Noor Azlin v Changi General Hospital: Negligence, Causation, Damages in Lung Cancer Misdiagnosis

In Noor Azlin bte Abdul Rahman and another v Changi General Hospital Pte Ltd and others, the General Division of the High Court of Singapore addressed the issue of damages following the Court of Appeal's decision that Changi General Hospital (CGH) was liable for negligence to Ms. Noor Azlin. The court, presided over by Belinda Ang Saw Ean JAD, considered whether CGH's negligence caused Ms. Azlin's death and assessed the quantum of damages. The court found CGH's negligence caused Ms. Azlin's cancer to progress from Stage IB to Stage IIA, leading to her relapse and death. The court awarded a total of $326,620.61 in damages to the Estate.

1. Case Overview

1.1 Court

General Division of the High Court

1.2 Outcome

Judgment for the Estate.

1.3 Case Type

Civil

1.4 Judgment Type

Judgment

1.5 Jurisdiction

Singapore

1.6 Description

CGH liable for negligence in lung cancer misdiagnosis, causing disease progression. Court assesses damages, focusing on causation and diminished life expectancy.

1.7 Decision Date

2. Parties and Outcomes

Party NameRoleTypeOutcomeOutcome TypeCounsels
Noor Azlin Binte Abdul RahmanPlaintiffIndividualJudgment for the EstateWon
Azmi Bin Abdul RahmanPlaintiffIndividualJudgment for the EstateWon
Changi General Hospital Pte LtdDefendantCorporationLostLost
Imran Bin Mohamed NoorDefendantIndividualNeutralNeutral
Yap HsiangDefendantIndividualNeutralNeutral
Soh Wei Wen, JasonDefendantIndividualNeutralNeutral

3. Judges

Judge NameTitleDelivered Judgment
Belinda Ang Saw EanJudge of the Appellate DivisionYes

4. Counsels

Counsel NameOrganization
Vijay Kumar RaiArbiters Inc Law Corporation
Kuah Boon ThengLegal Clinic LLC
Samantha Oei Jia HsiaLegal Clinic LLC
Yong Kailun KarenLegal Clinic LLC

4. Facts

  1. Ms. Azlin visited CGH's A&E department multiple times over several years with different medical complaints.
  2. A nodule in Ms. Azlin's right lung was picked up in an X-ray during one visit.
  3. Radiological reports in April 2010 and July 2011 recommended follow-up on the opacity of a nodule in Ms. Azlin’s right lung.
  4. CGH failed to ensure proper follow-up in Ms. Azlin’s case.
  5. Ms. Azlin was diagnosed with stage IIA non-small cell lung cancer in March 2012.
  6. Ms. Azlin underwent a lobectomy and adjuvant chemotherapy in March 2012.
  7. In August 2014, a recurrence of her lung cancer occurred, progressing to stage IV.
  8. Ms. Azlin was retrospectively diagnosed in 2014 to have been suffering from ALK-positive lung cancer in 2012.
  9. Ms. Azlin passed away on 1 April 2019.

5. Formal Citations

  1. Noor Azlin bte Abdul Rahman and another v Changi General Hospital Pte Ltd and others, Suit No 59 of 2015, [2021] SGHC 10

6. Timeline

DateEvent
Ms. Azlin visited CGH’s A&E department complaining of lower chest pain and shortness of breath.
Ms. Azlin went to CGH’s Specialist Outpatient Clinic and was attended to by Dr Imran.
Ms. Azlin went to CGH’s A&E department complaining of right lower chest pain.
Ms. Azlin returned to the CGH A&E department for a presenting complaint.
The July 2011 X-rays report was prepared.
Ms. Azlin attended at the Raffles Medical Clinic and was seen by Dr Wong.
Ms. Azlin returned to the Raffles Medical Clinic for a chest X-ray.
Ms. Azlin returned to the Raffles Medical Clinic.
Ms. Azlin was seen by Prof Sridhar at CGH’s SOC.
A biopsy of the nodule was performed by Dr Tan.
Prof Sridhar explained to Ms. Azlin that there was a good chance that she could have a complete cure with a lobectomy.
Ms. Azlin underwent a lobectomy.
A recurrence of her lung cancer was discovered on a CT scan.
Ms. Azlin was treated with Crizotinib.
Ms. Azlin was treated with Crizotinib.
Ms. Azlin started on Ceritinib and Nivolumab.
The cancer progressed to her brain and mediastinal lymph node.
Ms. Azlin was treated with Lorlatinib.
Court of Appeal Judgment.
Ms. Azlin passed away.
Assessment of damages trial began.
Assessment of damages trial concluded.
Judgment reserved.

