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Malayan Law Journal Reports/2013/Volume 10/Abdul Razak b n !atuk Abu "ama# $%la med as a w dower to &at ma# ' Ro#an bt (a nal) on be#al* o* t#e de%eased+ , Ra-a .adrul / s#am b n Ra-a (ezeman "#a# 0 1rs 2 320134 10 MLJ 35 2 11 Apr l 2013 22 pages 320134 10 MLJ 35

Abdul Razak bin Datuk Abu Samah (claimed as a widower to Fatimah @ Rohani bt Zainal, on behalf of the deceased) v Ra a !adrul "isham bin Ra a Zezeman Shah # $rs
"%&" '$(R) (*(A+A +(,-(R) .AZ//R A+A, ,0D%1 2' '%.%+ S(%) 1$ 341'.'567 $F 3844 44 A9ril 384: Tort -- Negligence -- Professional negligence -- Medical negligence -- Patient refused to insert tube to pump out build up fluid before surgery -- Consent to perform surgery obtained -- Tube inserted after administration of anaesthesia resulting in complications and patient's death -Whether inserting tube after administration of anaesthesia acceptable medical practice -Whether patient and husband informed of risks of surgery and not inserting tube before surgery -Whether surgical team failed to act in accordance with standard of care expected of them -Whether surgical team breached duty of care owed to patient and husband 6#e pla nt ** soug#t *or damages aga nst t#e de*endants on t#e grounds o* medical ne;li;ence w# %# resulted n t#e deat# o* t#e pla nt **7s w *e $7t#e de%eased7+8 6#e de%eased w#o was 91 years old) #ad %ompla ned o* abdom nal pa n and ,om t ng and went under t#e %are o* t#e * rst de*endant $7!r .adrul7+) a %olore%tal surgeon8 " n%e !r .adrul was away) #e #ad nstru%ted # s surg %al tra nee $7!r Leong7+ to nsert a Ryle7s tube $7t#e tube7+ nto t#e de%eased7s stoma%#) t#roug# #er nose to pump out bu ld up stoma%# *lu d %aused by ntest nal obstru%t on8 "ee ng t#e need *or a surgery) !r .adrul nstru%ted !r Leong to get t#e de%eased to %onsent to a surgery8 6#e de%eased %ompla ned t#at t#e tube %aused #er d s%om*ort and made #er ,om t8 !r .adrul t#en re:uested t#e se%ond de*endant) a %onsultant anaest#et st) to attend to t#e nsert on o* t#e tube8 6#e se%ond de*endant was unable to attend to t#e de%eased and n turn re:uested *or t#e #elp o* t#e t# rd de*endant w#o was also a %onsultant anaest#et st8 !r .adrul spoke to t#e pla nt ** and t#e de%eased on t#e p#one ad, s ng t#em o* t#e need *or an mmed ate surgery and %onsent was subse:uently obta ned8 6#e surg %al team %ons sted o* !r .adrul) t#e t# rd and se%ond de*endants and t#e * *t# de*endant w#o ass sted t#e se%ond and t# rd de*endants8 " n%e t#e de%eased re*used to #a,e t#e tube nserted be*ore anaest#es a was adm n stered) t#e surg %al team de% ded to nsert t a*ter t#e adm n strat on o* anaest#es a8 ;# le anaest#es a was be ng adm n stered a*ter t#e de%eased passed out) t#e de%eased regurg tated a large amount o* stoma%# *lu d w# %# entered #er lungs) %aus ng resp ratory *a lure w# %# later led to #er deat# t#e ne<t day8 =n t#e present %la m) t#e pla nt ** %ontended t#at t#e de*endants *a led to a%t n a%%ordan%e w t# t#e standard o* %are e<pe%ted o* t#em> #ad brea%#ed t#e r duty o* %are owed to bot# t#e de%eased and t#e 1 !"# $% at $& pla nt ** and t#at t#e de*endants *a led to e<pla n t#e r sks o* t#e surgery and anaest#es a be*ore obta n ng %onsent *or t#e surgery8 =t was *urt#er argued !r .adrul) as a do%tor n %#arge) s#ould #a,e nserted t#e tube # msel* and not nstru%t ot#er sta**) part %ularly a tra nee) to nsert t8

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"eld, allow ng %la ms aga nst t#e * rst) t# rd) *ourt# and * *t# de*endants> d sm ss ng t#e %la m aga nst t#e se%ond de*endant?

