Case Summaries

Wong Meng Hang v Singapore Medical Council and other matters [2018] SGHC 253

SUPREME COURT OF SINGAPORE

23 November 2018

Case Summary

Wong Meng Hang v Singapore Medical Council and other matters [2018] SGHC 253
Court of Three Judges Originating Summonses Nos 1, 2 and 3 of 2018

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Decision of the Court of Three Judges (delivered by Chief Justice Sundaresh Menon)

C3J allows SMC’s appeals against sentences imposed on two aesthetic doctors who negligently caused a patient’s death; strikes lead doctor off the register and suspends assisting doctor for 18 months

Pertinent and significant points of the judgment

  • In the context of disciplinary proceedings, broader public interest considerations are paramount. These considerations include the need to uphold the standing and reputation of the profession, to prevent an erosion of public confidence in the trustworthiness and competence of its members, and to protect the public. Other sentencing considerations such as the offender’s personal mitigating circumstances may be outweighed or even rendered substantially irrelevant by countervailing public interest concerns: at [23], [24], [26] and [75(a)].

  • The Court set out the appropriate sentencing approach for cases where the misconduct of a medical practitioner has caused harm to the patient, and laid down a sentencing matrix based on the two principal parameters of harm and culpability: at [29], [30], [33], [43] and [75(c)].

  • The sentencing court or tribunal should not hesitate to strike off an errant doctor where the misconduct was so serious that it renders the doctor unfit to remain as a member of the profession: at [75(d)].

  • In cases where the element of dishonesty reveals a character defect rendering the errant doctor unsuitable for the profession, such as where the dishonesty is integral to the commission of a criminal offence of which the doctor has been convicted, or where it violates the relationship of trust and confidence between doctor and patient, striking off will be the presumptive penalty, absent exceptional circumstances. In other cases of dishonesty, all the relevant facts and circumstances should be carefully considered to determine whether striking off is nonetheless warranted: at [75(e)] and [75(f)].

 

Background

1          These appeals concerned two doctors, Dr Wong Meng Hang (*Dr Wong”) and Dr Zhu Xiu Chun @ Myint Myint Kyi (“Dr Zhu”), who each pleaded guilty to a charge of professional misconduct under s 53(1)(d) of the Medical Registration Act (Cap 174, 2014 Rev Ed). Originating Summons No 1 of 2018 was an appeal by Dr Wong against his sentence. Originating Summonses Nos 2 and 3 of 2018 were appeals by the Singapore Medical Council (“the SMC”) against the sentences imposed on Dr Wong and Dr Zhu respectively.

The material facts

2          Dr Wong and Dr Zhu were registered medical practitioners practising at an aesthetic clinic. On 30 December 2009, Dr Wong was scheduled to perform a liposuction procedure on a patient. Shortly before the procedure, Dr Wong asked Dr Zhu to assist in the procedure and to monitor the patient.

3          Dr Wong decided to administer Propofol, an anaesthetic drug and potent sedative that could rapidly depress the patient’s airway, impede respiration and cause blood pressure to fall. The instruction sheet provided by the manufacturers stated that it should only be administered by physicians trained in anaesthaesia or in the management of patients under intensive care. Dr Wong and Dr Zhu proceeded to administer Propofol to the patient even though they were not anaesthetists or intensivists and lacked the necessary training and experience to do so. To compound matters, they did so using a complex technique of continuous intravenous infusion by titration, which could only be provided by a well-trained and experienced sedationist, which neither of them was. The dosage of Propofol administered was excessive and caused the patient to enter a state of deep sedation to the point of general anaesthesia, a state of unconsciousness.

4          During the course of the liposuction procedure, Dr Wong also inadvertently caused multiple puncture wounds to the patient’s intestines which went unnoticed because the patient was in a state of general anaesthesia and did not manifest any signs of pain.

5          At the end of the procedure, Dr Zhu left the procedure room and Dr Wong left to use the toilet shortly afterwards. The patient was left unattended by any doctor or nurse for at least five minutes even though it was essential that his circulation and respiration be closely monitored. During this period, he developed an airway obstruction and suffered asphyxia leading to cardiac arrest. He was then discovered to have collapsed and was sent to the hospital.

6          Dr Wong told the accident and emergency (“A&E”) doctors that the patient had only been given pain medication and local anaesthesia without sedation. This was a false statement which evidenced Dr Wong’s knowledge that it had been improper for him to have administered Propofol.

7          The patient, aged 44, passed away that day. 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”. These findings were referred to the SMC in February 2012. Dr Wong and Dr Zhu were sent notices of complaint in November 2013 and served formal notices of inquiry in February 2017.

8          Each doctor pleaded guilty to a charge of professional misconduct under s 53(1)(d) of the Medical Registration Act in that their conduct amounted to such serious negligence that it objectively portrayed an abuse of the privileges which accompanies registration as a medical practitioner. The Disciplinary Tribunal (“the DT”) sentenced Dr Wong to 18 months’ suspension from practice, and Dr Zhu to six months’ suspension from practice. Dr Wong appealed against his sentence, and the SMC appealed against both doctors’ sentences.

