By Yasmeen Banu
In March of 2011, 27-year old Lian Huizuan collapsed in Changi Women’s Prison after a drills session.
She died shortly after.
There were many signs before her sudden passing. There were even observations made by her father that were reported to prison officers, but all of them either went unnoticed, were not detected earlier, or were not given enough attention by prison officers and doctors who attended to her.
“Every time I visited her, I knew something was very wrong with her,” Mr Lian Hock Kwee, 61 and a taxi driver, said of his daughter.
Huizuan had been sent to Changi Women’s Prison (CWP) for inhalant abuse in May 2010. She died on 2 March 2011, about a week before she was to be released from the detention order.
Huizuan was later found to have died from overmedication of the drugs that was prescribed to her while in prison.
The post mortem revealed that the blood level of a medicine – Amitriptyline - she was prescribed was 19 times higher than the expected therapeutic range.
Forensic Pathologist Professor Teo Eng Swee from the Health Sciences Authority said “that at three to six times the Amitriptyline level, it would have caused death to a normal person."
Before being admitted to prison on the 6th of May 2010 for inhalant abuse, Huizuan was prescribed medicine from the Institute of Mental Health (IMH) to treat her depression. She was given four different drugs: Chlorpromazine, Faverin, Artane and Valproate.
Upon her admission into CWP, while Huizuan was under the care of medical doctor Dr Ranjeet Narulla and psychiatrist Dr Tan Soo Teng, both from Raffles Medical Group (RMG), Dr Tan changed two of the drugs prescribed by IMH.
When questioned during the Coroner’s Inquiry into Huizuan’s death, on why he did this, Dr Tan replied that it was to help Huizuan sleep better, although Huizuan didn’t seem to have complained that she had trouble sleeping at that point.
The new sets of drugs were Chloropromazine, Valproate and Amitriptyline.
Dr Tan then subsequently increased the dosage for Chlorpromazine from 100mg to 150mg and Amitriptyline from 75mg to 100mg.
However, on the 27th of August 2010, Huizuan was admitted to Changi General Hospital (CGH) for about 9 days. Because of her serious condition, she was placed on the Dangerously Ill List (DIL) for three days.
While in hospital, Huizuan had her first epilepsy attack despite not having had any past history of fits. She was observed to also have had “an altered mental state where she was noted to be crying and hyperventilating.”
When Huizuan finally returned to CWP, her dosage of Amitriptyline was increased again - from 100mg to 150mg.
Later, she was instructed to take her dosage of 400mg of Valproate twice a day.
Dr Tejpal Singh, a doctor from IMH who was roped in as an expert by the Coroner for his views, said that Huizuan’s first fits attack and the subsequent attacks that followed suggested Amitriptyline toxicity, especially since Huizuan had no history of fits.
“Another tell-tale sign was the abdominal pain which is also a side effect of Amitriptyline toxicity,” Dr Singh said.
The signs – “file was too thick”
After Huizuan’s discharge from the hospital, she was constantly seen withdrawn, gloomy, had complaints of pain, had multiple falls in the toilet and claimed to have injuries, was not too keen to talk, and had backaches.
Huizuan’s cellmate said, “I also do not know why she would always faint. Every time she faints, we would call out for help. As (she) was not very healthy, sometimes she would faint while marching.”
Huizuan, over a period of 4 months, had 11 occasions of falls, faints and fits but Dr Tan only noted Huizuan having had two falls, saying that the nurse had told him so.
When asked why he didn’t read Huizuan’s medical file before making changes to Huizuan’s prescriptions, Dr Tan said this was because “the file was too thick.”
Both Dr Tan and Dr Ranjeet apparently did not pick up the signs of Huizuan’s medical state although it was well documented in the file.
Dr Singh testified at the Coroner’s Inquiry that he “would have been very concerned” by the number of falls, faints and fits Huizuan experienced. He also testified that if he were to prescribe the drugs as Dr Tan did, he would have monitored Huizuan closely as the side effects were well known.
In December, Dr Tan reduced Huizuan’s dosage of Chlorpromazine from 150mg to 100mg and Valproate from 400mg twice a day to 200mg twice a day.
The dosage for Amitriptyline remained.
The 24th of September 2010 was the last time Dr Ranjeet certified Ms Lian fit for drills. This was never reviewed again until Huizuan collapsed and died in March 2011.
4-minute medical consultation
It was subsequently found that Huizuan received very little consultation time with Dr Tan, who only saw her nine times over the course of 10 months and had only spent an average of four minutes with her each session. This, the Coroner observed, was a “rushed affair.”