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6#e non2 nsert on o* t#e tube pr or to ndu%t on o* anest#es a was a%%eptable med %al pra%t %e) so long as t#e med %al team was prepared *or poss ble e,entual ty o* asp rat on) as was t#e %ase #ere8 &a lure to stop t#e regurg tat on o* stoma%# *lu d d d not mean t#at t#e t# rd and * *t# de*endants were negl gent n t#e r %are or #ad not pro, ded t#e ne%essary and a%%eptable standard o* pro*ess onal %are8 /owe,er) t#e * rst) t# rd and * *t# de*endants *a led to d s%#arge t#e r duty o* %are owed to t#e de%eased to duly n*orm and ad, se t#e de%eased ade:uately and su** % ently o* t#e n#erent and mater al r sks o* pro%eed ng w t# t#e surgery and anest#es a w t#out t#e nsert on o* t#e tube $see paras 3@ 0 5A+8 6#e * rst de*endant sa d not# ng to t#e pla nt ** about t#e n#erent dangers or r sks o* pro%eed ng w t# t#e surgery w t#out nsert ng t#e tube8 6#e * rst de*endant #ad merely n*ormed t#e pla nt ** o* t#e need *or surgery and t#e %on,ersat on ended w t# t#e pla nt ** agree ng to t#e surgery8 B,en t#oug# t#e %onsent *orm d d not re:u re t#e %onsent o* t#e pla nt **) t#e * rst de*endant owed a duty to n*orm t#e pla nt ** o* t#e nature o* t#e surgery and t#e n#erent and mater als r sk o* t#e pro%edure) espe% ally n l g#t o* t#e de%eased7s re*usal to #a,e t#e tube nserted $see para 5@+8 6#ere was no re%ord n t#e med %al %ase notes to s#ow t#at t#e de%eased #ad been ad, sed o* t#e n#erent and/or mater al r sks o* pro%eed ng w t# t#e surgery w t#out #a, ng #ad t#e tube nserted or w t#out t#e stoma%# be ng empt ed o* ts %ontent8 =t was n%umbent upon t#e * rst) t# rd and * *t# de*endants to #a,e %ounseled t#e de%eased on t#e n%reased r sk o* asp rat on and deat# *rom asp rat on w#en undergo ng t#e surgery w t#out t#e pr or nsert on o* t#e tube and t#e empty ng o* t#e stoma%# %ontent8 6#e * rst) t# rd and * *t# de*endants depr ,ed t#e de%eased o* su%# mater al n*ormat on and %aused #er to %onsent to t#e surgery and anest#es a w t#out #a, ng #er appre% ate t#e gra,e r sks n,ol,ed n t#e same $see paras 502 5A+8 6#e se%ond de*endant #ad a ,ery l m ted role n t#e %are o* t#e de%eased and t#e med %al de% s ons t#at were taken8 6#ere was nsu** % ent e, den%e aga nst t#e se%ond de*endant to establ s# negl gen%e8 As su%#) t#e %la m aga nst t#e se%ond de*endant was d sm ssed $see para 5C+8 1 !"# $% at $'

Pla nt * menuntut gant rug ter#adap de*endan2de*endan atas dasar ke%ua an perubatan yang tela# menyebabkan kemat an ster pla nt * $7s mat 7+8 " mat yang berus a 91 ta#un) tela# mengadu sak t d ba#ag an abdomen dan munta#2munta# dan tela# berada d bawa# -agaan de*endan pertama $7!r .adrul7+) seorang pakar beda# %olore%tal8 Memandangkan !r .adrul t ada) d a tela# mengara#kan pelat # pembeda#an $7!r Leong7+ untuk memasukkan t ub Ryle $7t ub tersebut7+ ke dalam perut s mat ) melalu # dungnya untuk mengepam keluar lend ran dalam perutnya yang tela# menyebabkan #alangan dalam usus8 Mel #atkan keperluan untuk melakukan pembeda#an) !r .adrul mengara#kan !r Leong untuk mendapatkan kebenaran s mat untuk men-alankan pembeda#an8 " mat mengadu ba#awa t ub tersebut menyebabkan rasa t dak selesa dan membuatkannya munta#8 !r .adrul kemud annya mem nta de*endan kedua) pakar perund ng anestet k) untuk memasukkan t ub tersebut8 !e*endan kedua t dak dapat merawat s mat dan sebal knya mem nta bantuan de*endan ket ga yang -uga merupakan seorang pakar perund ng anestet k8 !r .adrul tela# ber%akap dengan pla nt * dan s mat dalam tele*on dan