The court’s decision

9          In the disciplinary context, broader public interest considerations are paramount. These considerations include the need to uphold the standing and reputation of the profession, to prevent an erosion of public confidence in the trustworthiness and competence of its members, and to protect the public who are dependent on doctors for medical care. The courts will also have regard to key sentencing principles such as general and specific deterrence. Finally, considerations of fairness to the offender may, in appropriate cases, warrant the imposition of a lighter sentence, but may also be outweighed or even rendered substantially irrelevant by countervailing concerns in the public interest: at [23] to [26] and [75(a)].

10        The Court set out the appropriate sentencing approach for cases where the misconduct of a medical practitioner has caused harm to the patient. The first step is for the sentencing court or tribunal to evaluate the seriousness of the offence, having regard to the two principal parameters of harm and culpability. Having assessed the levels of harm and culpability based on the facts, the second step is to identify the applicable indicative sentencing range according to the sentencing matrix laid down by the Court. The Court noted that the sentences in many of the cited precedents were too lenient, and at least some of these precedents would have been decided differently under the sentencing matrix. The third step is to identify the appropriate starting point within the applicable range, again having regard to harm and culpability. The fourth step is to consider the offender-specific aggravating and mitigating factors. Throughout the analysis, regard should be had to the sentencing objectives and public interest considerations: at [29], [30], [33], [38], [43], [44] and [75(c)].

11        The Court identified a number of considerations to guide the sentencing analysis when striking off is contemplated as a possible sanction. The ultimate question is whether the misconduct was so serious that it renders the doctor unfit to remain as a member of the medical profession. Striking off should be considered when: (a) the misconduct involves a flagrant abuse of the privileges accompanying registration as a medical practitioner; (b) the misconduct has caused grave harm; (c) the doctor’s level of culpability for the harm is especially high, such as where he has acted deliberately and improperly over an extended period of time and in disregard of his professional duties and/or the wellbeing of others; (d) the misconduct evinces a serious defect of character; (e) the facts of the case disclose an essential element of dishonesty; and (f) any of the foregoing factors exist, and the doctor has shown a persistent lack of insight into the seriousness and consequences of his misconduct: at [45], [65] and [67].

12        The Court considered that there is a need for greater consistency in the approaches taken in relation to dishonesty in the medical and legal professions. As a general rule, in cases where the element of dishonesty reveals a character defect rendering the errant doctor unsuitable for the profession, such as where the dishonesty is integral to the commission of a criminal offence of which the doctor has been convicted, or where it violates the relationship of trust and confidence between doctor and patient, striking off will be the presumptive penalty, absent exceptional circumstances. In other cases of dishonesty, all the relevant facts and circumstances should be carefully considered to determine whether striking off is nonetheless warranted: at [70] to [74] and [75(f)].

13        The Court was satisfied that the appropriate order was to strike Dr Wong off the register. Dr Wong’s case involved the most severe harm imaginable as his actions were the sole and direct cause of the patient’s death. His misconduct was also of a high degree of culpability in that his treatment of the patient was grossly unsatisfactory and strikingly deficient in every way: he had recklessly decided to embark on a risky sedation procedure despite being untrained; administered the sedative improperly by giving an excessive dosage; wounded the patient by performing the liposuction improperly; left the patient unattended post-procedure as a result of which the patient asphyxiated and died; and lied to the A&E doctors. The applicable indicative sentencing range was three years’ suspension or an order of striking off, but only the latter was sufficient because of the seriousness of his misconduct. Bearing in mind the compelling public interest in imposing the harshest punishment on Dr Wong, his personal mitigating circumstances such as his early plea of guilt and the SMC’s inordinate delay in the proceedings ultimately carried no weight in the sentencing analysis: at [82], [84], [92], [95], [98], [99] and [104].

14        The Court increased Dr Zhu’s sentence to eighteen months’ suspension from practice. Her misconduct had caused severe harm and her degree of culpability fell in the “medium” category. Her misconduct was serious but not as grave as Dr Wong’s in that she: (a) was only tasked to assist in the procedure and acted under Dr Wong’s direction; (b) was not responsible for the intestinal wounds inflicted on the patient; (c) left the procedure room with Dr Wong’s permission while Dr Wong was still present; and (d) did not act dishonestly. For the same reasons as Dr Wong, her personal mitigating circumstances were overridden by the public interest in upholding public confidence in the medical profession and the need to deter other junior doctors faced with the wholly improper actions of their seniors: at [108] to [112].

15        The Court further directed that this case be reported to the Public Prosecutor so that the doctors involved may be investigated for any relevant criminal offences that may have been committed including that of causing death by rash or negligent act under s 304A of the Penal Code (Cap 224, 2008 Rev Ed): at [114].

 

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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