Noor Azlin v Changi General Hospital: Negligence, Breach of Duty, and Delayed Lung Cancer Diagnosis

Noor Azlin bte Abdul Rahman appealed against the High Court's decision in favor of Changi General Hospital Pte Ltd, Dr. Imran bin Mohamed Noor, Dr. Yap Hsiang, and Dr. Soh Wei Wen Jason, regarding a medical negligence claim. The Court of Appeal found Changi General Hospital negligent for failing to have a proper system for follow-up, leading to a delay in diagnosing Noor Azlin's lung cancer. The court remitted the issue of loss and damage to the Judge for her decision.

1. Case Overview

1.1 Court

Court of Appeal of the Republic of Singapore

1.2 Outcome

Appeal allowed in part against Changi General Hospital; the issue of loss and damage, including the quantum of damages to be awarded (if any), is remitted to the Judge for her decision.

1.3 Case Type

Civil

1.4 Judgment Type

Judgment

1.5 Jurisdiction

Singapore

1.6 Description

Appeal regarding alleged negligence by doctors and Changi General Hospital, leading to delayed lung cancer diagnosis. The court found CGH negligent in its follow-up system.

1.7 Decision Date

2. Parties and Outcomes

Party NameRoleTypeOutcomeOutcome TypeCounsels
Noor Azlin Binte Abdul RahmanAppellant, PlaintiffIndividualAppeal allowed in partPartial
Changi General Hospital Pte LtdRespondent, DefendantCorporationAppeal allowed in partPartial
Imran Bin Mohamed NoorRespondent, DefendantIndividualAppeal dismissedWon
Yap HsiangRespondent, DefendantIndividualAppeal dismissedWon
Soh Wei Wen, JasonRespondent, DefendantIndividualAppeal dismissedWon

3. Judges

Judge NameTitleDelivered Judgment
Sundaresh MenonChief JusticeNo
Andrew Phang Boon LeongJudge of AppealYes
Judith PrakashJudge of AppealNo

4. Counsels

Counsel NameOrganization
Vijay Kumar RaiEngelin Teh Practice LLC
Lee Xiancong JensonEngelin Teh Practice LLC
Kuah Boon Theng SCLegal Clinic LLC
Samantha Oei Jia HsiaLegal Clinic LLC
Yong Kailun KarenLegal Clinic LLC
Sim Mei Jun AudreyDentons Rodyk & Davidson LLP
Lek Siang PhengDentons Rodyk & Davidson LLP
Zoe PittasDentons Rodyk & Davidson LLP
Vanessa Lim Choon HsiaDentons Rodyk & Davidson LLP

4. Facts

  1. Noor Azlin visited CGH's A&E on 31 October 2007, complaining of chest pain and shortness of breath.
  2. A chest X-ray revealed an opacity in the right mid-zone of Noor Azlin's chest.
  3. Dr. Imran, a respiratory physician, saw Noor Azlin on 15 November 2007 and ordered repeat chest X-rays.
  4. Dr. Imran assessed that the opacity appeared to be resolving and gave Noor Azlin an open date for follow-up.
  5. Noor Azlin returned to the A&E on 29 April 2010, attended to by Dr. Yap, who noted the opacity had been present since 2007.
  6. Dr. Yap concluded the opacity was an incidental finding and prescribed painkillers.
  7. Noor Azlin returned to the A&E on 31 July 2011, attended to by Dr. Soh, who did not notice the opacity.
  8. Noor Azlin was diagnosed with Stage IIA non-small cell lung cancer in March 2012.