Page 5 menas #at mereka akan keperluan suatu pembeda#an segera dan kebenaran seterusnya d perole# 8 Pasukan pembeda#an terd r dar pada !r .adrul) de*endan kedua dan ket ga dan de*endan kel ma yang membantu de*endan kedua dan ket ga8 1le# kerana s mat enggan membenarkan t ub d masukkan sebelum anestet k d ber kan) pasukan pembeda#an memutuskan untuk memasukkannya selepas anestet k d ber kan8 "emasa anestet k d ber kan selepas s mat t dak sedarkan d r ) s mat merembeskan lend ran perut yang banyak yang memasuk paru2 parunya) menyebabkan kegagalan resp rator yang seterusnya membawa kepada kemat annya pada keesokan #ar 8 !alam tuntutan n ) pla nt * meng#u-a#kan ba#awa de*endan2de*endan gagal bert ndak selaras dengan standard ber#at 2#at yang d -angka dar pada mereka> tela# melanggar kewa- pan ber#at 2#at ter#adap s mat dan pla nt * dan ba#awa de*endan2de*endan gagal untuk men-elaskan mengena r s ko2r s ko pembeda#an dan anestet k sebelum mendapatkan kebenaran bag pembeda#an8 ! #u-a#kan lag ba#awa !r .adrul) sebaga doktor yang bertugas sepatutnya memasukkan t ub tersebut send r dan bukan mengara#kan sta* la n) k#ususnya seorang pelat #) untuk memasukkannya8 Di9utuskan, membenarkan tuntutan2tuntutan ter#adap de*endan pertama) ket ga) keempat dan kel ma> menolak tuntutan ter#adap de*endan kedua?

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6 dak memasukkan t ub sebelum member anestet k adala# langka# perubatan yang d ter ma) selag pasukan perubatan bersed a untuk kemungk nan berlakunya asp ras ) sepert yang berlaku dalam kes n 8 Degagalan untuk meng#ent kan rembesan lend ran perut t dak bermaksud de*endan ket ga dan kel ma %ua dalam -agaan atau t dak member kan standard pen-agaan pro*es onal yang perlu dan bole# 1 !"# $% at $( d ter ma8 ;alau baga manapun) de*endan pertama) ket ga dan kel ma gagal melepaskan kewa- pan ber#at 2#at mereka ter#adap s mat dengan sewa-arnya memaklumkan dan menas #at s mat se%ukupnya akan r s ko2r s ko sed a ada dan mater al dalam meneruskan dengan pembeda#an dan anestet k tanpa memasukkan t ub $l #at perenggan 3@ 0 5A+8 !e*endan pertama t dak menyatakan kepada pla nt * tentang ba#aya atau r s ko sed a ada meneruskan pembeda#an tanpa memasukkan t ub tersebut8 !e*endan pertama sekadar memaklumkan kepada pla nt * akan keperluan untuk pembeda#an dan perb %angan tamat dengan persetu-uan pla nt * untuk men-alankan pembeda#an8 ;alaupun borang kebenaran t dak memerlukan kebenaran pla nt *) de*endan pertama mempunya kewa- pan memaklumkan kepada pla nt * mengena s *at pembeda#an dan r s ko2r s ko prosedur yang sed a ada dan mater al) k#asnya mel #atkan pada keengganan s mat untuk memasukkan t ub tersebut $l #at perenggan 5@+8 6 ada rekod dalam nota2nota kes perubatan yang menun-ukkan ba#awa s mat tela# d maklumkan mengena r s ko2r s ko sed a ada dan/atau mater al apab la meneruskan pembeda#an tanpa memasukkan t ub tersebut atau tanpa mengosongkan perut terleb # da#ulu8 Adala# men-ad kewa- pan de*endan pertama) ket ga dan kel ma untuk member ta#u s mat mengena pen ngkatan r s ko asp ras apab la men-alankan pembeda#an tanpa sebelum tu memasukkan t ub tersebut dan mengosongkan perut8 !e*endan pertama) ket ga dan kel ma meng#alang s mat dar pada mener ma maklumat mater al dan menyebabkan d a bersetu-u dengan pembeda#an dan anestet k tanpa d a mema#am r s ko2r s ko besar yang terl bat $l #at perenggan 5025A+8 !e*endan kedua mempunya peranan yang ter#ad dalam -agaan s mat dan keputusan2keputusan perubatan yang d buat8 6 dak terdapat keterangan yang

