 2011, the plaintiff went to a Raffles Medical Clinic complaining of cough, breathlessness and blood in her sputum. Dr Melvyn Wong (“Dr Wong”), who attended to her three times over the next one and a half weeks, initially treated her with cough medication. The plaintiff returned three days later still complaining of cough with blood. Dr Wong then ordered an X-ray (“December 2011 X-ray”) and observed an opaque lesion in the X-ray. He gave her a cough suppressant and antibiotics. He received the X-ray report a week later, which confirmed the presence of a round patch and ill-defined shadows at the mid-zone of the right lung and stated that “this is likely to be the result of infection”. Dr Wong then referred her to a respiratory physician at the Hospital for further evaluation.

A/Prof Sridhar attended to the plaintiff and ordered a number of tests, including a Computed Tomography (“CT”) chest scan and another chest X-ray (“second December 2011 X-ray”). The radiologist conducting the CT scan was Dr Elizabeth Chan (“Dr Chan”). The CT scan revealed a lesion that appeared to be a pulmonary hamartoma (ie, benign lesion), but Dr Chan recommended a biopsy for “baseline histological correlation” because of the lesion’s interval increase in size, lobulated margins, pleural tagging and the plaintiff’s smoking history. As Professor Goh Boon Cher (“Prof Goh”), the defendants’ expert, explained, baseline biopsy was recommended by Dr Chan because there had been no previous biopsy. The biopsy was hence intended to establish a baseline, a starting point, for the plaintiff’s nodule, so that future comparisons could be made should there be any subsequent changes to the nodule.

Dr Andrew Tan (“Dr Tan”) carried out the biopsy in February 2012, which revealed that the plaintiff had lung cancer. A/Prof Sridhar broke the news to the plaintiff but assured her that her likelihood of total recovery was high and referred her to consider a lobectomy (removal of a part of the affected lung). Before the lobectomy, she was clinically staged as Stage I, which was early stage cancer. The plaintiff underwent a right lobectomy in March 2012. After the lobectomy, she was diagnosed as Stage IIA non-small cell lung cancer and attended follow-up medical care and treatment by A/Prof Koong Heng Nung (“A/Prof Koong”) and Dr Daniel Tan Shao Weng (“Dr Daniel Tan”). She underwent chemotherapy for around four months.

Although her tumour was removed in the 2012 lobectomy, the plaintiff suffered a relapse of her cancer two years later in August 2014. She underwent a biopsy, which revealed that she was at Stage IV. In December 2014, under Dr...

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5 cases
  • Noor Azlin bte Abdul Rahman and another v Changi General Hospital Pte Ltd
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    • Court of Appeal (Singapore)
    • 29 November 2021
    ...59/2015 (“Suit 59”). Her claim was dismissed by the Judge in Noor Azlin bte Abdul Rahman v Changi General Hospital Pte Ltd and others [2019] 3 SLR 1063 (“the first HC Judgment”) after a lengthy 28-day trial (“the Original Hearing”). Ms Azlin appealed and her appeal in CA/CA 47/2018 was allo......
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    ...3 SLR(R) 674 at [3], [134] and [135] and the High Court in Noor Azlin bte Abdul Rahman v Changi General Hospital Pte Ltd and others [2019] 3 SLR 1063 at [16], in relation to psychiatric and physical harm 20 See the Court of Appeal in TV Media Pte Ltd v De Cruz Andrea Heidi and another appea......
  • Noor Azlin bte Abdul Rahman and another v Changi General Hospital Pte Ltd
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    • Court of Appeal (Singapore)
    • 9 June 2021
    ...59/2015 (“Suit 59”). Her claim was dismissed by the Judge in Noor Azlin bte Abdul Rahman v Changi General Hospital Pte Ltd and others [2019] 3 SLR 1063 (“the first HC Judgment”) after a 28-day trial (“the Original Hearing”). Ms Azlin appealed and her appeal in CA/CA 47/2018 (“the Original A......
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    • Court of Appeal (Singapore)
    • 26 February 2019
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4 books & journal articles
  • Tort Law
    • Singapore
    • Singapore Academy of Law Annual Review No. 2018, December 2018
    • 1 December 2018
    ...v Barclays Bank plc [2007] 1 AC 181. 81 [2018] SGHC 66. 82 [2005] 2 AC 176. 83 (2010) 240 CLR 537. 84 [1970] AC 170 at 176. 85 [2019] 3 SLR 1063. 86 [1987] 1 QB 730. 87 Noor Azlin Bte Abdul Rahman v Changi General Hospital Pte Ltd [2019] 3 SLR 1063 at [27]. 88 Noor Azlin Bte Abdul Rahman v ......
  • Biomedical Law and Ethics
    • Singapore
    • Singapore Academy of Law Annual Review No. 2018, December 2018
    • 1 December 2018
    ...2 AC 176 at [223]–[225]. 29 Gregg v Scott [2005] 2 AC 176 at [90]. See also Tabet v Gett [2010] 265 ALR 227 at [102], per Crennan J. 30 [2019] 3 SLR 1063. 31 Noor Azlin v Changi General Hospital [2019] 3 SLR 1063 at [85]. 32 Citing Wilsher v Essex Area Health Authority [1987] 1 QB 730 at 77......
  • Biomedical Law and Ethics
    • Singapore
    • Singapore Academy of Law Annual Review No. 2019, December 2019
    • 1 December 2019
    ...Law (Ian Kennedy & Andrew Grubb eds) (Oxford University Press, 2nd Ed, 2004) ch 8 at para 8.65. 7 Noor Azlin v Changi General Hospital [2019] 3 SLR 1063 at [117]. 8 [2020] 1 SLR 133. 9 [1998] AC 232. 10 Bolitho v City and Hackney Health Authority [1998] AC 232 at 240, per Lord Browne—Wilkin......
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    • Singapore
    • Singapore Academy of Law Annual Review No. 2021, December 2021
    • 1 December 2021
    ...Hospital [2021] SGHC 10 at [215]. 10 [2021] 2 SLR 1239. 11 (2020) 21 SAL Ann Rev 161 at 161–165, paras 6.2–6.12. 12 [2021] SGHC 243. 13 [2019] 3 SLR 1063 at [85]. 14 [2021] 5 SLR 681. 15 Cap 174, 2014 Rev Ed. 16 Cap 174, 2004 Rev Ed. 17 [2013] 1 SLR 83 at [72]. 18 Pang Ah San v Singapore Me......

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