Case Summaries

Singapore Medical Council v Looi Kok Poh and another matter [2019] SGHC 134

SUPREME COURT OF SINGAPORE

27 May 2019

Case summary

Singapore Medical Council v Looi Kok Poh and another matter [2019] SGHC 134                   

Originating Summonses Nos 11 and 12 of 2018

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Decision of the High Court (delivered by Judith Prakash JA):

High Court sets aside doctor’s conviction on charges of failing to ensure that adequate medical leave was given to patient.

Background

1          The cross-appeals before the court related to disciplinary proceedings taken by the Singapore Medical Council (“the SMC”) against one Dr Looi Kok Poh. The Disciplinary Tribunal (“the Tribunal”) found Dr Looi guilty on two charges of professional misconduct in that he had failed to ensure that adequate medical leave was given to his patient (“the Patient”). The Tribunal suspended Dr Looi from practice for six months. Dr Looi appealed against his conviction and sentence, while the SMC appealed against the sentence: at [1].

2          The Patient was at the material time employed by Tellus Oceanic Pro Pte Ltd (“Tellus”) as a welder at a shipyard. On 7 August 2011, the Patient sustained an injury to the fingertip of his right middle finger, resulting in loss of soft tissue and a comminuted fracture. The Patient was taken to a medical centre run by West Point Hospital Pte Ltd (“the Hospital”) and seen by Dr Looi that day. Dr Looi performed the first stage of a two-stage surgery on the Patient’s finger. The first stage of the surgery involved attaching the Patient’s injured finger to a skin flap from the base of his thumb, so as to allow the blood vessels in the palm to sustain the tissue of the finger as it healed (“the First Stage surgery”). The second stage of the surgery would then involve detaching the healed finger from the flap (“the Second Stage surgery”): at [3] and [4].

3          After the surgery, the Patient was hospitalised for one night. Dr Looi left notes for the Hospital staff to discharge the Patient the next day with one day of medical leave and seven days of light duties. The Patient was visited the next day by Mr Jimmy Chia (“Mr Chia”), a safety officer with Tellus, who asked for the Patient to be discharged. The Patient was then discharged by Dr Stephen Tan, who issued a medical certificate granting two days of medical leave and no light duties. The Patient was held back to see Dr Looi that afternoon, and no certification for medical leave or light duties was given at that review: at [5] and [6].

4           At the Patient’s next review on 12 August 2011, Dr Looi certified the Patient fit for light duties until the subsequent review on 22 August 2011. On 20 August 2011, the Patient visited Singapore General Hospital (“SGH”) complaining of pain over the stitched area, and was tended to by Dr Tan Chong Hun. Dr Tan Chong Hun noted that the Patient’s wound was clean, and gave the Patient medical leave until 22 August 2011. At the review on 22 August 2011, Dr Looi recorded that the flap was good. On 7 September 2011, the Patient returned to SGH and was seen by Dr Sreedharan Sechachalam, who recorded that the flap was viable. Two days later, Dr Sreedharan performed the Second Stage surgery. The Patient was hospitalised until 14 October 2011, and has since returned to India: at [7][12].

5          The SMC received the complaint forming the subject of these proceedings on 3 October 2011. Eventually, two charges (“the Charges”), and two charges in the alternative (“the Alternative Charges”), for professional misconduct were brought against Dr Looi. The Charges and the Alternative Charges related to Dr Looi’s reviews with the Patient on 8 August 2011 and 12 August 2011. It was alleged that, on each occasion, Dr Looi failed to ensure that adequate medical leave was given to the Patient: at [13] and [14].

Decision on appeal

6         The court decided two preliminary points as follows:

(a)          First, the court found that Dr Looi had performed an axial pattern thenar flap procedure on the Patient, as opposed to a random pattern thenar flap procedure. The difference between the two was that the random pattern thenar flap procedure was less robust, and resulted in greater immobilisation of the thumb, as compared to the axial pattern thenar flap procedure. As there was evidence that the axial pattern thenar flap procedure was by far the preferred procedure in Singapore, the court accepted that Dr Looi would have performed that procedure, even if he had not specifically recorded this detail in his notes: at [34][40].