Page A men%ukup ter#adap de*endan kedua untuk membukt kan ke%ua an8 !engan tu) tuntutan ter#adap de*endan kedua d tolak $l #at perenggan 5C+8 1otes &or %ases on pro*ess onal negl gen%e) see 12 !allal's )igest $5t# Bd) 2011 Re ssue+ paras 135C2 152C8 'ases referred to *olam + ,riern -ospital !anagement Committee 31EA94 2 All BR 11C) F.! $re*d+ ,oo ,io Na + )r .oo ,ook !un / 0nor 320094 1 MLJ AE3> 320094 1 GLJ 22E) &G $re*d+ 1 !"# $% at $1 2urmit 3aur a4p #aswant .ingh + Tung .hin -ospital / 0nor 320124 5 MLJ 2@0) /G $re*d+ !athew .cott 5akley / 5rs + )r 2eorge 6arughese / 0nor 3200E4 MLJH 152E> 320104 10 GLJ 322) /G $re*d+ 7oe + !inister of -ealth and 0nother Woolley + .ame 31EA54 2 F. @@) GA $re*d+ 7oger + Whitaker $1EE2+ 19A GLR 59E) /G $re*d+ Wu .iew 8ong + Pulau Pinang Clinic .dn *hd / 0nor 320114 3 MLJ A0@> 320114 1 GLJ 2AA) /G $re*d+ 0mbiga .reene+asan 9#ames 3hong and #oanne "eong with her: 9#ames 3hong: for the plaintiff; ,C "ee *oon 3oon 9)eputy Public Prosecutor< 0ttorney 2eneral's Chambers: for the defendants; .azeer Alam ,<din 2'= >4? 6# s s an a%t on *or damages broug#t aga nst t#e de*endants *or pro*ess onal negl gen%e n t#e management and treatment o* t#e pla nt **7s late w *e &at ma# ' Ro#an bt (a nal $7t#e pat ent7+ at t#e Duala Lumpur /osp tal $7/DL7+8 6#e * rst de*endant s a %olore%tal surgeon w#o as t#e pat ent7s pr mary do%tor and %areg ,er per*ormed a surg %al pro%edure on t#e pat ent) t#at s t#e sub-e%t matter o* t# s su t8 6#e se%ond and t# rd de*endants are %onsultant anest#et sts) w# lst t#e * *t# de*endant an anest#et % med %al o** %er ass sted t#e se%ond and t# rd de*endants n t#e operat ng t#eatre dur ng t#e surgery8 6#e * rst to t# rd and t#e * *t# de*endants were at t#e mater al t me employed by t#e *out# de*endant and atta%#ed to /DL8 >3? 6#e pat ent t#en aged 91 was adm tted to /osp tal "ultan /a- A#mad) 6emerlo#) Pa#ang) on 21 May 2010 *ollow ng abdom nal pa n and ,om t ng8 At t#e 6emerlo# /osp tal t#e pat ent was d agnosed w t# ad#es on %ol % and treated %onser,at ,ely w t# med %at on and ntra,enous $7=V7+ *lu ds8 As #er %ond t on d d not mpro,e) t#e pat ent was upon t#e pla nt **7s re:uest trans*erred to /DL on 2C May 2010 under t#e pr mary %are o* t#e * rst de*endant8 >:? 6#e pla nt ** spoke to t#e * rst de*endant and t#e * rst de*endant agreed to treat t#e pat ent8 6#e pla nt ** #ad spe% * %ally arranged *or t#e * rst de*endant to treat t#e pat ent) as #e knew t#e * rst de*endant personally) #a, ng been pre, ously treated by t#e * rst de*endant pro*ess onally8 6#e * rst de*endant #ad also assessed t#e pat ent7s %ond t on by speak ng to #er do%tors at t#e 6emerlo# /osp tal8 >@? Hpon adm ss on at /DL) t#e pat ent was n t ally treated %onser,at ,ely8 A day a*ter adm ss on) t#e pat ent was re*erred to t#e * rst de*endant7s surg %al 1 !"# $% at $=

