Yeo Peng Hock Henry v Pai Lily

• Jurisdiction: Singapore
• Judge: Chao Hick Tin JA
• Judgment Date: 26 October 2001
• Neutral Citation: [2001] SGCA 72
• Docket Number: Civil Appeal No 600048 of
• Date: 26 October 2001
• Published date: 19 September 2003
• Year: 2001
• Plaintiff Counsel: Quek Mong Hua and Adeline Foo (Lee & Lee)
• Citation: [2001] SGCA 72
• Defendant Counsel: Harpreet Singh Nehal, Edmund Kronenburg and Shirin Tang (Drew & Napier LLC)
• Court: Court of Appeal (Singapore)
• Subject Matter: Whether doctor negligent and/or in breach of duty of care,Doctor's failure to advise patient to seek immediate specialist attention,Negligence,Causation,Whether doctor's negligence and/or breach of duty caused or materially contributed to patient's loss of vision on balance of probabilities,Medical negligence,Resultant delay in diagnosis and treatment leading to loss of vision in left eye,Tort

Judgment

1. This is an appeal from the decision of the High Court in which Dr Yeo Peng Hock Henry, the appellant, was held liable in damages to Ms Lily Pai, the respondent, for the loss of vision in her left eye as a result of his negligence and/or breach of duty in attending to her as his patient. Only liability was determined and the quantum of damages was to be assessed.

The facts

2. The relevant facts giving rise to the appeal are as follows. Dr Yeo is a general medical practitioner of more than 20 years experience. He graduated from the University of Singapore with the degree of MBBS in 1969. He is a member of the College of General Practitioners and a fellow of the College of Family Practitioners, Singapore. Since 1979, he has been a clinical tutor for undergraduate medical students of the National University of Singapore (NUS), and since 1996, has been a clinical tutor for post-graduate doctors sitting for the Master of Medicine (Family Medicine) degree at the NUS and also an examiner for such degree.

3. Ms Pai runs a translation business. She holds a Bachelor of Arts degree from the NUS. She had been consulting Dr Yeo in respect of general medical problems since February 1992. On 18 December 1996, she consulted Dr Yeo with complaints of fever, backache and giddiness. Dr Yeo examined her and prescribed medication. On the following morning, 19 December 1996, Ms Pai found that there was no improvement, and she went back to see Dr Yeo again with substantially the same complaints and an additional complaint of cough. Dr Yeo examined her and prescribed further medication. Ms Pai returned home, rested and took the medication as advised. However, at about 8 pm the same day, she felt that her heart was beating quickly and she was breathless and was shivering. As Dr Yeos clinic was closed at that hour, she went to another clinic, Bedok Family Clinic and Surgery, where she was seen by one Dr Teng Shi Chong. Ms Pai described her symptoms to him and gave details of her two prior consultations with Dr Yeo. She also showed Dr Teng the medication prescribed by Dr Yeo. Dr Teng noted that Ms Pai complained of fever and running nose. He found that her temperature was 37 degrees, her heart and lungs were clear and her general condition was well. Dr Teng prescribed medication, but no antibiotics were prescribed.

4. Over the next three days, Ms Pai took the medicine prescribed by Dr Teng. However, she felt the fever subsiding and returning at intervals. By the morning of 23 December 1996, she had completed the course of medicine, but she still felt feverish. She decided to return to consult Dr Yeo, as he was her regular physician. Although she arrived at the clinic at 11 am, she managed to see him only sometime past 2 pm. She complained of fever with chills, giddiness and pain over the right kneecap and for the first time complained that she had a blurring of vision and saw spots in her left eye. Dr Yeo carried out a physical examination on her. He found her not feverish, her right knee joint was not swollen and her throat was not inflamed. He also examined Ms Pais eyes and found that both pupils were equal and reactive to light and both her left and right eye corneas were clear. He then carried out a urine examination and found out that there were leucocytes (white blood cells) and blood present in the urine. There was no protein or sugar in the urine. At the end of the consultation the doctor suspected that Ms Pai had:

(a) a detached retina, and

(b) a urinary tract infection that required treatment and follow-up urine tests.

He then prescribed medication for Ms Pai, including an antibiotic called Apo-Sulphatrim and advised what she should do. As to what Dr Yeo actually advised Ms Pai to do is an issue of fact which is in serious dispute before us as well as before the trial judge. We shall refer to this material aspect of the case in detail shortly. For the moment, it is sufficient to say that the judge found that Dr Yeo did not advise Ms Pai to go immediately to see an eye specialist at the Singapore General Hospital (SGH) or Singapore National Eye Centre (SNEC), or to see an eye specialist in private practice. The judge found that he only advised her to go to SGH or SNEC, should the condition of her eye deteriorate.

