Wong Meng Hang v Singapore Medical Council and other matters

• Jurisdiction: Singapore
• Judge: Sundaresh Menon CJ
• Judgment Date: 23 November 2018
• Neutral Citation: [2018] SGHC 253
• Docket Number: Originating Summons No 1, 2 and 3 of 2018
• Date: 23 November 2018
• Published date: 27 April 2019
• Plaintiff Counsel: Christopher Chong Fook Choy and Melvin See Hsien Huei (Dentons Rodyk & Davidson LLP)
• Defendant Counsel: S Selvaraj and Leong Hoy Fok Edward (MyintSoe & Selvaraj)
• Court: High Court (Singapore)
• Hearing Date: 04 September 2018
• Subject Matter: Professional misconduct,Medical profession and practice,Professions

Sundaresh Menon CJ (delivering the judgment of the court):

These appeals concern two doctors at an aesthetic clinic who administered a potent sedative to a patient during a liposuction procedure despite lacking the necessary training or expertise to do so. They then failed to adequately monitor the patient during and after the procedure. This led to the death of the patient. Each doctor pleaded guilty to a charge of professional misconduct under s 53(1)(d) of the Medical Registration Act (Cap 174, 2014 Rev Ed) on the basis of an agreed statement of facts relevant to his or her case.

Dr Wong Meng Hang (“Dr Wong”), the doctor who carried out and was in charge of the procedure, was sentenced by the Disciplinary Tribunal (“DT”) to 18 months’ suspension from practice. The DT sentenced Dr Zhu Xiu Chun @ Myint Myint Kyi (“Dr Zhu”), the assisting doctor, to six months’ suspension from practice.

Originating Summons No 1 of 2018 (“OS 1”) is Dr Wong’s appeal against his sentence. Originating Summonses Nos 2 and 3 of 2018 (“OS 2” and “OS 3”) are appeals by the Singapore Medical Council (“the SMC”) against the sentences imposed by the DT on Dr Wong and Dr Zhu respectively.

We state at the outset that this was among the most egregious cases of medical misconduct we have come across. In this judgment, we set out the appropriate sentencing approach in disciplinary cases involving serious professional misconduct by doctors that results in harm to patients, and apply this to consider the sentences imposed by the DT on Dr Wong and Dr Zhu. In particular, we highlight the importance of sentencing considerations such as general deterrence and the need to uphold public confidence in the medical profession, which might in certain cases be sufficiently compelling to override any personal mitigating circumstances that may be found to exist. We also lay down the relevant principles that should guide courts and tribunals when considering whether an order striking the errant doctor off the register may be the appropriate punishment. Further, we make some observations on the relevance of dishonesty in this context.

Background Events of 30 December 2009

Dr Wong and Dr Zhu were registered medical practitioners practising at an aesthetics clinic known as Reves Clinic. On 30 December 2009, Dr Wong was scheduled to perform a liposuction procedure on one of his patients. Shortly before the commencement of the procedure, Dr Wong called Dr Zhu into the procedure room to assist in the procedure and to monitor the patient. A third person, Ms Fiona Hong, was also present, but she was not a registered medical practitioner.

No anaesthetist was in attendance. Instead, Dr Wong took it upon himself to manage the sedation of the patient, and for this purpose, he chose to use Propofol, which is an anaesthetic drug and a potent sedative that can rapidly depress the airway, impede respiration, and cause the recipient’s blood pressure to fall. Because of its potency, the instruction sheet provided by its manufacturers clearly states that it should only be administered by physicians trained in anaesthesia or in the management of patients under intensive care. The rationale for this appears to be explained in the American Society of Anesthesiologists’ 2002 “Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists” (“the ASA Guidelines”) which are referred to in the agreed statements of facts that were prepared for the proceedings before the DT. The ASA Guidelines advise that practitioners administering Propofol should be qualified to rescue patients from any level of sedation including general anaesthesia, and medical practitioners who are not anaesthetists or intensivists would generally lack the training to perform such a task.

It is useful here to briefly explain some of the relevant medical terms for context. Sedation refers to a continuum of drug-induced states ranging from minimal to moderate to deep sedation and, at the end of the spectrum, general anaesthesia. General anaesthesia is a state of unconsciousness from which a patient cannot be aroused, even by painful stimulation. Patients in general anaesthesia may have impaired cardiovascular function and may often require assistance in maintaining their airways. Local anaesthesia, on the other hand, refers to the administration of an anaesthetic drug to a specific area of the patient’s body for pain relief and does not involve sedation.