Page @ department and was t#en e<am ned) managed and %ared *or by a surg %al team8 6#e * rst de*endant was attend ng a %on*eren%e n Mala%%a on 2E230 May 2010 and d d not personally attend to t#e pat ent on t#ese dates8 =t s t#e * rst de*endant7s e, den%e t#at w# lst #e was away # s surg %al tra nee one !r Leong A G#en $7!r Leong7+ %onta%ted # m on t#e p#one to report on t#e general med %al %ond t on o* t#e pat ent *rom t me to t me8 6#e * rst de*endant nstru%ted !r Leong to n,est gate t#e pat ent *or ntest nal obstru%t on> to keep t#e pat ent *ast ng> and to nsert an =V dr p as well as a ryle7s tube8 A ryle7s tube s nserted to t#e stoma%# t#roug# t#e nostr l and esop#agus8 6#e purpose o* a ryle7s tube s to pump out stoma%# *lu d and ease t#e pa n and d s%om*ort asso% ated w t# ntest nal obstru%t on8 >A? &urt#er) upon t#e * rst de*endant7s orders and as part o* t#e n,est gat ,e pro%edure) an urgent G6 s%an was done on 2E May 20108 6#e G6 s%an re,ealed t#at t#e pat ent was #a, ng small bowel obstru%t on se%ondary to ad#es on8 A%%ord ng to t#e * rst de*endant) on t#e n g#t o* 30 May 2010) based on # s telep#one %ommun %at on w t# t#e surg %al team at /DL) #e #ad *ormed t#e , ew t#at t#e pat ent would re:u re surgery8 /e #ad t#en ordered # s surg %al tra nee to prepare t#e pat ent *or surgery t#e ne<t morn ng8 >7? 1n t#e morn ng o* 31 May 2010) t#at s t#ree days a*ter t#e pat ent was adm tted to /DL) t#e * rst de*endant de% ded de* n t ,ely t#at an urgent surgery #ad to be done t#e ,ery day8 6#e * rst de*endant t#en d s%ussed t#e proposed surgery w t# t#e pat ent8 6#e pat ent t#en %alled t#e pla nt ** on t#e telep#one and asked t#e * rst de*endant to speak to t#e pla nt **8 =n t# s regard) t#e pla nt ** n answer to :uest on A o* # s w tness statement $7P;"17+ sa d t#at?
1n t#e morn ng o* 318A82010) = was at #ome prepar ng to , s t my w *e w#en = re%e ,ed a telep#one %all *rom #er8 "#e told me t#at Ra-a .adrul wanted to speak to me8 1,er t#e telep#one) Ra-a .adrul n*ormed me t#at #e #ad to operate on my w *e t#at ,ery day8 = agreed to t#e operat on8

A%%ord ng to t#e pla nt **) t#at was all t#e * rst de*endant sa d to # m and t#e pla nt ** ab ded by t#e * rst de*endant7s de% s on and re%ommendat on8 >B? 6#e pla nt ** states t#at not know ng w#en t#e surgery was to be undertaken) #e arr ,ed at /DL somet me about noon on 31 May 20108 /e wa ted *or t#e pat ent at t#e ward) w#ere no one spoke to # m8 =t was only n t#e e,en ng t#at t#e pla nt ** *ound out t#at t#e operat on was o,er and t#at t#e pat ent was warded n t#e ntens ,e %are un t8 6#e * rst de*endant %ame to see t#e pla nt ** and n*ormed # m t#at #e #ad su%%ess*ully %arr ed out t#e surgery8 >C? /owe,er) t#e se%ond de*endant #ad pa nted a d **erent p %ture8 A%%ord ng to t#e se%ond de*endant) t#e pat ent #ad re*used nsert on o* t#e 1 !"# $% at % ryle7s tube be*ore ndu%t on o* anest#es a8 6#e se%ond de*endant also n*ormed t#e pla nt ** t#at dur ng ndu%t on o* anest#es a t#e pat ent #ad regurg tated large amount o* stoma%# *lu d t#at #ad entered nto t#e pat ent7s lungs) w# %# #ad %aused problems8 6#e pat ent7s %ond t on deter orated two #ours nto t#e operat on8 And was attended to by t#e t# rd and * *t# de*endants8 6#e se%ond de*endant n*ormed t#e pla nt ** t#at t#e pat ent7s post operat ,e %ond t on was ,ery %r t %al8 /a, ng #eard t#e se%ond de*endant7s assessment o* t#e pat ent7s %ond t on) t#e * rst de*endant t#en adm tted to t#e pla nt ** t#at #e %ould #a,e done better8 >6? 6#e pat ent passed away on 1 June 2010 *rom asp rat on pneumon a o%%as oned *rom damage %aused to #er lungs and a rways *rom asp rat on o* stoma%# *lu d dur ng ndu%t on o* anest#es a8 >48? 6#oug# t#e pla nt ** #as ra sed ,ar ous ssues n # s plead ngs) dur ng %los ng arguments %ounsel *or t#e pla nt ** #as %on* ned t#e %la m to t#e *ollow ng ssues?