7. Legal Issues

  1. Negligence
    • Outcome: The court found CGH negligent due to its failure to have an adequate patient management system.
    • Category: Substantive
    • Sub-Issues:
      • Breach of duty of care
      • Causation
      • Damages
    • Related Cases:
      • [2019] 1 SLR 834
  2. Causation
    • Outcome: The court found a causal link between CGH's negligence and Ms. Azlin's death.
    • Category: Substantive
    • Sub-Issues:
      • Causal link between negligence and death
      • Diminution of life expectancy
    • Related Cases:
      • [2020] 1 SLR 133
  3. Damages
    • Outcome: The court awarded damages for pain and suffering, loss of amenity, medical expenses, and a dependency claim.
    • Category: Substantive
    • Sub-Issues:
      • Assessment of damages
      • Quantification of loss
      • Pain and suffering
      • Loss of amenity
      • Medical expenses
      • Loss of earnings
      • Loss of inheritance
      • Dependency claim

8. Remedies Sought

  1. Damages

9. Cause of Actions

  • Negligence

10. Practice Areas

  • Personal Injury
  • Medical Malpractice
  • Litigation

11. Industries

  • Healthcare

12. Cited Cases

Case NameCourtAffirmedCitationJurisdictionSignificance
Noor Azlin bte Abdul Rahman v Changi General Hospital Pte Ltd and othersCourt of AppealYes[2019] 1 SLR 834SingaporeThe Court of Appeal found CGH liable in negligence to Ms. Azlin.
Noor Azlin bte Abdul Rahman v Changi General Hospital Pte Ltd and othersHigh CourtYes[2019] 3 SLR 1063SingaporeReports the facts and issues in dispute.
Armstrong, Carol Ann (executrix of the estate of Peter Traynor, deceased, and on behalf of the dependents of Peter Traynor, deceased) v Quest Laboratories Pte Ltd and another and other appealsCourt of AppealYes[2020] 1 SLR 133SingaporeDealt with the issue of causation in medical negligence.
ACES System Development Pte Ltd v Yenty Lily (trading as Access International Services)Court of AppealYes[2013] 4 SLR 1317SingaporeStates the aim of an award of damages is to restore a plaintiff to the same position as if the tortious wrong had not been committed.
Robertson Quay Investment Pte Ltd v Steen Consultants and anotherSingapore Court of AppealYes[2008] 2 SLR(R) 623SingaporeStates a plaintiff claiming damages must do “its level best” to prove both the fact of damage and its amount.
Au Yeong Wing Loong v Chew Hai Ban and anotherUnknownYes[1993] 2 SLR(R) 290SingaporeDefines pain and suffering.
Tan Kok Lam (next friend to Teng Eng) v Hong Choon PengUnknownYes[2001] 1 SLR(R) 786SingaporeDefines loss of amenity.
Lua Bee Kiang (administrator of the estate of Chew Kong Seng, deceased) v Yeo Chee SiongUnknownYes[2019] 1 SLR 145SingaporeStates the guiding principle for non-pecuniary loss is that of “fair compensation”.
TV Media Pte Ltd v De Cruz Andrea Heidi and another appealCourt of AppealYes[2004] 3 SLR(R) 543SingaporePrecedent on pain and suffering and loss of amenity.
Ramesh s/o Ayakanno (suing by the committee of the person and the estate, Ramiah Naragatha Vally) v Chua Gim HockHigh CourtYes[2008] SGHC 33SingaporePrecedent on pain and suffering and loss of amenity.
Tan Juay Mui (by his next friend Chew Chwee Kim) v Sher Kuan Hock and another (Liberty Insurance Pte Ltd, co-defendant; Liberty Insurance Pte Ltd and another, third parties)High CourtYes[2012] 3 SLR 496SingaporePrecedent on pain and suffering and loss of amenity.
Siew Pick Chiang v Hyundai Engineering and Construction Co Ltd and anotherHigh CourtYes[2016] SGHC 266SingaporeDecision on pain and suffering.
Gregg v ScottHouse of LordsYes[2005] 2 AC 176United KingdomObservations on added or extra pain and suffering.
Poh Huat Heng Corp Pte Ltd and others v Hafizul Islam Kofil UddinCourt of AppealYes[2012] 3 SLR 1003SingaporeDamages for loss of marriage prospects were awarded.
Lo Lee Len v Grand Interior Renovation Works Pte Ltd and othersUnknownYes[2004] 2 SLR(R) 1SingaporeStates the object of an award of damages is to place the injured party as nearly as possible in the same financial position as he would have been in but for the negligence.
