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Changi General Hospital’s negligence caused delay in lung cancer patient’s diagnosis: Apex court

SINGAPORE — If not for the negligence of Changi General Hospital (CGH), a patient with lung cancer would have been diagnosed and received treatment earlier, the Court of Appeal ruled on Tuesday (Feb 26), disagreeing with an earlier decision by a High Court judge.

Changi General Hospital’s negligence caused delay in lung cancer patient’s diagnosis: Apex court

Ms Noor Azlin sued Changi General Hospital and three doctors who attended to her over a four-year-period from 2007 to 2011, arguing that their negligence caused a delay in the detection of her cancer.

SINGAPORE — If not for the negligence of Changi General Hospital (CGH), a patient with lung cancer would have been diagnosed and received treatment earlier, the Court of Appeal ruled on Tuesday (Feb 26), disagreeing with an earlier decision by a High Court judge.

The issue of damages that the hospital should pay Ms Noor Azlin Abdul Rahman, 39, will now be sent back to the High Court to be assessed by Justice Belinda Ang.

Delivering the Court of Appeal’s ruling, Judge of Appeal Andrew Phang noted that Ms Noor Azlin’s cancer is now at the fourth stage and encouraged CGH to consider an amicable settlement with her.

“(Ms Noor Azlin) will continue to face physical and emotional challenges as a result of her medical condition and we think that an amicable settlement will assist (her) in achieving some sense of closure and allow her to focus on battling her cancer and recovering as best as she can,” said Mr Phang, who ruled together with Chief Justice Sundaresh Menon and Judge of Appeal Judith Prakash.

“In our view, given our finding that CGH was negligent and delayed diagnosing (her) with lung cancer, it would be appropriate for CGH to consider the possibility of a settlement in the interests of expediency and resolution.”

‘SERIOUS INADEQUACIES’ IN SYSTEM

Ms Noor Azlin was diagnosed with lung cancer in February 2012.

She sued CGH and three doctors who attended to her over a four-year period from 2007 to 2011, arguing that their negligence caused a delay in the detection of her cancer and caused her to suffer the loss of a better medical outcome. Her claim was dismissed by the High Court in February last year, but she appealed.

The highest court of the land ruled on Tuesday that she likely suffered from first-stage lung cancer in July 2011 — when she visited CGH’s emergency department for a third time — and should have been diagnosed and given the appropriate treatment then or shortly after.

The delay in diagnosis allowed the aggressive lung cancer to progress to stage 2A, involving a lymph node, Mr Phang said.

The Court of Appeal found the three doctors not liable in negligence.

There were serious inadequacies in CGH’s system to ensure proper follow-up of patients, the judges said.

CGH’s system routes radiological reports on incidental findings ordered by the emergency department back to the department for review. But this “makes little sense” as the department operates under severe time pressure and is focused on acute episodes, the judges said.

The radiological reports of Ms Noor Azlin should have been seen and assessed by a respiratory physician instead of an emergency doctor.

CGH’s system of reviewing radiological reports did not allow for comprehensive management of a patient, Mr Phang added.

Each time Ms Noor Azlin went to the emergency department and had a radiological report on her nodule prepared, “it was seemingly treated as an isolated incident”, the judge said. “There was no evidence of any consolidation of what was already known about her.”

The hospital’s emergency doctors also did not have complete information about a patient’s visit to other departments in the hospital.

CGH also did not have a system in place to properly record decisions made, when two emergency doctors reviewing radiological reports both decide against a radiologist’s recommendation to follow-up, the apex court said. Such a process lacks accountability, as patients would not know the decision that was made, and any doctor further down the line would have no reference on why such a decision was made.

“Looked at in its totality, the patient management system that CGH had in place resulted, in the context of this present case, in a patient with a persistent nodule in her lung having been seen by only one respiratory specialist over a period of four years,” it said.

“The sole respiratory specialist had erroneously concluded that the opacity as seen on the chest X-ray was resolving or had resolved. Yet, the system did not alert any of the six doctors… who saw the chest X-rays thereafter and who were involved in her case, to this mistake.”

CGH therefore breached its duty to Ms Noor Azlin, the Court of Appeal said.

FACTS OF THE CASE

Ms Noor Azlin began visiting CGH from 2007 for various medical conditions.

Oct 31, 2007: She visited CGH’s emergency department for lower chest pain and shortness of breath. An X-ray showed an opacity in the right mid-zone of her chest. A doctor referred her to the hospital’s Respiratory Medicine Specialist Outpatient Clinic to review the opacity, which was an incidental finding unrelated to symptoms she had.

November 2007: Ms Noor Azlin saw respiratory physician Imran Mohamed Noor at the Specialist Outpatient Clinic and had a repeat X-ray done. Dr Imran assessed that the opacity “appeared to be resolving or had resolved on its own”. He gave her an open date for follow-up and advised her to return if she felt unwell.

April 29, 2010: Ms Noor Azlin went to CGH’s emergency department complaining of right-lower chest pain. A locum medical officer, Dr Yap Hsiang, ordered an electrocardiogram and X-ray. The X-ray showed an opacity. He compared it with the 2007 X-rays and observed the opacity to be stable in size, and unrelated to her presenting symptoms.

July 31, 2011: Ms Noor Azlin went to the emergency department for intermittent left-lower ribcage pain. A medical officer, Dr Jason Soh Wei Wen, ordered two chest X-rays. A report from the X-rays was prepared but Dr Soh did not receive the report. He was unaware that the radiologist had detected the opacity in the right mid-zone of her lung, noted that it was stable and recommended a follow-up on the opacity.

November and December 2011: Ms Noor Azlin went to Raffles Medical Clinic and a doctor referred her to a respiratory physician at CGH for further evaluation.

Dec 15, 2011: Ms Noor Azlin had chest X-rays and a computed tomography scan. The CT scan revealed a nodule that appeared to be benign, but the radiologist recommended a biopsy.

Feb 16, 2012: A biopsy of the nodule confirmed it was malignant and that Ms Noor Azlin had lung cancer.

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