D’Conceicao v Tong: Medical Negligence, Redo CABG, Duty of Care

D’Conceicao Jeanie Doris, administratrix of the estate of Milakov Steven, sued Dr. Tong Ming Chuan in the High Court of Singapore on 22 August 2011, alleging medical negligence and breach of contract related to a redo coronary artery bypass graft surgery performed on the deceased. The plaintiff claimed Dr. Tong was negligent in recommending and performing the surgery, and in advising the patient about the risks and alternatives. The court dismissed the plaintiff's action, finding that Dr. Tong did not breach his duty of care in recommending, advising on, or performing the surgery.

1. Case Overview

1.1 Court

High Court

1.2 Outcome

Plaintiff's action dismissed; judgment for Defendant.

1.3 Case Type

Civil

1.4 Judgment Type

Grounds of Decision

1.5 Jurisdiction

Singapore

1.6 Description

Medical negligence claim against Dr. Tong for alleged negligence/breach of contract in redo CABG surgery. Judgment for the defendant; claim dismissed.

1.7 Decision Date

21 August 2011

2. Parties and Outcomes

Party Name	Role	Type	Outcome	Outcome Type	Counsels
D'Conceicao Jeanie Doris (administratrix of the estate of Milakov Steven, deceased)	Plaintiff	Individual	Claim Dismissed	Lost	Palaniappan S of Straits Law Practice
Tong Ming Chuan	Defendant	Individual	Judgment for Defendant	Won	Tham Hsu Hsien of Allen & Gledhill Mak Wei Munn of Allen & Gledhill Edwin Tong of Allen & Gledhill

3. Judges

Judge Name	Title	Delivered Judgment
Tay Yong Kwang	Judge	Yes

4. Counsels

Counsel Name	Organization
Palaniappan S	Straits Law Practice
Tham Hsu Hsien	Allen & Gledhill
Mak Wei Munn	Allen & Gledhill
Edwin Tong	Allen & Gledhill

4. Facts

Milakov Steven (MS) underwent a redo coronary artery bypass graft surgery (redo-CABG) performed by Dr. Tong Ming Chuan.
MS passed away six weeks after the redo-CABG due to post-operative complications.
MS had a history of borderline diabetes and hypertension.
MS suffered a first major adverse cardiac event (MACE) on 17 January 2007 in Houston, USA.
MS underwent a triple CABG on 19 January 2007 in Houston.
MS suffered an acute myocardial infarction (AMI) on 9 March 2007 in Singapore.
Dr. Christopher Chew recommended that MS obtain a surgical opinion from a cardiothoracic surgeon, and referred him to Dr. Tong.

5. Formal Citations

D’Conceicao Jeanie Doris (administratrix of the estate of Milakov Steven, deceased) v Tong Ming Chuan, Suit No 270 of 2010, [2011] SGHC 193

6. Timeline

Date	Event
1989-01-01	Plaintiff and Milakov Steven married.
2007-01-17	Milakov Steven experienced first major adverse cardiac event in Houston, USA.
2007-01-18	Milakov Steven underwent coronary angiography at St Joseph Medical Center.
2007-01-19	Milakov Steven underwent triple CABG at St Joseph Medical Center.
2007-02-01	Milakov Steven returned to Singapore.
2007-02-23	Milakov Steven consulted Dr. Christopher Chew.
2007-03-09	Milakov Steven experienced chest pain and presented at Mount Elizabeth Hospital; suffered an AMI.
2007-03-09	Dr. Christopher Chew performed a coronary angiography on Milakov Steven.
2007-03-09	Dr. Tong examined Milakov Steven.
2007-03-12	Dr. Tong performed redo coronary artery bypass graft surgery on Milakov Steven.
2007-04-23	Milakov Steven passed away from post-operative complications.
2010-03-22	Letters of Administration of the estate of Milakov Steven were granted to the plaintiff.
2010-04-15	Grant of Letters of Administration extracted.
2010-01-01	Plaintiff brought suit against Dr Tong.
2011-08-22	Judgment reserved.

