Noor Azlin bte Abdul Rahman v Changi General Hospital Pte Ltd

• Jurisdiction: Singapore
• Judge: Sundaresh Menon CJ,Andrew Phang Boon Leong JA,Judith Prakash JA
• Judgment Date: 26 February 2019
• Neutral Citation: [2019] SGCA 13
• Year: 2019
• Date: 26 February 2019
• Published date: 01 March 2019
• Hearing Date: 17 October 2018
• Plaintiff Counsel: Vijay Kumar Rai and Lee Xiancong Jenson (Engelin Teh Practice LLC)
• Defendant Counsel: Lek Siang Pheng, Vanessa Lim Choon Hsia, Sim Mei Jun Audrey and Zoe Pittas (Dentons Rodyk & Davidson LLP),Kuah Boon Theng SC, Yong Kailun Karen and Samantha Oei Jia Hsia (Legal Clinic LLC)
• Court: Court of Appeal (Singapore)
• Citation: [2019] SGCA 13
• Docket Number: Civil Appeal No 47 of 2018

Andrew Phang Boon Leong JA (delivering the judgment of the court): Overview

This is an appeal against the decision of the High Court judge (“the Judge”) in Noor Azlin Binte Abdul Rahman v Changi General Hospital Pte Ltd and others [2018] SGHC 35 (“the Judgment”). At the heart of the Appellant’s case is the allegation that the three doctors who attended to her (over a four-year period) as well as the hospital at which they worked were negligent. The Appellant argues that their negligence had delayed the detection of the malignancy which resulted in the lung cancer she is presently afflicted with, and caused her to suffer the loss of a better medical outcome.

Two of the doctors who attended to her were doctors from the Accident and Emergency (“A&E”) department – the Third Respondent, Dr Yap Hsiang (“Dr Yap”) and the Fourth Respondent, Dr Soh Wei Wen Jason (“Dr Soh”), respectively. Dr Yap attended to the Appellant in the A&E department on 29 April 2010 whilst Dr Soh attended to her in the same department about a year later on 31 July 2011.

The third doctor was the Second Respondent, Dr Imran bin Mohamed Noor (“Dr Imran”). He is a specialist respiratory physician who attended to the Appellant in the hospital’s specialist outpatient clinic (“SOC”) on 15 November 2007.

By way of the briefest of backgrounds in the present broad overview, the Appellant had in fact first visited the A&E department of the hospital on 31 October 2007, on which occasion she had complained of lower chest pain and shortness of breath. A chest X-ray was ordered and an opacity in the right mid-zone of the Appellant’s chest was noted. As a result, the Appellant was, inter alia, referred to the SOC where she was attended to by Dr Imran.

We pause to note that the fact that Dr Yap and Dr Soh on the one hand and Dr Imran on the other belonged to different medical specialities (and hence different departments of the hospital) is significant in so far as the standard of care they had, respectively, to observe vis-à-vis the Appellant is concerned.

The First Respondent is the hospital itself, Changi General Hospital (“CGH”). In this particular regard, we note that the possible liability of CGH may be viewed from two perspectives. The first is by way of primary liability for negligence if the Appellant could demonstrate, on a balance of probabilities, that CGH was negligent because of the system which it had in place at the material time. The second is by way of secondary liability for the negligence of Dr Yap, Dr Soh and/or Dr Imran, provided of course that such negligence on the part of one or more of the aforementioned doctors could be established (again, on a balance of probabilities).

Before we conclude this extremely brief overview, we note that one major issue in the court below that impacted all the defendants (the Respondents in the present appeal) was the issue of causation. Put simply, even assuming that one or more of the Respondents could be demonstrated to have been negligent, could such negligence be considered to have caused the delay in diagnosis and any consequential damage which forms the bedrock or centrepiece of the Appellant’s case? In this regard, the key finding by the Judge in the court below was that, even if negligence were proved, as it was the finding of the court, on a balance of probabilities, that the Appellant was not afflicted with cancer as at July 2011, such negligence could not have caused the delay in diagnosis.

With this briefest of overviews, we turn now to consider the background facts in detail as these are crucial to the findings made by the Judge in the court below.

Facts

The Appellant began to visit CGH for various medical conditions from 2007 but was only clinically diagnosed with lung cancer in 2012. Three of these visits form the subject-matter of her claim in medical negligence and we set them out in a chronological fashion below.

31 October 2007 – the first visit to the A&E department

The Appellant first visited CGH’s A&E department on 31 October 2007 and was attended to by Dr Yeo Cheng Hsun Jonathan (“Dr Yeo”). She complained of lower chest pain and shortness of breath. The records reflected Dr Yeo’s note that the Appellant was a non-smoker. Dr Yeo ordered a chest X-ray (“the October 2007 X-ray”) and reviewed it with Dr Steven Lim Hoon Chin. The doctors noted an opacity in the right mid-zone of the Appellant’s chest.