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w#et#er n t#e % r%umstan%e o* t# s %ase) t#e * rst) se%ond) t# rd and/or * *t# de*endants #ad) n t#e treatment o* t#e pat ent) a%ted n a%%ordan%e w t# t#e standard o* %are e<pe%ted o* t#e * rst) se%ond) t# rd and/or * *t# de*endants) part %ularly as regards to w#et#er t#e sa d de*endants oug#t to #a,e nserted a ryle7s tube pr or to ndu%t on o* anest#es a> w#et#er t#e deat# o* t#e pat ent %an be sa d n law to #a,e been negl gently %aused or mater ally %ontr buted by t#e * rst) se%ond) t# rd and/or * *t# de*endants n brea%# o* t#e r respe%t ,e dut es o* %are owed to t#e pat ent> w#et#er n t#e % r%umstan%e t#e *ourt# de*endant s , %ar ously l able *or t#e negl gen%e o* t#e * rst) se%ond) t# rd and/or * *t# de*endants> w#et#er n t#e % r%umstan%e o* t# s %ase) t#e de*endants #ad brea%#ed t#e r duty o* %are owed to t#e pla nt ** by *a l ng) re*us ng and/or negle%t ng to ad, se or e<pla n to t#e pat ent and/or pla nt ** pr or to t#e surgery t#e r sks asso% ated w t# t#e proposed surgery and n part %ular t#e tak ng o* t#e pat ent7s %onsent as well as t#e pro%edures ne%essary t#ere*or or t#e urgen%y *or t#e same> w#et#er n t#e % r%umstan%e o* t# s %ase) t#e de*endants #ad brea%#ed t#e r duty o* %are owed to t#e pla nt ** by *a l ng) re*us ng and/or negle%t ng to obta n t#e ne%essary pr or %onsent *rom t#e pla nt ** to pro%eed w t# surgery or any pro%edure n %onne%t on to or lead ng to t#e surgery on 31 May 2010> and w#et#er n t#e % r%umstan%e) t#e pla nt ** s ent tled to damages) nterest and %ost as pleaded n t#e statement o* %la m8 1 !"# $% at %1

>44? !ur ng t#e %ourse o* t#e tr al) t#e *ollow ng w tnesses test * ed?

2a) 2b) 2c) 2d) 2e) 2f) 1g) 1h) 1i) 1j) 1k)

P;1? Abdul Razak b n !atuk Abu "ama#) t#e pla nt **> P;2? !r Dattayat Mo#andas) %onsultant anest#es olog st 22 t#e pla nt **7s e<pert w tness> !;1? !r Ra-a .adrul / s#am b n Ra-a (ezeman "#a# 22 t#e * rst de*endant> !;2? !r Rus# n a/l Mar a 22 t#e * *t# de*endant> !;3? " t Rok a# bt 1sman 22 sta** nurse at /DL> !;5? Damal a bt /uss n 22 sta** nurse at /DL> !;A? !r Azr n b n Mo#d Az d n 22 t#e t# rd de*endant> !;@? !r Ra-a Jasm naz bt Ra-a Jamalud n 22 t#e se%ond de*endant> !;9? !r L m ;ee Leong 22 "en or Gonsultant Anest#es olog st at "unga .ulo# /osp tal 22 t#e de*endants7 e<pert w tness> !;C? Iur la# 1t#man) nurse at /DL> and !;E? Mazn bt A#mad 22 nurse at /DL8

>43? =t s well settled t#at t#e pla nt ** bears t#e burden o* proo* n %ases o* t# s nature8 =t s t#e pla nt **7s burden to pro,e negl gen%e aga nst t#e de*endants on t#e bas s t#at w#at was done was w#at a reasonably %ompetent pra%t t oner sk lled n t#at part %ular art would #a,e done or would not #a,e done $see Wu .iew 8ong + Pulau Pinang Clinic .dn *hd / 0nor 320114 3 MLJ A0@> 320114 1 GLJ 2AA and !athew .cott 5akley / 5rs + )r 2eorge 6arughese / 0nor 3200E4 MLJH 152E> 320104 10 GLJ 322+8 >4:? 1n t#e ssue o* standard o* %are n medical ne;li;ence, t#e &ederal Gourt n ,oo ,io Na + )r .oo ,ook !un / 0nor 320094 1 MLJ AE3> 320094 1 GLJ 22E departed *rom t#e de%ades old pr n% ple la d down n *olam + ,riern -ospital !anagement Committee 31EA94 2 All BR 11C and appl ed up t ll t#en n t#e Malays an %ourts and adopted t#e test la d down n t#e Austral an %ase o* 7oger + Whitaker $1EE2+ 19A GLR 59E8 6#e &ederal Gourt #eld t#at t#e standard o* %are s not