5. After Ms Pai left Dr Yeos clinic, she returned home and rested. She did not go anywhere for treatment of her eye. Nor did she go to the SGH or SNEC. On the following morning, she found that her eye condition had deteriorated, and her vision had become blurred. However, she decided to wait at home for the assistance of her friend before going to the Accident & Emergency (A&E) Unit, and only arrived there at 3.20 pm. She was then seen by doctors at SGH, and was later transferred to the SNEC where she underwent a vitrectomy on her left eye on 26 December 1996. Ms Pai was found to have a liver and blood infection from the very rare but virulent bacteria called Klebsiella. Her eye infection worsened after showing some initial improvements, and she eventually lost the vision of her left eye in January 1997.

6. Some three years later, Ms Pai brought an action against Dr Yeo claiming damages for negligence and/or breach of duty on the two occasions when she consulted him, namely on 19 December 1996 and 23 December 1996. With regard to the first occasion, she claimed that, having regard to her medical history and in the context of her consultation, Dr Yeo should have carried out a urine test for urinary tract infection (which he did not), and that if he had done so, he would have found out that she had an infection and would have prescribed the appropriate antibiotics for it, which would then have prevented her from having the eye infection. In respect of this claim, the trial judge, having considered the medical evidence before him, found that as of 19 December 1996 there was nothing to indicate to Dr Yeo that Ms Pai was prone to urinary tract infection and therefore Dr Yeo was not negligent and/or in breach of duty in failing to carry out a urine test for urinary tract infection. Turning to the consultation on the second occasion on 23 December 1996, the judge found that Dr Yeo, although suspecting that Ms Pai had a detached retina, nevertheless did not advise her to go immediately to the hospital to see an eye specialist or to see an eye specialist in private practice, and that in not doing so, Dr Yeo had fallen short of the standard of care required of him as a general practitioner.

7. The judge next turned to the question of causation, i.e. whether Ms Pais eye would have been saved had Dr Yeo advised her to go immediately to the A & E Unit at the SGH, SNEC or to an eye specialist in private practice. He found that Ms Pai would have gone to the A & E Unit immediately, if she had been so instructed by Dr Yeo. She was an educated person who would have understood the health risk involved, and she was indeed concerned about her health, given that she had seen two doctors on four occasions during the seven days she was suffering from fever. Next, he found that had Ms Pai reported to the A&E Unit on the evening of 23 December 1996, as opposed to the afternoon of 24 December 1996, her eye would probably have been saved.

The appeal

8. Before us, Mr Quek Mong Hua, counsel for Dr Yeo, raises mainly three contentions. First, he submits that the trial judge erred in finding that Dr Yeo fell short of the standard of care required of him as a general practitioner in failing to advise Ms Pai to seek urgent attention to her eye at the A & E Unit at the SGH or at the SNEC or from an eye specialist in a private clinic on the basis of his preliminary diagnosis of a suspected detached retina. Secondly, he submits that, assuming that Dr Yeo was in such breach of duty, his breach was not the cause of Ms Pais loss of vision in her left eye. Thirdly, he submits that, again assuming that Dr Yeo was in breach, the loss sustained by Ms Pai was not foreseeable as a direct consequence of such breach of duty.

Breach of duty of care

9. Counsels first argument is directed at the finding of fact made by the trial judge. In the court below, Ms Pai and Dr Yeo each gave a different version of the material events that took place on 23 December 1996 at Dr Yeos clinic. Ms Pai in her affidavit evidence-in-chief said, inter alia, the following:

9. The Defendant examined me as he had done previously, but this time, he also conducted a urine test on me. After testing the sample I provided, he told me that there was blood in my urine. He mumbled something like he would not give me anything for my eye, and that he did not know what to do about it. The Defendant then mentioned various options that might be open for me to consider:-

(a) treatment at the Singapore National Eye Centre ("SNEC");

(b) consultation with, and treatment by, an eye specialist; or

(c) treatment at the Accident & Emergency Unit of a hospital.

10. The Defendant did not inform me that there was any infection in my body. Neither did he tell me that I needed treatment through any of the above options immediately i.e. without further delay. Neither did the Defendant inform me that my condition was serious or that I required immediate medical treatment above and beyond the medical treatment that he could provide in his own skill and expertise, at his clinic.

11. Instead, the Defendant simply prescribed me some medication and wrote a note for me to undergo a blood test at a polyclinic after Christmas, i.e. 25 December 1996.

10. On the other hand, Dr Yeo said he told her that she required to see an eye specialist urgently. The material part of his affidavit evidence-in-chief was as follows:

10. I informed her that she required an urgent referral to see an Eye Specialist and that she had to go to the Accident and Emergency ("A&E") Unit of Singapore General Hospital ("SGH") where there is an eye specialist on duty after the SNEC closes.

11. At the end...