Dr Yeo diagnosed the Appellant with a possible case of gastritis and prescribed medication accordingly. He then referred her to CGH’s Respiratory Medicine SOC for good measure to review the opacity, even though the incidental finding of the opacity was unrelated to the symptoms that the Appellant presented with at the A&E department.

November 2007 visit to the specialist clinic

The Appellant visited CGH SOC two weeks later on 15 November 2007 and was attended to by Dr Imran, who is, as aforementioned, a respiratory physician and the Second Respondent.

At the consultation, Dr Imran reviewed the notes taken by Dr Yeo. Dr Imran noted that: the Appellant had visited the A&E department for centralised chest discomfort, nausea and mild breathlessness; upon examination, the Appellant had mild epigastric discomfort and her left lower anterior ribs were mildly tender on palpation, but her heart and lung sounds were normal; and the Appellant was a non-smoker.

Dr Imran conducted a physical examination and noted that the Appellant did not complain of respiratory symptoms such as cough or blood in her sputum and did not report any appetite or weight loss. She also did not present with symptoms of infection such as fever or cough. As the October 2007 X-ray contained “an artifact or an opacity in the right mid zone”, Dr Imran ordered a repeat chest X-ray in two views – an erect posterior anterior view (“the erect view”) and a right lateral view.

The two chest X-rays (“the November 2007 X-rays”) were reviewed by Dr Imran in wet film format using a light box. At that time, the state of technology was such that Dr Imran was unable to digitally manipulate the November 2007 X-rays for size, contrast or brightness. Dr Imran’s assessment was that the opacity noted on the October 2007 X-ray “appeared to be resolving or had resolved on its own”. Dr Imran thus gave the Appellant an open date for follow-up and advised the Appellant to return if she felt unwell.

29 April 2010 – the second visit to the A&E department

The Appellant went to the A&E department again on 29 April 2010. This time, she complained of right lower chest pain which started an hour before the consultation. The Appellant said that the pain worsened with deep inhalation which caused shortness of breath. When asked, she denied having respiratory symptoms such as cough, running nose and sore throat.

Dr Yap, who was then a locum medical officer at the A&E department, attended to her.

Dr Yap ordered an electrocardiogram (“ECG”) and the April 2010 X-ray. The ECG tracings showed a normal sinus rhythm and ruled out any heart-related problems. The April 2010 X-ray showed an opacity over the right mid-zone of the Appellant’s lungs. Upon noticing this opacity, Dr Yap checked the Appellant’s medical records and retrieved the October 2007 X-ray and the November 2007 X-rays. At that time, no radiological reports had yet been made on the 2007 X-rays. Comparing the 2007 X-rays with the April 2010 X-ray, Dr Yap saw that the opacity had been present since 2007 and noted that it appeared to be stable as its size remained more or less the same. He did not take any measurements and came to this conclusion simply by comparing the X-rays using the naked eye. Dr Yap also observed that the opacity was regular, round and did not have the feathering or speckled appearance that were typical of malignant nodules. Dr Yap also ruled out pneumothorax as there were no indications suggesting this (such as a visible visceral pleural edge, ie, very thin sharp white line, or a collapsed lung). He also ruled out pneumonia and infective causes (ie, infections) as there were “no focal or diffuse opacities, air bronchograms or parapneumonic effusions” on the April 2010 X-ray. Dr Yap also took the view that the presenting symptoms of the Appellant on this visit were not related to the opacity. The opacity was therefore deemed to be an “incidental finding”, which is a term used to refer to findings that are not related to the patient’s presenting symptoms.

Partly given that the pain had only started in the hour prior to the Appellant’s examination and because the Appellant had told Dr Yap that she had consulted a respiratory specialist, Dr Imran and was told she was fine, Dr Yap concluded that the opacity was an incidental finding (ie, unrelated to the patient’s presenting symptoms), and came to the assessment that the pain was musculoskeletal in nature and unrelated to the opacity. We note that Dr Yap did not have Dr Imran’s notes and relied on the Appellant’s account of what Dr Imran had told her. Dr Yap then ran his diagnosis by the senior doctor, Dr Mohan Tiruchittampalam (“Dr Mohan”), who was on duty to supervise junior doctors like Dr Yap. Dr Mohan agreed with Dr Yap’s assessment that the nodule appeared to be stable and that the pain was musculoskeletal in nature. Dr Yap recommended that the Appellant be prescribed painkillers, discharged and told to return if the symptoms persisted or worsened. Dr Yap’s own notes also requested that the patient be recalled if necessary after the X-ray report was out. Dr Mohan agreed. Dr Mohan was not called as a witness for the trial.

Dr Yap prescribed painkillers for the Appellant and discharged her. She was also advised to return if the symptoms persisted or worsened. Dr Yap then sent the April 2010 X-ray for reporting. The report was issued in due course but it was never received personally by Dr Yap.

31 July 2011 – the third visit to the A&E department...