SINGAPORE: A coroner on Monday (Sep 16) recommended policy changes to patients’ care after a 78-year-old woman died from multi-organ failure following knee surgery.
Mrs Yuen Ingeborg, a Singapore permanent resident, died on Nov 7, 2016 after she underwent total knee replacement surgery conducted by Dr Sean Ng Yung Chuan at Mount Elizabeth Hospital on Nov 1, 2016.
A seven-day coroner's inquiry, which heard from Mrs Yuen's family, doctors and nurses involved in Mrs Yuen's care, as well as independent experts, learnt that Dr Ng had left for a medical conference in Tokyo less than two days after the operation, leaving Mrs Yuen without specialist care.
Following surgery, Dr Ng said he saw the patient twice in her ward - once on Nov 1 and again on the morning of Nov 2, 2016.
He continued to observe Mrs Yuen for recovery and ordered the necessary post-surgery care including a blood transfusion, the court heard.
Mrs Yuen also began physiotherapy that day and “did not complain of anything” to her doctor, coroner Kamala Ponnampalam recorded in her findings.
On the night of Nov 2, 2016 Dr Ng left for a medical conference in Tokyo without handing Mrs Yuen’s case over to another specialist.
That evening, a nurse found Mrs Yuen’s left foot to be cold and that the patient was in a lot of pain.
After not being able to find a pulse, the nurse alerted a resident medical officer, Dr Jeffrey Mah, who was also unable to find a pulse.
When he could not contact Dr Ng, Dr Mah got in touch with Dr Chin Pak Lin, an orthopaedic surgeon who had helped Dr Ng during surgery. He came to the hospital and took over.
A scan found that severed blood vessels had caused an ischaemic limb, which is a lack of blood flow to a limb.
An emergency operation was conducted successfully but Mrs Yuen continued to deteriorate. Dr Chin decided on emergency high above knee amputation to save her life but post-surgery, Mrs Yuen went into cardiac arrest and developed multi-organ failure.
She died on the night of Nov 7, 2016.
In her findings, Ms Ponnampalam stated that Mrs Yuen’s children were concerned about the post-surgery specialist and nursing care given to their mother.
“Mrs Yuen’s children were unhappy over the fact that Dr Sean Ng had chosen to leave the country soon after the surgery and was not present to attend to her when complications arose,” the coroner wrote in her findings.
“In their view, the patient management by Dr Sean Ng had been inadequate.”
They wanted to know if early detection of the vascular injury, which had led to Mrs Yuen’s follow-up operations, would have changed her probability of survival.
They also questioned the “competencies and training” of the five nurses who took care of their mother after the surgery, and asked if there had been “lapses in terms of documentation and observations”.
“Specifically, Mrs Yuen’s daughter was aggrieved that despite pointing out to the nurses on two separate occasions, on the evening of Nov 1, 2016 and on the morning of Nov 2, 2016, that the operated limb felt icy cold, she was informed that this was normal and nothing further was done.”
POST-SURGERY MEDICAL CARE
Dr Ng, who has been a practising orthopaedic surgeon since 2011, said he had told Mrs Yuen about the conference in Tokyo and had suggested performing the surgery upon his return.
“According to Dr Sean Ng, Mrs Yuen was quite insistent on having the surgery done before his departure but did not say why,” the coroner recorded.
Dr Ng said that prior to his departure, he had checked how Mrs Yuen was progressing and was told “everything was fine”. He said it was not mentioned to him that her lower left limb was cold.
Dr Ng said that while he was in Tokyo, ward nurses told him Mrs Yuen complained of leg numbness and he called the anesthetist who assisted him on the knee replacement surgery Dr Adrian Ng to review her. Dr Adrian Ng told him to continue with his trip, Dr Ng said.
When the elderly woman’s condition worsened, the surgeon said he cut his trip short and returned to Singapore on Nov 5, 2016.
“Dr Sean Ng stated that he did not hand over care of Mrs Yuen to another specialist during his absence because there were no post-surgical complications prior to his departure and her progress was acceptable,” the coroner wrote in her findings.
“He added that he was unable to comment if there would have been a significant difference to life and death if the vascular damage had been identified and managed intra-operatively.”
In addition, Ms Ponnampalam found that Dr Ng had documented his reviews of Mrs Yuen's condition retrospectively in the case notes, instead of at the time of the reviews on Nov 1, 2016 and Nov 2, 2016.
"The making of retrospective case notes is a clear contravention of SMC guidelines," the coroner wrote.
According to the coroner’s report, the hospital also had concerns about the nurses who cared for the patient, with one being given a “verbal warning” for having documented circulation as normal in the care pathway chart when she did not personally assess the patient.
“ACTED WITH BEST OF INTENTIONS”
In her conclusion, Ms Ponnampalam said the evidence showed that an artery and vein were likely transected during the initial knee replacement operation conducted by Dr Ng, and that although a “relatively rare complication”, it was a known risk and should have been accounted for during the surgical approach.
Ms Ponnampalam also said: “Dr Sean Ng leaving the country on post-operative day two after performing a major surgery with a failure to hand over the patient’s care to an appropriate specialist was injudicious and may have resulted in the delayed recognition of the ischaemic limb.”
“The decision not to arrange for a covering specialist during his absence was short-sighted,” she said.
The coroner also said that the documentation of Mrs Yuen’s post-surgery care was “less than ideal” and “found to be unreliable” by the medical expert.
There was a “dire lack of details” in Dr Ng’s notes and that the retrospective entries days after were “unhelpful” as the patient’s condition had “severely deteriorated”.
The nurses’ notes were also “brief and in some instances, inaccurate”, and one nurse had relied on Dr Ng’s observations instead of making independent checks.
Ms Ponnampalam noted that an inquiry is not meant to make a determination of guilt or negligence, but it does assess "if an act has fallen short of reasonable standards".
She said there was no basis to suspect foul play.
“It is accepted that all the medical professionals involved in Mrs Yuen’s care acted with the best of intentions,” she added.
She said that the independent experts found gaps in the post-operative medical management.
“Dr Sean Ng’s failure to arrange for cover and then not to have made conscientious notes knowing that he is going to be away, goes beyond mere human error,” she said.
“It demonstrated a clear departure from the standards expected of a physician who had primary care of a post-surgery patient.
“It may be prudent in my view, to introduce a policy which mandates that a doctor delivering primary care to a post-surgery patient, must arrange for another doctor to cover him if he is going to be unavailable.
“There should also be guidelines for a proper handover.”
The coroner noted that Mount Elizabeth Hospital had reviewed its nursing protocols for post-surgery care for total replacement knee procedures, with effect from April 2018.
Nurses are also now required to conduct limb circulation assessment and document their findings on the limb circulation chart for all patients who have undergone total knee replacement surgery.
Additional notes and details have also been included in the revised protocols to make the intervention required more specific.
“These are important and necessary improvements to the documentation process,” said Ms Ponnampalam, adding that “it is hoped that the changes instituted … to improve patient monitoring and documentation would increase clinical awareness”.