After being found liable for negligence against a patient for its delay in diagnosing her lung cancer, Changi General Hospital (CGH) on Tuesday (19 January) was ordered to pay S$326,620 in damages to her estate.
The sum was awarded by the High Court to the late Noor Azlin Abdul Rahman’s estate as general damages encompassing claims for pain, suffering, loss of amenity and dependency.
Justice Belinda Ang also ordered CGH to pay Ms Azlin’s estate an additional S$22,620 for special damages, including medical expenses.
CGH to date has paid an interim sum of S$200,000.
Ms Azlin’s estate had sought about S$1 million in damages for Ms Azlin’s pain, suffering and loss of amenity, which Justice Ang said “is manifestly excessive” and “completely at odds with the precedents”.
CGH asked for S$10,000, which the judge said was also “out of line with the precedents”, noting also that CGH did not appeal against the decision to award S$200,000 in interim payment.
Ms Azlin passed away in April 2019 at the age of 39 — months after winning the legal battle against CGH in February that year after making an appeal. She was in Stage Four of her lung cancer.
She was first diagnosed with lung cancer in February 2012, following which she went through surgery to remove part of her right lung in March 2012.
Ms Azlin later found out that she was suffering from Stage 2A lung cancer.
Justice Ang in her judgement remarked that Stage 2A is often still considered “a relatively “early” stage” from a medical perspective, which would have given her the opportunity to be cured of her cancer — that is, to have no relapse or recurrence over a given period of time.
Referencing CGH’s expert witness, Professor Goh Boon Cher’s explanation on why Ms Azlin’s cancer relapsed in 2014 despite having part of her right lung removed, Justice Ang noted that Prof Goh’s testimony “provides an explanation to the missing link of whether CGH’s delay in diagnosis caused Ms Azlin’s relapse and death: the answer must be yes”.
“The Court of Appeal had already found that CGH’s negligence caused a delay in diagnosing Ms Azlin with lung cancer in July 2011, which caused her to suffer from nodal metastasis and a progression of the lung cancer from stage I to stage IIA,” she said.
Prof Goh’s explanation, said Justice Ang, highlights how nodal metastasis “resulted in a higher risk of relapse even with a lobectomy that removed both the tumour and the affected lymph node”.
Nodal metastasis refers to cancer cells from another part of the body entering lymph nodes, leading to cancer growing within the lymph node.
“In this case, the removal of both the tumour and affected lymph node in March 2012, coupled with the absence of distant metastasis then, did not stop a relapse of her cancer in 2014,” said Justice Ang.
At Stage 1B, nodal metastasis likely would not have occurred, and thus cancer cells would not have entered the lymphatic system yet, the judge said.
“In other words, on a balance of probabilities, there would have been no microscopic node involvement if Ms Azlin had undergone lobectomy and adjuvant chemotherapy at Stage IB of the disease,” Justice Ang added.
In finding CGH liable of negligence, falling short of its duty of care to Ms Azlin, the Court of Appeal observed that CGH did not provide her with a proper system through which it could adequately follow-up with her radiological results.
The absence of such a system in Ms Azlin’s case had led to the delay in her lung cancer diagnosis.
The apex court also found CGH’s radiological report review system “inadequate”, as it did not permit comprehensive management of patients.
Each visit by Ms Azlin to the Accident & Emergency department was handled in isolation, and the doctors did not corroborate their notes.
While the Court of Appeal found the first CGH doctor Ms Azlin saw in breach of duty of care for failing to set up a follow-up appointment for her, the court did not find such a breach on the part of the two doctors from the A&E department.
Justice Ang rejected CGH’s submission that there was no guarantee that Ms Azlin could make a complete recovery even if she was treated earlier.
“CGH submitted that its breach did not cause Ms Azlin to die in the way that she had because all of the medical literature adduced by both parties’ expert witnesses shows that the survival rate of a lung cancer patient is never 100 per cent at 10 years or even 5 years after treatment, even if the patient was treated at stage IA [1A] or stage IB [1B].
“The statistical evidence showing that there is never any 100 per cent chance of a complete cure is only one factor in the entire mix of factors to consider if Ms Azlin would more likely than not have been ‘cured’ (that is, have no relapse within a specified timeframe) and live to her full life expectancy,” she said.
Background of the case
It all started in 2007 when Ms Azlin visited CGH a number of times between October that year and December 2011 for chest pains. She was finally diagnosed with lung cancer in February 2012.
Following her diagnosis, she went through surgery to remove part of her right lung in March 2012 and later found out that she was suffering from Stage IIA lung cancer.
She then underwent chemotherapy.
Unfortunately, in August 2014, she suffered a relapse and her biopsy confirmed that her cancer had progressed to Stage IV.
The following year, in January 2015, Ms Azlin sued CGH and three doctors for the delay in diagnosing her illness.
However, the High Court dismissed her case in February 2018.
She went on appeal against the decision, following which the Court of Appeal found CGH guilty of negligence for not having a system for proper follow-up of radiological results and patient management.
The apex court stated that Ms Azlin had Stage I lung cancer in July 2011 and that if the negligence did not happen from the hospital’s side, she would have received a proper diagnosis and be treated accordingly.
Although radiological reports prepared in April 2010 and July 2011 recommended a follow-up, none was conducted on Ms Azlin.
The case was transferred back to the High Court for assessment of damages.
The Court of Appeal also ordered parties to consider looking into a settlement on the quantum to help Ms Azlin get closure and allow her to concentrate on recovering from her disease.
Unfortunately, Ms Azlin lost her life to the disease on 1 April, just five weeks after the court’s verdict.