Minichit Bunhom v Jazali bin Kastari and anotherCourt of AppealYes[2018] 1 SLR 1037SingaporeStates there are two well-established exceptions to the basic rule against double recovery.
The “MARA”UnknownYes[2000] 3 SLR(R) 31SingaporeStates there are two well-established exceptions to the basic rule against double recovery.
National Insurance Co of New Zealand Ltd v EspagneHigh Court of AustraliaYes(1961) 105 CLR 569AustraliaExplains the reasoning behind the exceptions to the rule against double recovery.
Koh Chai Kwang v Teo Ai LingUnknownYes[2011] 3 SLR 610SingaporeStates Singapore courts have repeatedly stressed the distinction between loss of future earnings from loss of earning capacity.
AOD (a minor suing by his litigation representative) v AOEUnknownYes[2016] 1 SLR 217SingaporeStates s 10(3)(a)(ii) of the CLA “did not disallow” damages for one’s loss of income during the lost years from being awarded in a claim brought by a “living plaintiff”.
Lassiter Ann Masters (suing as the widow and dependant of Lassiter Henry Adolphus, deceased) v To Keng Lam (alias Toh Jeanette)UnknownYes[2005] 2 SLR(R) 8SingaporeStates s 10(3)(a)(ii) of the CLA specifically states that, where a cause of action survives for the benefit of the estate of a deceased person, “the damages recoverable for the benefit of the estate of that person shall not include any damages for loss of income in respect of any period after that person’s death”.
ACB v Thomson Medical Pte Ltd and othersCourt of AppealYes[2017] 1 SLR 918SingaporeDefines aggravated and punitive damages.
Li Siu Lun v Looi Kok Poh and anotherUnknownYes[2015] 4 SLR 667SingaporeAwarded aggravated damages.
Ling Kee Ling v Leow Leng SiongUnknownYes[1994] 3 SLR(R) 395SingaporeStates in assessing the claim of any dependant, the relationship between the deceased and the dependant, the personal circumstances of the deceased and the dependant, such as age, occupation, financial means and needs, and marital status, have to be considered in order to determine what the reasonable expectations would be.
Seto Wei Meng (suing as the administrator of the estate and on behalf of the dependants of Yeong Soek Mun, deceased) and another v Foo Chee Boon Edward and others (Singapore General Hospital Pte Ltd, third party)High CourtYes[2020] SGHC 260SingaporeThe High Court noted that the average life expectancy of a female in Singapore is about 86 years’ old.
Wee Sia Tian v Long Thik BoonUnknownYes[1996] 2 SLR(R) 420SingaporeStates the general rule is that special damages have to be strictly proven.
Bocotra Construction Pte Ltd v ThorkildsenCourt of AppealYes[1994] 2 SLR(R) 387SingaporeThe Court of Appeal accepted only the documentary evidence given to establish the plaintiff’s earnings and did not accept his oral evidence because it was inconsistent with the documents and no adequate explanation for the inconsistency was given.
Teo Sing Keng and another v Sim Ban KiatUnknownYes[1994] 1 SLR(R) 340SingaporeInterest for general damages for pain and suffering and loss of amenity should run from the date of service of the writ to the date of the judgment.

13. Applicable Rules

Rule Name
Rules Of Court (Cap 322, R 5, 2014 Rev Ed)

14. Applicable Statutes

Statute NameJurisdiction
Civil Law Act (Cap 43, 1999 Rev Ed)Singapore
Retirement and Re-employment Act (Cap 274A, 2012 Rev Ed)Singapore
Supreme Court of Judicature Act (Cap 322, 2007 Rev Ed)Singapore

15. Key Terms and Keywords

15.1 Key Terms

  • Nodule
  • Lung cancer
  • Lobectomy
  • Adjuvant chemotherapy
  • ALK-positive lung cancer
  • Nodal metastasis
  • Relapse
  • Diminution of life expectancy
  • Patient management system
  • Radiological report

15.2 Keywords

  • Medical negligence
  • Lung cancer
  • Misdiagnosis
  • Damages
  • Causation
  • Singapore
  • Hospital liability

17. Areas of Law

Area NameRelevance Score
Damages Assessment95
Negligence90
Torts80
Causation75
Quantum65
Personal Injury60
Medical Malpractice40
Civil Litigation30

16. Subjects

  • Medical Law
  • Torts
  • Civil Litigation
  • Damages Assessment