Page C determ ned solely or e,en pr mar ly by re*eren%e to t#e pra%t %e *ollowed or supported by a reasonable body o* med %al op n on $7t#e *olam test7+8 1n t#e %ontrary t s 7*or t#e %ourt to determ ne w#at t#e reasonable do%tor would #a,e done) not t#e pro*ess on8 ;#at t#e pro*ess on does n a g ,en s tuat on w ll be an mportant nd %ator o* w#at oug#t to #a,e been done) but t s#ould not ne%essar ly be determ nat ,e8 =n t#e * nal analys s) t#e %ourt s#ould set t#e standard o* %are n negl gen%e) draw ng upon t#e e, den%e presented7 $see p 2A9 o* t#e -udgment o* t#e &ederal Gourt+8 1 !"# $% at %> >4@? B,en t#oug# t#e :uest on o* reasonable standard o* %are s a :uest on *or t#e %ourt7s determ nat on) e, den%e o* a%%epted med %al pra%t %e s st ll a use*ul gu de *or %ourts to *ormulate t#e r %on%lus on8 6# s was e<pressly re%ogn sed by t#e Austral an / g# Gourt n 7ogers + Whitaker8 6# s pr n% ple #as been *ollowed by my brot#er Just %e /arm ndar " ng# !#allwal n !athew .cott 5akley w#ere #e #eld t#at?
=n t#e %ase o* d agnos s and treatment) t#e %ourt would #a,e to rely on e<pert op n on8 "tandards and pra%t %es generally a%%epted by d st ngu s#ed members o* t#e med %al pro*ess on w ll normally be de% s ,e8 =n *olitho) Lord .rowne ; lk nson re terated $at p 99E+?

= emp#as se t#at) n my , ew) t w ll ,ery seldom be r g#t *or a -udge to rea%# t#e %on%lus on t#at , ews genu nely #eld by a %ompetent med %al e<pert are unreasonable8 6#e assessment o* med %al r sks and bene* ts s a matter o* %l n %al -udgment w# %# a -udge would not normally be able to make w t#out e<pert e, den%e8 As t#e :uotat on *rom Lord "%arman makes %lear) t would be wrong to allow su%# assessment to deter orate nto seek ng to persuade t#e -udge to pre*er one o* two , ews bot# o* w# %# are %apable o* be ng log %ally supported8 =t s only w#ere a -udge %an be sat s* ed t#at t#e body o* e<pert op n on %annot be log %ally supported at a l t#at su%# op n on w ll not pro, de t#e ben%# mark by re*eren%e to w# %# t#e de*endant7s %ondu%t *alls to be assessed8

Iow) t#at s t#e law as t stands on t#e standard o* %are re:u red o* med %al pro*ess onals w#en t relates to d agnos s and treatment8 = w ll now analyse t#e e, den%e n l g#t o* t#e legal pr n% ples enun% ated abo,e8 >4A? 6#e part es are n agreement as to t#e %ause o* t#e pat ent7s deat#8 "#e #ad asp rated dur ng anest#es a $regurg tat on o* stoma%# %ontent nto t#e resp ratory system+ %aus ng resp ratory *a lure t#at ult mately led to #er dem se *rom asp rat on pneumon a8 >47? .ot# e<pert w tnesses $P;2 and !;9+ are also n agreement t#at?

3a) 3b) 3c) 3d)

asp rat on may o%%ur at t#e po nt or at any po nt a*ter t#e pat ent loses %ons% ousness dur ng anest#es a> mass ,e asp rat on o* ,ery a% d % stoma%# %ontent s # g#ly l kely to %ause se,ere damage to t#e resp ratory system> su%# asp rat on %ould %ause deat#> and ,ery l ttle %ould be done to e**e%t ,ely address or re,erse t#e e**e%ts o* asp rat on on%e stoma%# %ontent #a,e entered nto t#e lungs8

>4B? 6#e e<perts and t#e * rst) se%ond and t# rd de*endants agree t#at n order to redu%e t#e r sk o* asp rat on) pump ng out stoma%# *lu d be*ore surgery by t#e nsert on o* a ryle7s tube t#roug# t#e nasal %a, ty o* a pat ent s 1 !"# $% at %$ a re%ogn sed and re%ommended med %al te%#n :ue8 /owe,er) t#ey also agree t#at t#e nsert on o* a ryle7s tube may not ne%essar ly el m nate t#e r sks o* asp rat on %ompletely> but t ser,es to

Page E m t gate su%# r sks by remo, ng some amount o* stoma%# %ontent be*ore an operat on8 As su%# t would be prudent med %al pra%t %e t#at n all surg %al %ases n,ol, ng ntest nal obstru%t on a ryle7s tube s nserted pr or to an operat on8 =t s pre% sely *or t# s reason t#at t#e * rst de*endant #ad g ,en nstru%t ons *or t#e nsert on o* t#e ryle7s tube w#en t#e pat ent was * rst adm tted nto /DL8 6#e * rst de*endant ga,e e, den%e to t#e e**e%t t#at #e appre% ated t#e mportan%e o* ryle7s tube nsert on be*ore t#e operat on and ga,e repeated nstru%t ons *or t#e ryle7s tube nsert on to be per*ormed n t#e ward8 6#e se%ond de*endant n #er test mony dur ng %ross2e<am nat on #ad a%knowledged t#e mportan%e o* t#e ryle7s tube and n t#e % r%umstan%e w#at s#e would #a,e done n t#e *ollow ng terms?

