Singapore doctor gets suspended for 13 months after failing to refer his patient for specialist treatment despite serious infection, which led to leg amputation

SINGAPORE: A Singapore doctor has been suspended for 13 months after repeatedly treating a diabetic patient’s worsening foot infection without referring him to hospital care, a delay that ended with the patient losing his right leg and his ability to walk.

The patient visited general practitioner Dr Lim Geok Leong five times over 29 days in 2022 while suffering from a serious diabetic foot condition that included infection, tissue death and gangrene. Despite the severity of the condition, Dr Lim continued treatment with oral medication and follow-up reviews instead of sending the patient to a hospital emergency department or specialist.

The turning point came only after the patient sought a second opinion, which was obtained the next day, after his fifth consultation, when another clinic documented extensive wet gangrene affecting the foot. He was then admitted to the hospital and underwent multiple amputations that permanently left him unable to walk, Channel NewsAsia (CNA) reported (May 18).

The diabetic patient’s serious foot infection was assessed as improving despite severe cellulitis

The disciplinary tribunal found that Dr Lim had recognised signs consistent with severe cellulitis and severe diabetes from the first consultation. Yet across all five visits, he assessed the condition as stable or improving and stayed with the same course of treatment.

Medical guidelines require patients with active diabetic foot disease showing symptoms such as cellulitis, inflammation, or wet gangrene to be referred immediately to a hospital emergency department, but the tribunal found that this standard was not met by Dr Lim.

An expert report presented during proceedings concluded that the delay materially increased the patient’s risk of needing major amputation.

The report also showed medical findings showing that delays beyond 14 days between the first assessment and restoring blood flow are linked to a higher risk of losing a limb in diabetic patients with circulation problems. In this case, the consultations stretched across 29 days.

The tribunal classified the doctor’s conduct as serious negligence

Medical disciplinary cases investigate whether a doctor recognised when a case had gone beyond what could safely be managed in a clinic. In this case, the tribunal accepted that Dr Lim didn’t intend to harm the patient and classified the conduct as serious negligence.

Dr Lim’s legal team, Mr Eric Tin and Mr Samuel Lim from Donaldson & Burkinshaw, argued for a shorter suspension and pointed to his previously clean record over more than four decades in practice. Patient testimonials were also submitted in his defence.

The Singapore Medical Council had sought a 14-month suspension. The tribunal settled on 13 months. Along with the suspension, Dr Lim was censured, ordered to give a written undertaking not to repeat similar conduct and directed to pay the costs of proceedings.

If symptoms keep worsening, get a second medical opinion early

Cases like this tend to raise eyebrows because they involve something most people assume happens automatically: being sent to the right place when a condition becomes dangerous.

Singapore’s healthcare system relies heavily on primary care clinics to manage chronic disease, but this model only works when early signs are detected, and escalation occurs fast, as demonstrated in this particular case, which is a warning of how rapidly diabetic complications can worsen and how one delayed handover can carry consequences long after treatment ends.

Common sense still applies in all cases: if symptoms keep worsening, if treatment is not changing the outcome, or if something feels wrong, getting a second, or even a third medical opinion early can make a life-saving difference than waiting for one more negligent review.