GP fined S$1,500 for negligence after giving medication to patient without pre-prescription tests

SINGAPORE — A retired general practitioner was fined S$1,500 on Thursday (Feb 10) for his negligence in prescribing medication for a construction worker's psoriasis without running pre-prescription tests on the patient first.

Haridass Ramdass, 77, pleaded guilty to a single charge of endangering Savarimuthu Arul Xavier’s personal safety by a negligent act. He was handed the maximum fine.

Savarimuthu died in 2014 aged 28. Haridass was originally charged with causing Savarimuthu’s death by a rash act, but the charge was later reduced by the prosecution.

The medication that Haridass prescribed, methotrexate, is often used in the treatment of cancer and severe psoriasis — a skin disease that causes itchy and scaly patches. Methotrexate can also lead to serious and life-threatening toxic reactions.

Haridass ran Tekka Clinic Surgery on his own in the Little India area at the time, the court heard.

Around Oct 20 in 2014, Savarimuthu developed rashes over his body, face and upper and lower limbs. This prompted him to visit three different doctors to seek treatment.

At Healthway Medical Clinic in Chua Chu Kang, he was prescribed an antiseptic solution, some antihistamines and steroid cream. He went back about two weeks when he noticed his skin rashes had worsened.

He was diagnosed with psoriasis and was prescribed largely the same medication.

He then visited Bless Medical Centre in Boon Lay five days later with skin lesions on his body and limbs, which he said he had been having for months with no improvement.

He was again diagnosed with psoriasis and prescribed medication such as psoriasis oil.

On Nov 24 in 2014, he went to Haridass’ clinic. The doctor noted that he had extensive reddish and round lesions all over his body, including his scalp.

Savarimuthu said that his skin condition had persisted for 20 days, after which Haridass diagnosed him with psoriasis and administered an injection of Dexamethasone, which is an anti-inflammatory steroid.

Haridass also prescribed 10 tablets of methotrexate, 10 tablets of prednisolone — similarly used to treat inflammation — and 10 tablets of chlorpheniramine, an antihistamine.

The court heard that Haridass was negligent in failing to arrange for or ensure that Savarimuthu underwent the relevant pre-prescription tests for renal function, liver function and full blood count.

As a result, Haridass failed to discover the patient’s pre-existing renal impairment and was not conscious of the potentially increased toxic side effects of methotrexate.

Past court documents stated that Savarimuthu later developed neutropenia and mucositis, leading to a fatal invasive fungal infection.

Neutropenia occurs when a person lacks a certain type of white blood cell, which helps to fight infections. Mucositis happens when a person’s mouth or gut becomes sore and inflamed — a common side effect of chemotherapy for cancer.

Deputy Public Prosecutors (DPPs) Timotheus Koh and Grace Chua said that methotrexate use in patients with impaired renal function should be “undertaken with extreme caution” as the impairment will decrease the body’s ability to eliminate the drug.

While the prosecutors noted that deaths have been reported following the use of methotrexate in the treatment of psoriasis, they also agreed with the defence not to make reference on whether Savarimuthu had suffered any adverse effect resulting from its consumption.

'GENUINELY REMORSEFUL'
The prosecution sought the maximum fine, noting that the sentence must adequately deter negligence by medical professionals.

“Doctors are vested with enormous responsibility and influence by their patients who, in entrusting their health and well-being to them, often accept their professional judgements unquestioningly.

“This dynamic is even more pronounced in the case of foreign workers like the patient, who lack the knowledge and language ability to effectively interrogate their doctors’ recommendations,” the prosecution added.

The risk to Savarimuthu was also of significant danger, the DPPs said. Methotrexate toxicity has been reported to cause fatal opportunistic infections, such as by fungi, which can be aggravated in patients with impaired renal function such as Savarimuthu.

In mitigation, Haridass’ lawyer, Senior Counsel Davinder Singh from Davinder Singh Chambers, said that there was no risk of the doctor committing the offence again as he has retired and not renewed his practising certificate.

“Haridass is genuinely remorseful and accepts he was wrong,” Mr Singh added in agreeing for a fine of S$1,500 to be imposed.

District Judge Eddy Tham noted that the doctor had been charged only with endangering Savarimuthu’s personal safety.

“I will assume that none of the grave consequences (mentioned in court) had come to pass… If any significant harm had resulted to the patient, in fact, I would have had no hesitation in imposing a custodial sentence,” he told the court.

Those convicted can be jailed for up to three months or fined up to S$1,500, or punished with both.

CORRECTION: An earlier version of the headline implied that the patient had died because of the medication prescribed to him by the doctor. However, the prosecution and defence had agreed his death was not directly linked to the doctor's prescription. We are sorry for the error.