• Madam Shirley Seah’s TCM physician had instructed her not to consume both western and TCM medicines at the same time
• He also told her to maintain a four-hour interval between her western medicine and TCM herbs
• But Mdm Seah might have been confused with the instructions, the state coroner found
• This might have led her to administer the medicines incorrectly or inadvertently overdosing, she said

SINGAPORE — A 51-year-old former cancer patient who took Traditional Chinese Medicine (TCM) herbs while receiving western medical intervention likely died of drug-induced liver injury because she might have been confused about when to consume the TCM prescriptions, a coroner’s court has found.

Madam Shirley Seah, who underwent chemotherapy and radiotherapy for a brain tumor between August 2018 and March 2019, died in August 2019 soon after doctors found she had symptoms suggestive of early impending acute liver failure.

She was diagnosed with cancer in June 2018 and soon after consulted a TCM physician to complement the chemo and radiation therapy. 

The TCM physician, Mr Ong Liang Seng, had instructed her not to consume both western and TCM medicine at the same time. 

He had also told her that each packet of herbs was to be consumed only once a day, and about 12 hours apart.

In particular, Mr Ong, who retired in 2019, instructed her to maintain a four-hour interval between consuming her western medicine and TCM herbs.

But Mdm Seah might have been confused with the instructions on when to take her TCM medication, resulting in the possible wrong administration of herbs or inadvertent overdosing, State Coroner Kamala Ponnampalam said.

She assessed that this could be the case as there were conflicting details of the regime Mdm Seah had followed in the accounts of the TCM physician and Mdm Seah’s aunt, who was caring for her.

The aunt, Mdm Annie Lim Sai Luang, thought that the TCM physician had advised Mdm Seah to stop her TCM prescription one week prior to her scheduled radiotherapy and chemotherapy sessions.

“If there was some confusion about the dosage during the cancer treatment, it raises the possibility that the confusion persisted even after her therapy at the National Cancer Centre Singapore (NCCS), resulting in possible wrong administration of the herbs or inadvertent overdosing,” Ms Ponnampalam wrote in her findings, which were released on Monday (May 31).

Calling Mdm Seah’s demise an “unfortunate medical misadventure”, she stressed the importance for medical practitioners, even those in TCM practice, to clearly explain to patients the dosage and use of drugs and medications dispensed. 

She noted it is common for cancer patients to seek TCM and western treatment at the same time, and suggested that hospitals consider implementing a protocol compelling patients to disclose if they are seeking alternative treatments.

This is so that patients can be properly advised to avoid unfortunate outcomes such as in Mdm Seah’s case, she said.

HOW HER CONDITION DETERIORATED

Mdm Seah discovered that she had cancer after she went for an emergency operation on June 15, 2018 to remove a tumour in her brain.

She then started a course of combined chemo and radiation therapy, followed by six cycles of chemotherapy at NCCS, at the Singapore General Hospital campus.

When the treatment was completed in March 2019, a magnetic resonance imaging of her brain indicated that she had recovered from the brain tumour.

But a few months later on July 10, she was admitted to Khoo Teck Puat Hospital for jaundice, nausea, vomiting and abdominal discomfort. 

That was when doctors found that her liver function had already become “severely deranged”, with symptoms suggestive of early impending acute liver failure. 

After Mdm Seah declared that she had consumed TCM medicine for four months before the flare-up, doctors got her started on an antidote targeted to treat drug-induced liver injury from TCM medication. 

Mdm Seah later died at National University Hospital on Aug 2 in 2019 after doctors there found her to be an unsuitable candidate for a liver transplant in view of her brain tumour history.

Dr Paul Chui, the forensic pathologist who performed Mdm Seah’s autopsy, said it is not possible to establish the link definitively if TCM had caused her death, although circumstantial and clinical suspicion pointed to that.

TCM DOSAGE ‘APPROPRIATE’

The court heard that Mdm Seah started consulting Mr Ong on July 14, 2018 – two days after her discharge from the hospital from the emergency tumour excision procedure.

In total, she went for 18 follow-up consultations at the clinic, her last trip being on June 25, 2019, not long before she was admitted to the hospital with a failing liver. 

She had continued with the TCM prescriptions even after NCCS stopped prescribing her medication following her final cycle of cancer treatment, which ended on March 19 in 2019.

Between then and June 25, 2019, she was dispensed TCM herbs six more times – thrice without consultation with the physician as she had collected the herbs when accompanying her mother to the clinic – the court heard.

According to Mr Ong, the herbs prescribed were “very mild”, and Mdm Seah did not appear to have developed any side effects from taking them. 

He added that Mdm Seah had told him that she had complied with his instructions to take the TCM herbs and western medicine four hours apart.

During the course of the coroner's inquiry, Mr Sng Kia Hock, the second vice president of the Academy of Chinese Medicine, reviewed the TCM herbs Mr Ong had prescribed and found them to be those routinely used in clinical TCM practices in Singapore.

He said the prescription and dosage were appropriate, and were therefore unlikely to have affected the liver function. Mr Sng further commented that there should not be any problems as long as the gap between the intake of Chinese and western medicine is several hours. 

While making her findings that confusion could have been at play, Ms Ponnampalam reiterated that it remained unclear how the TCM herbs had caused Mdm Seah’s liver failure and ruled that the prescription dosage was appropriate.