Medical Professional Misconduct and Service Standards: Insights from [2024] SGHC 126

In a landmark judgment, the Court of Three Judges of the General Division of the High Court in Singapore delivered its decision in [2024] SGHC 126, addressing critical issues of professional misconduct and the standards of professional services expected of medical practitioners. This case, Ang Yong Guan v. Singapore Medical Council, involved appeals from both the doctor, Dr. Ang Yong Guan, and the Singapore Medical Council (SMC), and provides important clarifications on the standards and expectations for medical professionals in Singapore.

Case Background

Dr. Ang Yong Guan, a psychiatrist, was charged by the Singapore Medical Council with professional misconduct and failing to provide professional services of a quality expected of him. The charges arose from Dr. Ang’s treatment of a patient, Mr. Quek Kiat Siong, who passed away due to mixed drug intoxication. The crux of the case involved Dr. Ang’s prescription practices, which allegedly deviated from the Ministry of Health (MOH) guidelines and the product inserts of the medications prescribed.

Key Legal Issues

1. Professional Misconduct under s 53(1)(d) of the Medical Registration Act (MRA):

• The primary issue was whether Dr. Ang’s actions constituted an intentional and deliberate departure from the standards observed or approved by members of the profession of good repute and competency.
• The SMC argued that Dr. Ang’s awareness of the guidelines and his deviation from them without justifiable reasons amounted to professional misconduct.

2. Failure to Provide Professional Services of Expected Quality under s 53(1)(e) of the MRA:

• This charge focused on whether Dr. Ang failed to provide services of the quality which it is reasonable to expect of him.
• The SMC contended that Dr. Ang did not conduct a proper risk-benefit analysis, discuss these risks and benefits with the patient, or obtain informed consent for the deviations from the guidelines.

Factual Background and Findings

Patient’s Treatment History:

• Dr. Ang treated the patient, Mr. Quek, for various conditions including insomnia, depression, post-traumatic stress disorder, obsessional ruminations, and anxiety from February 2010 to July 2012.
• Dr. Ang prescribed numerous medications, including benzodiazepines and antidepressants, which deviated from MOH guidelines.

Critical Deviations from Guidelines:

1. Switching Antidepressants: Dr. Ang switched between antidepressants without ensuring that each was continued for at least 4 to 6 weeks, as recommended by the MOH Clinical Practice Guidelines for Depression.
2. Long-Term Use of Benzodiazepines: He prescribed benzodiazepines for periods exceeding the short-term relief limit of 2 to 4 weeks and did not limit their use to intermittent use for insomnia, contrary to the MOH Administrative Guidelines on the Prescribing of Benzodiazepines.
3. Concurrent Use of Multiple Benzodiazepines: Dr. Ang concurrently prescribed multiple benzodiazepines and opioid analgesics, increasing the risk of significant drug interactions, CNS depression, and other severe adverse effects.
4. Exceeding Recommended Dosages: He prescribed doses of Mirtazapine and Zolpidem Controlled Release (CR) that exceeded the maximum recommended limits set out in their product inserts.

Patient’s Death:

• Mr. Quek passed away four days after receiving a prescription from Dr. Ang that included 60mg of Mirtazapine and 25mg of Zolpidem CR.
• The post-mortem indicated “multi-organ failure with pulmonary haemorrhage, due to mixed drug intoxication,” with elevated levels of various prescribed drugs.

Court’s Findings

On Professional Misconduct Charges:

• The court upheld the Disciplinary Tribunal’s (DT) decision to acquit Dr. Ang of the professional misconduct charges. It agreed that not every departure from accepted standards would amount to professional misconduct.
• The court found that although Dr. Ang deviated from the guidelines, there was no malicious intent or financial motive, and he demonstrated care and concern for the patient. Therefore, the deviations did not constitute an intentional and deliberate departure from professional standards.

On Professional Services Charges:

• The court affirmed the DT’s conviction of Dr. Ang on the charges of failing to provide professional services of the expected quality.
• The court emphasized the necessity for medical practitioners to justify deviations from guidelines by conducting a thorough risk-benefit analysis, discussing these with the patient, and obtaining informed consent.
• It highlighted that these deviations must be objectively justifiable based on the patient’s specific circumstances.

Legal Standards Clarified

1. Standard of Conduct for Medical Practitioners:

• The guidelines set out by the MOH and the product inserts serve as the presumptive standard of care.
• Deviations from these guidelines can be justified if supported by clear medical grounds, including a proper risk-benefit analysis and informed consent.

2. Burden of Proof:

• When deviations occur, the evidential burden shifts to the medical practitioner to justify these deviations.
• The justification must be rooted in a clear understanding of the guidelines’ rationales and be supported by a responsible body of medical opinion.

Relevant Case Law

1. Low Cze Hong v. Singapore Medical Council [2008] 3 SLR(R) 612:

• Established the two-limb test for professional misconduct: intentional and deliberate departure from standards, or serious negligence amounting to an abuse of privileges.
• Applied in assessing whether Dr. Ang’s actions constituted professional misconduct.

2. Gobinathan Devathasan v. Singapore Medical Council [2010] 2 SLR 926:

• Emphasized the need for medical practitioners to justify deviations from standard treatments, highlighting the importance of patient safety and adherence to accepted medical standards.

3. Yong Thiam Look Peter v. Singapore Medical Council [2017] 4 SLR 66:

• Discussed the elementary clinical standards expected of medical practitioners and the necessity for clear medical grounds when deviating from guidelines.

4. Ho Tze Woon v. Singapore Medical Council [2023] SGHC 254:

• Reiterated that deviations from guidelines must be objectively justifiable and supported by a responsible body of medical opinion.

Practical Implications for Medical Practitioners

• Adherence to Guidelines: Medical practitioners should adhere to MOH guidelines and product inserts unless there are clear, justifiable reasons for deviation.
• Documentation: It is crucial to document the risk-benefit analysis and the informed consent process when deviating from established guidelines.
• Informed Consent: Patients should be fully informed about the risks and benefits of any treatment that deviates from standard guidelines, and their consent should be obtained and recorded.

Conclusion

The judgment in [2024] SGHC 126 underscores the importance of adhering to professional standards and the rigorous requirements for justifying any deviations from these standards. It serves as a crucial reference for medical practitioners in Singapore, ensuring that patient care is upheld to the highest standards of professionalism and integrity.

For further legal insights and advice on professional conduct and medical malpractice, contact IRB Law. Our team of experienced lawyers is dedicated to providing comprehensive legal support to healthcare professionals.