(b)          Second, the court held that Dr Looi was to be assessed on the basis of his intended post-operative management plan for the Patient, rather than what was in fact provided by Dr Stephen Tan. In other words, it was to be taken that Dr Looi had prescribed one day of medical leave and seven days of light duties to the Patient. To hold otherwise would be to hold Dr Looi accountable for Dr Stephen Tan’s conduct in not following the post-operative treatment instructions that Dr Looi had given: at [41][44].

7          Having considered the evidence, the court set aside Dr Looi’s conviction on the First Charge as the SMC failed to establish that Dr Looi had departed from the applicable standard of conduct. In particular, the court found as follows:

(a)          Certifying the Patient fit for light duties was a medically appropriate course of action, and the applicable standard of conduct therefore permitted Dr Looi to give either medical leave or light duties. The evidence by the SMC’s expert, Dr Vaikunthan Rajaratnam, properly understood, was that light duties could be appropriate in the right circumstances. This was consistent with the evidence given by Dr Looi, and his witnesses, Dr Tan Soo Heong and Ms Vicki Pang, an occupational therapist. In determining whether there were the “right circumstances” that would have allowed light duties to be medically appropriate, the relevant inquiry was what circumstances the doctor was aware of regarding the Patient at the time he made the decision. Dr Looi’s evidence was that he was aware of the general working conditions as well as the systems that a typical shipyard would have in place for workers sent back for light duties. He was also aware that Tellus had systems in place to ensure that patients assigned light duties would be given simple duties, such as tasks in the office or in the guardhouse, that would not jeopardise their injuries. These constituted the “right circumstances” in which light duties could be medically appropriate: at [67], [72], [75] and [78].

(b)          As the parties advanced their cases below and on appeal that part of the applicable standard of conduct was that Dr Looi had to first ascertain whether there were adequate conditions for a patient’s rest and rehabilitation before certifying a patient fit for light duties, the court proceeded on the basis that this was part of the applicable standard of conduct: at [79].

(c)          Dr Looi had not departed from the applicable standard. In particular, he had certified the Patient fit for light duties, because he had knowledge of the light duties available in Tellus which would promote the Patient’s rest and rehabilitation and had also made efforts to establish the availability of light duties for the Patient. Dr Looi had spoken to someone who accompanied the Patient to the Hospital on 7 August 2011 and did not simply assume that previous arrangements would be made available for the Patient: at [81] and [88].

(d)          The Patient had also in fact carried out light duties when he returned to his workplace at Tellus. There was no reason not to accept the evidence that the Patient had been on light duties which involved classroom-based safety training as part of a rehabilitation programme: at [89]

8          The court also set aside Dr Looi’s conviction on the Second Charge for the following reasons:

(a)          In the absence of evidence to the contrary, the starting point was that the applicable standard of conduct was the same as that which applied to the First Charge, ie, light duties were medically appropriate. The evidence in fact suggested that the Patient’s position had improved between 8 August 2011 and 12 August 2011. This supported Dr Looi’s case that light duties were still appropriate as of 12 August 2011: at [96] and [97].

(b)          Dr Looi had not departed from the applicable standard. In particular, he had certified the Patient fit for light duties, having first ascertained that there were adequate conditions for the Patient’s rest and rehabilitation. Similar to the First Charge, the evidence showed that Dr Looi had also discussed the availability of light duties at Tellus with the patient and the accompanying safety officer, Mr Chia, at the review on 12 August 2011: at [102] and [103].

9          On the Alternative Charges, the court disagreed with the view expressed by the Tribunal that it would have been justified in convicting Dr Looi on the Alternative Charges. In particular, given the court’s findings, it could not be said that Dr Looi had failed to consider the Patient’s pain levels, or the existence and nature of light duty arrangements when he ordered the same. Consequently, there was no basis to find that Dr Looi had been seriously negligent: at [108].

10          The court therefore allowed Dr Looi’s appeal on conviction, and set aside his convictions on, and all orders made by the Tribunal on, the Charges. As the question of sentence did not arise, the SMC’s appeal against sentence was dismissed: at [112].

 

This summary is provided to assist in the understanding of the Court’s judgment. It is not intended to be a substitute for the reasons of the Court. All numbers in bold font and square brackets refer to the corresponding paragraph numbers in the Court’s judgment.

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