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Changi General Hospital found guilty of medical negligence in Stage IV cancer patient

Instead of detecting the lung cancer at an early stage, the cancer was only diagnosed after it spread to a lymph node.

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The apex court found Changi General Hospital (CGH) guilty of negligence in a case where a delayed diagnosis caused the cancer of a terminal stage patient to spread.

The patient, 39-year-old Ms Noor Azlin Abdul Rahman, had been referred to CGH’s respiratory specialist Dr Imran Mohamed Noor by the hospital’s emergency department (ED) nearly 12 years ago for an “opacity” in her lungs. The patient had visited the ED numerous times, in 2007, 2010 and 2011.

The doctors at CGH first detected a nodule in Ms Azlin’s right lung but found that the nodule was benign between 2007 and 2011. In 2010 and 2011, Ms Azlin underwent two X-rays at the hospital but she was not informed of the results of the X-rays.

Ms Azlin was diagnosed with lung cancer after she underwent a biopsy on 16 Feb 2012.

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Despite radiation therapy, Ms Azlin is now fighting Stage IV cancer that has progressed to her brain.

On Tuesday (26 Feb), the Court of Appeals found CGH negligent in their care of the patient and highlighted that its lack of a proper system caused the delayed diagnosis of cancer in the patient. The court noted that had the condition been diagnosed earlier, “we find it unlikely that the lung cancer would have progressed to Stage IIA.”

Last year, the High Court dismissed Ms Azlin’s negligence claims against CGH and the three doctors. High Court Justice Belinda Ang said in her decision grounds that, “The plaintiff does not have any definitive medical evidence showing that she had cancer from 2007 to 2011.”

The judge had added that “The medical evidence shows that (she) was diagnosed at the earliest possible stage of her cancer and received the full treatment available to her,” and that Ms Azlin “did not lose out on any opportunity to take advantage of any available treatments and did not undergo any treatment that could have been avoided”.

Ms Azlin, who lives with her 81-year-old father and 73-year-old mother, appealed the decision and the apex court ruled in her favour. Her lawyer told the press that she broke down when she heard the ruling.

The Court of Appeals said that Dr Imran should not have discharged her when he was not certain that her suspected infection had cleared and should have scheduled a follow-up consultation instead.

Noting that Dr Imran was “the last in line” examining the patient, the court pointed out that, “There would have been no one else who would have been in a better position to conduct the necessary follow-up action.”

Although it could not be proven that Ms Azlin had cancer in 2007, the court said that Dr Imran should have been more cautious and scheduled a repeat consultation, even if the patient was asymptomatic.

Dr Imran was not found liable given the lack of evidence to prove Ms Azlin had cancer in 2007. CGH, however, was censured for its “serious inadequacies” in implementing proper follow-up procedures for patients.

Noting that the radiologist had called for follow-up consultation after Ms Azlin’s X-rays in 2010 and 2011, the court expressed “grave concerns” over how the radiological reports were treated.

There was “no record whatsoever of the senior doctor who had supposedly reviewed the radiological reports and who made the clinical decision” not to book follow-up appointments with the patient.

According to CGH procedures, two senior doctors can decide against the radiologist’s recommendation of a follow-up. CGH, however, did not require a record of who these doctors were and what their reasons for the decision were.

Due to this, the patient was left uninformed about the decision and “more worryingly, that any doctor further down the line would have no reference against which to check why such a decision was made”. The court said such lack of accountability is unacceptable.

The apex court further blasted CGH for treating the patient’s problem as an isolated incident each time she visited the hospital. If the hospital had not treated the patient as such, the doctors seeing the patient later would have known that the “opacity” in her lung had not been resolved.

The court asked CGH “to consider the possibility of settlement in the interests of expediency and resolution,” as Ms Azlin “will continue to face physical and emotional challenges as a result of her medical condition and we think that an amicable settlement will assist the Appellant in achieving some sense of closure and allow her to focus on battling her cancer and recovering as best as she can”.

Ms Azlin told the local press that she is “relieved for now, but the settlement has not been decided on.” The Singaporean, who is working part-time to pay off her expensive medication bills, said that not all of these medications are covered by Medifund.

Ms Azlin said that she accepts that there is no cure for Stage IV cancer but she intends to fight it as long as she can. She said: “I love my life too much, and the people around me. I don’t want my mum to worry.”

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