SINGAPORE: A doctor who performed a botched liposuction procedure in 2013 has been found liable for negligence in the death of his patient and ordered to pay about S$5.6 million in damages, a High Court judge ruled on Thursday (Nov 26).
Dr Edward Foo Chee Boon's "negligent acts" were sufficient to cause the death of his patient, Ms Mandy Yeong Soek Mun, 44, who died after undergoing a liposuction and fat transfer procedure at TCS at Central Clinic in June 2013.
Justice Choo Han Teck ruled that Dr Foo was negligent in both his performance of the procedure and his management of Ms Yeong’s postoperative condition, as he delayed calling for an ambulance even after her blood oxygen dipped to emergency levels.
She died in Singapore General Hospital (SGH) of pulmonary fat embolism, a condition where fat globules are trapped in a patient's blood vessels and obstruct their pulmonary circulation.
She suffered from the fulminant form of fat embolism syndrome, which is rare and "almost always fatal", the judgment said.
PUNCTURED BLOOD VESSEL WHILE INJECTING FAT
In May 2013, Ms Yeong met Dr Foo for a consultation as she was dissatisfied with the uneven appearance of her thighs after two earlier liposuction procedures, including one performed by Dr Foo, according to the judgment.
Dr Foo recommended a further liposuction and a fat transfer procedure to correct the unevenness. This would involve transferring fat from her abdomen into her thighs.
The surgery took place from noon to about 2pm at the clinic in The Central shopping mall on Jun 28, 2013.
At 2.05pm, Ms Yeong’s blood oxygen level dropped to 72 per cent, according to the clinic’s anaesthetic record. Dr Foo attempted to raise her oxygen level back above 95 per cent without success, and by 2.45pm, Ms Yeong had suffered a cardiovascular collapse.
An ambulance was called at 2.53pm and reached the clinic within seven-and-a-half minutes.
Ms Yeong was then taken to the SGH's accident and emergency (A&E) ward, where she died at 5.46pm after further attempts to resuscitate her failed.
The plaintiffs in the case, including Ms Yeong’s husband, argued that Dr Foo negligently caused her death in three respects: Failing to obtain her informed consent, performing the procedure and managing her postoperative condition.
Dr Foo denied all three allegations.
In his judgment, Justice Choo found that the fat embolism occurred as a result of the surgery in which Dr Foo inserted a blunt tip cannula into Ms Yeong’s thigh and directly injected fat molecules into her bloodstream.
“That is not an accepted risk if the surgery is properly carried out, and thus, the inference must be that the surgeon was negligent in the course of the procedure itself,” the judge said.
He considered the scar tissue in Ms Yeong’s thighs that made it more difficult to inject fat into those areas, the "extremely rapid" onset of her symptoms, which meant that a large volume of fat had suddenly entered her bloodstream, as well as bruising on her abdominal walls and upper thighs.
“All things considered, it was more likely than not that Dr Foo had inadvertently punctured a blood vessel as he was injecting fat into (Ms Yeong’s) thigh,” Justice Choo said.
“I am accordingly of the view that Dr Foo’s negligent performance of (Ms Yeong’s) procedure caused her eventual demise.”
“TOTAL MAYHEM AND CONFUSION”
Turning to the management of Ms Yeong’s postoperative condition, Justice Choo said that from the point that her blood oxygen level fell, “evidence from those present is neither clear nor consistent, but the picture that emerges is that of total mayhem and confusion”.
“Nobody seemed to know what to do,” the judge added.
According to Dr Foo and Dr Chow Yuen Ho, another doctor called into the operating theatre to help slightly after 2pm, both tried various procedures to raise Ms Yeong’s oxygen saturation level.
Dr Foo was simultaneously trying to diagnose the cause of the drop in oxygen saturation before the ambulance was called, the judgment said.
“Contrary to Dr Foo’s claim that the patient’s condition was improving, evidence showed that Ms Yeong’s oxygen saturation level was moving up and down because of their efforts, but did not go above 92 per cent, the judge said.
“That is an emergency,” he said, adding that there was evidence in the form of photographs of the vital signs monitor.
“One was by a phone camera belonging to one of the nurses. The other was by Dr Chow's small digital camera that was not produced at trial although it seems that photographs might have been taken with that camera,” the judge said.
"NOT ADEQUATELY TRAINED"
Noting there was some dispute over the time at which Ms Yeong suffered a collapse, Justice Choo said the time between a patient’s collapse and the calling of an ambulance is “especially significant in cases involving fat embolism where time is of the essence”.
He also noted Dr Foo’s testimony that it was “medical procedure to gradually exclude one condition after another until the correct diagnosis was made”, but said there was no reason why he could not have called an ambulance while diagnosing the problem.
“Furthermore, there is no evidence that fat embolism was eventually diagnosed by Dr Foo. And the fact that it took him 45 to 50 minutes to realise that he could not figure out what was going on compels me to infer that Dr Foo was not adequately trained for such surgeries,” Justice Choo said.
“Liposuction and related procedures are generally considered the specialty of plastic and reconstructive surgeons, and Dr Foo is a general surgeon who only attended several overseas liposuction courses and internships before practising liposuction.
“This is not to say, however, that general surgeons should never be allowed to carry out liposuction surgeries,” the judge said, adding that it was ultimately for the health authorities and the medical profession to sort out these boundaries.
“The plaintiffs’ experts’ testimonies on this point were simple and direct – when a doctor finds himself unable to handle the situation, he must call for help,” Justice Choo said.
“In this case, calling for help is an understatement – Dr Foo should have pounded the alarm; and should have done so much earlier.”
From all the doctors who testified on behalf of the plaintiffs and SGH, Ms Yeong had arrived at the A&E department "too late to be saved", said the judge.
The “general consensus” among the doctors was that had the ambulance been summoned when Ms Yeong’s blood oxygen fell with no ostensible cause, she “would have had a chance” of surviving the fat embolism.
Patients with fat embolism have "reasonably good" chances of survival when given prompt expert resuscitation in a hospital with such facilities, added the judge.
“The SGH has the necessary resuscitation equipment, but not Dr Foo’s clinic … Hence, speedy conveyance to the SGH was vital, and I am of the opinion that Dr Foo’s delay in sending for the ambulance was an act of negligence.”
On the plaintiffs’ allegation that Dr Foo did not obtain Ms Yeong’s informed consent for the surgery, the judge found that the surgeon did not adequately draw his patient’s attention to the risk of fat embolism before the procedure, but stopped short of finding him negligent.
“Given the rare nature of the risk of pulmonary embolism, (Ms Yeong’s) personal experience with liposuction, as well as her desire to correct the unevenness of her thighs, it would seem that she would be more likely to accept the risk and proceed,” said Justice Choo.
ABOUT S$5.6 MILLION IN DAMAGES AWARDED
Ms Yeong is survived by two elderly parents, her husband and two sons aged 17 and 13 at the time of her death.
In deciding the plaintiffs’ claims on damages, Justice Choo noted that Ms Yeong was Roche Diagnostics Asia Pacific’s head of regional marketing development at the time of her death, and had worked there for nearly 20 years.
He awarded about S$3.8 million in damages for the projected loss of inheritance suffered by her dependants, as well as about S$1.7 million for a dependency claim.
Another sum of about S$31,390 was awarded for funeral, legal and administrative expenses, as claimed by her estate.
Dr Foo had argued that he should be liable for only one-third of the damages claimable, a position the judge described as a “non-starter”.
“As the analysis in this judgment makes clear, Dr Foo’s negligent acts alone were sufficient to cause Mandy Yeong’s death. He should thus be liable in full for the losses suffered by the plaintiffs.”