Dr Wong and Dr Zhu were neither anaesthetists nor intensivists, and, as they later admitted, did not have the necessary training or experience to administer Propofol safely or in accordance with the manufacturer’s instruction sheet. Indeed, from the clear warnings stated on the face of that instruction sheet, as well as from their prior involvement in surgeries in which Propofol had been administered by qualified anaesthetists, Dr Wong and Dr Zhu must be taken in fact to have known – and certainly ought to have known – about the potential dangers of administering Propofol. They would also have known that they lacked the qualifications and expertise to do so, given that they were not trained and qualified either as anaesthetists or as intensivists. In spite of this, they proceeded to administer Propofol to the patient at the start of the liposuction procedure.

To compound matters, they chose to administer Propofol in this case using a complex technique of continuous intravenous infusion by titration. This presented an even greater need for relevant expertise because when Propofol is administered in this way, its effects are prolonged according to the duration of the infusion. Both doctors accepted in the respective agreed statements of facts that the use of this titration technique to sedate a patient with Propofol is complex and “can only be provided by a well-trained, experienced and vigilant sedationist”, which neither of them was.

As a result of their incompetence in the use of Propofol, the sedation was carried out in a manner that can only be described as appalling. In brief, as and when the patient was observed to exhibit any signs of responding to pain stimulation or any movement or discomfort, Dr Wong would instruct Dr Zhu to increase the dosage of Propofol. In the event, the dosage of Propofol that was administered was excessive, and it caused the patient to enter a state of deep sedation to the point of general anaesthesia. Given their lack of training, neither doctor was able to recognise the signs of this happening.

The patient’s deep state of sedation owing to the overdose of Propofol had other repercussions on the liposuction procedure, which, as it transpired, was not performed competently. During the course of the liposuction procedure, Dr Wong inadvertently caused multiple puncture wounds to the patient’s intestines. However, these went unnoticed because the patient was in a state of general anaesthesia and did not manifest any signs of pain.

The procedure lasted about three hours and ended at around 3.45pm. At about 3.50pm, Dr Zhu left the procedure room with Dr Wong’s consent. Dr Wong proceeded to close the patient’s surgical wounds and then left the room to use the toilet. While Dr Wong was in the toilet, the patient was not in the care of any medical practitioner or nurse for at least five minutes. Perhaps as a result of their incompetence in the use of Propofol, the doctors failed to realise that it was essential that the patient be closely monitored in light of the Propofol-related risks. According to the 2002 “Guidelines on Safe Sedation Practice for Investigation and Intervention Procedures” published by the Academy of Medicine, Singapore, which were in force at the time of the offence, a patient under sedation must have his circulation “monitored at frequent and clinically appropriate intervals” and his “[r]espiration must be monitored continuously” [emphasis added]. Instead, the doctors left the patient unattended in the immediate aftermath of the administration of Propofol while he was still sedated, with scant regard to patient care and safety. During this period, the patient developed an airway obstruction and suffered asphyxia leading to cardiac arrest. It was only at about 4.15pm that the patient was discovered to have collapsed, and an ambulance was then called to take him to the hospital.

When the patient arrived at the accident and emergency (“A&E”) department of the hospital, he was found to be without a pulse. Dr Wong, who had accompanied the patient to the hospital, told the A&E doctors that the patient had been given Pethidine, a pain medication, and local anaesthesia but no sedation. This was plainly a false statement as Dr Wong knew that the patient had been sedated with Propofol, and, as we have noted, this is a potent sedative. In our judgment, the false statement made by Dr Wong to the A&E doctors evidenced his knowledge that it had been improper for him to have administered Propofol. There is no other plausible explanation for his false statement; and certainly none has been advanced.

Despite resuscitation attempts by the A&E doctors, the patient passed away that day. He was aged 44.

Investigations and charges

On 4 January 2012, the coroner recorded the patient’s death as a medical misadventure and that the patient had “died of the effects of asphyxia due to airway obstruction, secondary to intravenous Propofol administered.” The coroner further noted that the patient had sustained multiple intestinal punctures during the liposuction procedure. These findings were referred to the SMC on 13 February 2012.

Upon further investigation by the Complaints Committee, Notices of Complaint were sent to Dr Wong and Dr Zhu on 13 November 2013. On 11 May 2015, both doctors were notified of the Complaints Committee’s decision to convene a DT for an inquiry. On 9 February 2017, they were served formal Notices of Inquiry. By then, nearly five years had passed...