Senior Assistant Director of Medical Services Branch of Changi Prison, Dr Colin Teo Seng Minh, admitted in court that the consultation time given to Huizuan was too short.
Dr Tan said that on the days he visits CWP, he would treat inmates at Cluster A (which houses inmates in five blocks) and the Changi Prison Complex Medical Centre. This number about 100 patients in all.
He said, “There might be insufficient manpower to accompany me to see the patients.”
Dr Tan, who was also unaware that Huizuan had Hepatitis C, had little to no communication with Dr Ranjeet, who was a full time doctor in CWP.
Both doctors “never spoke to each other on the deceased’s medical condition,” the Coroner observed. “[It] was clear that they were working in silos, independently of each other.”
The Coroner also noted that Dr Ranjeet had said that she was “not aware of the side effects of the psychiatric medication” that was prescribed to Huizuan.
There were also instances where drugs that were prescribed by the doctor were not written in the prison medication record, and neither were there proper documentation of the dispensation of the medication.
Disinterest in signs
Investigations revealed that Huizuan had unusual behavioural tantrums that were ignored. Her cellmate, Ms Chan Ee Ling, said when she notified the prison officers about this, they did not seem interested.
Mr Lian said the prison “always thinks” his daughter is “making excuses… or that she’s lazy or just pretending.”
“Every time I saw her after she got admitted in hospital, I keep telling her to tell the doctors she was not feeling well,” Mr Lian recalled, “but every time she would tell me there’s no point, that the doctors wouldn’t believe her.”
“It really makes me sad because she was really in pain,” he added.
Mr Lian said that on the occasions he visited his daughter in CWP, he could tell she was suffering, especially because she was not coherent, had slurred speech and had told him that she was not coping well with the drills. Despite reporting this to the prison officials, no action was taken.
On the fateful day of 2nd of March 2011, ASP Claire Koo Qi Hui observed Huizuan was holding her leg while marching, and that she had complained that her leg was hurting, and had squatted in pain. She stumbled on a few occasions, sat down on the stairs at every level saying that her leg and back were hurting, sat at the corner of the security lobby at level 3, was leaning against the wall and was crying a little.
Up to this point, Huizuan had received no medical attention.
Then, she suffered another episode of fits, and collapsed.
She was pronounced dead soon after, at 12:45pm.
Mr Lian said he was not informed of what had happened to his daughter until some time later. “They called me around two hours after she died,” he said.
When he was finally allowed to see his daughter the day after, he didn’t know that the authorities had already performed an autopsy on her.
“I’m still sad, but imagine how the kids felt, looking at their mum for the last time the way they did,” Mr Lian said, his voice still angry with emotions. The children, he explained, were stunned to see their mother in such a state, with stitches all over her and in a bag.
“It’s hard to get over it,” Mr Lian said.
Huizuan’s daughters were seven and nine-years old then.
Cause of death
State Coroner Janet Wang said that the “unfortunate incident revealed various systemic lacunae.”
She found that the “probable cause of death” was the “slow and sustained increase in Amitriptyline toxicity” which she said was “in part contributed by the deceased’s condition of chronic hepatitis C infection.”
Looking for answers
“All I want are answers. Just answers…and an apology,” Mr Lian said. “I still haven’t gotten answers from MHA (Ministry of Home Affairs). I know she was in rehabilitation, but I want answers too. She was supposed to leave prison the following week, but she just died like that. Everyone ignored her, said she was pretending. They saw her collapsing after the drill, but did nothing… I’m still very hurt.”
Mr Lian, on behalf of the children, has filed a civil suit against the two doctors and RMG, who were providing the medical services at CWP. The civil suit is mainly to seek compensation for the care of the children.
Mr Raphael Louis, the lawyer representing the family, said, “There were obvious signs of overmedication over a period of at least 6 months, including fits, pain in the abdomen and fainting spells.”
He said that Huizuan’s death could have been avoided if someone had believed her complaints of pain and discomfort.
“Huizuan’s two young children lost their mother because of the indifference of the people who were entrusted to protect her,” Mr Louis said. “Every effort must be made to prevent another loss of life in our prison system.”
Huizuan had been looking forward to her release; she had wanted to start her life again, to get a job and to support her two young children.
Mr Louis said, “Mr Lian, still grieving over Huizuan’s death, is worried about his granddaughters’ future. The least the defendants could do now is to compensate them fairly. This will help them close this painful chapter in their lives.”
Huizuan’s two children are currently in a children’s home.