5. Formal Citations

  1. Noor Azlin bte Abdul Rahman v Changi General Hospital Pte Ltd and others, Civil Appeal No 47 of 2018, [2019] SGCA 13

6. Timeline

DateEvent
Noor Azlin visited Changi General Hospital's A&E department complaining of lower chest pain and shortness of breath.
Noor Azlin visited CGH SOC and was attended to by Dr. Imran.
Noor Azlin visited the A&E department complaining of right lower chest pain and was attended to by Dr. Yap.
Noor Azlin returned to the A&E department complaining of intermittent left lower ribcage pain and was attended to by Dr. Soh.
Radiology report prepared detecting opacity in right mid-zone of Noor Azlin's lung.
Noor Azlin attended Raffles Medical Clinic and was seen by Dr. Melvyn Wong, complaining of cough, breathlessness and blood in the sputum.
Noor Azlin returned to Raffles Medical Clinic and Dr. Wong ordered a chest X-ray.
Noor Azlin returned to discuss the findings of the report with Dr. Wong.
Noor Azlin was seen by Prof Sridhar at CGH SOC pursuant to Dr. Wong’s referral in relation to a right mid-zone lesion.
A biopsy of the nodule was conducted by Dr. Andrew Tan.
Noor Azlin saw Prof Sridhar again, who explained the results of the biopsy.
Prof Sridhar referred Noor Azlin to surgical oncologist Prof Koong.
Noor Azlin was advised to undergo a lobectomy to remove the part of her lung which had the tumour.
Noor Azlin underwent a lobectomy.
A CT scan revealed a new mass-like density in Noor Azlin's right middle lobe.
Dr. Daniel Tan carried out an analysis on the tumour that was resected in 2012 to determine its mutation type.
Noor Azlin commenced the action for medical negligence against the Respondents.
Noor Azlin started on a second-generation ALK-inhibitor, Ceritinib and Nivolumab as part of a clinical trial.
The cancer progressed to Noor Azlin's brain and mediastinal lymph node.
Noor Azlin has been treated with a third-generation ALK-inhibitor, Lorlatinib.
Hearing date.
Judgment date.

7. Legal Issues

  1. Breach of Duty of Care
    • Outcome: The Court of Appeal found that Changi General Hospital breached its duty of care by failing to have a proper system to ensure adequate follow-up of the Appellant’s case.
    • Category: Substantive
    • Sub-Issues:
      • Failure to follow up on radiological reports
      • Failure to refer to a specialist
      • Failure to properly manage patient care
    • Related Cases:
      • [1957] 1 WLR 582
      • [1998] AC 232
  2. Causation
    • Outcome: The Court of Appeal found that the negligence of Changi General Hospital caused a delay in diagnosing the Appellant with lung cancer, leading to the progression of the cancer and nodal metastasis.
    • Category: Substantive
    • Sub-Issues:
      • Delay in diagnosis
      • Progression of cancer
      • Nodal metastasis
  3. Standard of Care for A&E Doctors
    • Outcome: The Court of Appeal clarified the standard of care expected of doctors working in the A&E department, emphasizing the need for a targeted approach and the handling of incidental findings.
    • Category: Substantive
    • Sub-Issues:
      • Targeted approach
      • Incidental findings

8. Remedies Sought

  1. Damages for delayed diagnosis and treatment of lung cancer
  2. Loss of future earnings
  3. Damages to be awarded to dependants in the event of demise

9. Cause of Actions

  • Medical Negligence

10. Practice Areas

  • Medical Malpractice
  • Civil Litigation

11. Industries

  • Healthcare

12. Cited Cases

Case NameCourtAffirmedCitationJurisdictionSignificance
Noor Azlin Binte Abdul Rahman v Changi General Hospital Pte Ltd and othersHigh CourtYes[2018] SGHC 35SingaporeCited as the judgment under appeal.
Bolam v Friern Hospital Management CommitteeN/AYes[1957] 1 WLR 582England and WalesCited for the Bolam test in determining the standard of care in medical negligence cases.
Bolitho v City and Hackney Health AuthorityN/AYes[1998] AC 232England and WalesCited for the Bolitho test, an extension of the Bolam test, requiring that medical opinions be logically defensible.
Penney v East Kent Health AuthorityEnglish Court of AppealYes[2000] PNLR 323England and WalesCited regarding the application of the Bolam test in 'pure diagnosis' cases.
Muller v King’s College Hospital NHS Foundation TrustEnglish High CourtYes[2017] 2 WLR 1595England and WalesCited regarding the application of the Bolam test in 'pure diagnosis' cases.
Hii Chii Kok v Ooi Peng Jin London Lucien and anotherN/AYes[2017] 2 SLR 492SingaporeCited for the application of the Bolam-Bolitho test in medical negligence cases.

13. Applicable Rules

Rule Name
No applicable rules

14. Applicable Statutes

Statute NameJurisdiction
No applicable statutes

15. Key Terms and Keywords

15.1 Key Terms

  • Opacity
  • Nodule
  • ALK-positive lung cancer
  • Lobectomy
  • Nodal metastasis
  • Radiological report
  • A&E department
  • Bolam-Bolitho test
  • Standard of care
  • Causation

15.2 Keywords

  • Medical negligence
  • Lung cancer
  • Delayed diagnosis
  • Breach of duty
  • Changi General Hospital
  • Singapore
  • Court of Appeal

17. Areas of Law

Area NameRelevance Score
Medical Malpractice Litigation90
Medical Negligence90
Breach of Duty of Care80
Hospital Liability80
Causation70
Standard of Care70
Diagnosis60
Personal Injury60
Measure of Damages50
Evidence40
Contract Law10

16. Subjects

  • Medical Law
  • Negligence
  • Health Law