7. Legal Issues

Breach of Duty of Care
- Outcome: The court found that the defendant did not breach his duty of care in recommending, advising on, or performing the surgery.
- Category: Substantive
- Sub-Issues:
  - Failure to adequately consider proximity in time between initial CABG and redo-CABG
  - Failure to adequately consider patient's improving health
  - Failure to carry out further tests
  - Failure to advise on alternative treatment options
Informed Consent
- Outcome: The court found that the defendant adequately advised the patient regarding the risks and alternatives of the redo-CABG.
- Category: Substantive
- Sub-Issues:
  - Failure to provide sufficient information regarding mortality rate
  - Failure to provide sufficient information regarding morbidity risks
  - Failure to inform of risks associated with redo-CABG shortly after initial CABG and AMI
  - Failure to inform of option to postpone redo-CABG
  - Failure to inform of alternative treatment options
Medical Negligence in Performance of Surgery
- Outcome: The court found that the defendant did not perform the surgery negligently.
- Category: Substantive
- Sub-Issues:
  - Failure to use retrograde cardioplegia
  - Prolonged surgery and cardiopulmonary bypass time
  - Improper harvesting and grafting of RIMA
  - Improper use of Activated Factor VII

8. Remedies Sought

Monetary Damages

9. Cause of Actions

Medical Negligence
Breach of Contract

10. Practice Areas

Medical Malpractice Litigation
Commercial Litigation

11. Industries

Healthcare

12. Cited Cases

Case Name	Court	Affirmed	Citation	Jurisdiction	Significance
Khoo James v Gunapathy d/o Muniandy	Court of Appeal	Yes	[2002] 1 SLR(R) 1024	Singapore	Established the legal framework for medical negligence in Singapore, affirming the Bolam test as supplemented by Bolitho.
Bolam v Friern Hospital Management Committee	NA	Yes	[1957] 1 WLR 582	England	Established the Bolam test for medical negligence, defining the standard of care as that of a responsible body of medical men skilled in that particular art.
Bolitho v City and Hackney Health Authority	House of Lords	Yes	[1998] AC 232	England	Supplemented the Bolam test, clarifying that the court is not bound to find for a defendant doctor simply because a body of experts testified in his favor; the expert opinion must have a logical basis.
Doughty v North Straffordshire HA	NA	Yes	[1992] 3 Med LR 81	England	A patient’s consent to a medical procedure is not a defence in circumstances where no reasonably competent medical opinion would have proceeded at all.
Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital	NA	Yes	[1985] AC 871	England	Addressed the issue of informed consent and the doctor's duty to disclose risks to patients, with differing views on the applicability of the Bolam test to advice.
Pearce v United Bristol Healthcare NHS Trust	NA	Yes	[1999] ECC 167	England	Addressed the doctor's responsibility to inform the patient of significant risks so that the patient can determine for him or herself as to what course he or she should adopt.
Rogers v Whitaker	High Court	No	[1992] 175 CLR 479	Australia	Departed from the Bolam test in respect of the duty to advise, in favor of the approach of the Supreme Court of Canada in Reibl v Hughes.
Rosenberg v Percival	High Court	Yes	[2001] 205 CLR 434	Australia	Affirmed Rogers and reiterated that Australian law had moved away from the Bolam test in respect of the issue of advice.
Foo Fio Na v Dr Soo Fook Mun and Anor	Federal Court	Yes	[2007] 1 MLJ 593	Malaysia	Endorsed the Rogers approach in preference to the Bolam test.
Chester v Afshar	House of Lords	Yes	[2005] 1 AC 134	England	Addressed causation in medical negligence cases, emphasizing human rights and autonomy.
Sharpe v Southend HA	NA	Yes	[1997] 8 Med LR	England	An expert witness should make it clear in his/her report (if it be the case) that although the expert would have adopted a different approach/practice, he/she accepts that the approach/practice adopted by the defendant was in accordance with the approach/practice accepted as proper by a responsible body of practitioners skilled in the relevant field.
Yeo Peng Hock Henry v Pai Lily	Court of Appeal	Yes	[2001] 4 SLR 571	Singapore	Established that to succeed in a medical negligence claim, the plaintiff has to prove, on a balance of probabilities, that the alleged negligent act had caused or materially contributed to the injury.

13. Applicable Rules

Rule Name
No applicable rules

14. Applicable Statutes

Statute Name	Jurisdiction
Civil Law Act (Cap 43, 1999 Rev Ed)	Singapore

15. Key Terms and Keywords

15.1 Key Terms

Redo coronary artery bypass graft surgery
CABG
AMI
Cardioplegia
Coronary artery disease
Stenosis
LIMA-LAD graft
Activated Factor VII
Bolam test
Bolitho test
Duty of care
Informed consent

15.2 Keywords

Medical negligence
Coronary artery bypass graft
CABG
Duty of care
Informed consent
Bolam test
Bolitho test
Singapore
Cardiothoracic surgery

17. Areas of Law

Area Name	Relevance Score
Medical Negligence	95
Medical Malpractice	80
Breach of Duty of Care	70
Health Care	50
Breach of Contract	30
Contract Law	20

16. Subjects

Medical Law
Civil Litigation
Cardiothoracic Surgery