1 2

Gounsel $P+? Iow) #ere you say n your answer t#at you were t#e Anest#et st on %all t#at day) and you were n %#arge o* t# s part %ular pat ent and you re%e ,ed a %all *rom !r Ra-a .adrul8 Jou t#en pro%eeded n your answer to say t#at t#ere s a plan and you %all t 7t#e plan7 n your answer8 ;#at s t# s planK 2nd !e*endant? !r Ra-a .adrul n*ormed me t#at #e #as put up t# s %ase *or surgery some t me n t#e m d2morn ng8 = don7t remember t#e t me and t#en #e n*ormed me t#at t# s pat ent does not #a,e a Ryle7s tube n t#e ward8 =t was a br e* d s%uss on8 = sa d) 7;#y s t t#at s#e doesn7t #a,e a Ryle7s tubeK7 /e sa d 7pat ent re*used7 and t#en # s word was t#at 7Gan you do somet# ng about tK7 At t#at po nt = %an only take t t#at = w ll address t#e ssue o* #er not #a, ng t#e Ryle7s tube n t#e operat ng t#eatre8 =t7s unreasonable * #e were to e<pe%t me to go to t#e ward and address t# s ssue o* #er not #a, ng t#e Ryle7s tube8 = was t#e 1n2Gall Anest#et st and n /DL at any one t me) = was super, s ng s < to se,en t#eatres at t#at po nt n t me8 "o you %annot be e<pe%t ng me to go to t#e ward8 "o = -ust tell # m yes) we7ll %all t#e pat ent w#en s#e s ready and take t *rom t#ere8 "o my own plan was t#at = would try to attempt putt ng t#e Ryle7s tube be*ore ndu% ng #er8 Gounsel $P+? = sense t#at you at t#e t me probably *elt :u te strongly about t#e Ryle7s tube8 ;#y d d you #a,e t#ese *eel ngs t#at you know) we need to deal w t# t#e Ryle7s tubeK 2nd !e*endant? ;ell) t# s s a %ase o* ntest nal obstru%t on8 &rom undergraduate days) *rom #ouseman days) you know t7s a part o* management o* ntest nal obstru%t on8 "o t#e *a%t t#at s#e #as been n t#e ward and not #a, ng a Ryle7s tube s somet# ng pe%ul ar8 Gounsel $P+? Jou %ame to t#e %on%lus on t#at t# s pat ent needed a Ryle7s tube and you ntended to nsert t#e Ryle7s tube later) s t#at %orre%tK 2nd !e*endant? = would8 My ntent on was to address t#e ssues w#en s#e arr ,es n t#e t#eatre8

3 4 5 6

/owe,er) t#e pat ent #ad stead*astly re*used t#e ryle7s tube nsert on be%ause t 1 !"# $% at %% was ,ery un%om*ortable and made #er ,om t8 6#e * rst) t# rd and * *t# de*endants as well as t#e nurses $!;3) !;5) !;C and !;E+ %on* rmed t# s n t#e r test mony8 6#e pat ent7s re*usal to #a,e t#e ryle7s tube nsert on s also re%orded n t#e pat ent7s #osp tal re%ords tendered n e, den%e86#e pat ent #ad also re*used t#e ryle7s tube nsert on w#en s#e was at t#e 6emerlo# /osp tal8 6#e * rst de*endant7s e, den%e n t# s regard s *ound n # s w tness statement $!;"1+?

11: 11: 12: 12: 13:

! d s#e #a,e a Ryle7s tube pr or to t#e operat onK Io) s#e d d not8 ;#yK "#e re*used *or t#e nsert on o* t#e tube desp te se,eral attempts8 ! d you ad, se Madam &at ma# regard ng t#e nsert on o* Ryle7s tubeK

Page 10

13:

Jes) = d d8 = n*ormed #er t#at t#e Ryle7s tube would be un%om*ortable but we would try to put t n gently8 6# s was n t#e morn ng o* t#e day t#at s#e was n*ormed about t#e emergen%y surgery8 "#e was ob, ously d stressed by t#e news t#at s#e would #a,e to undergo an emergen%y surgery w t# all t#e poss ble %ompl %at ons8 = * nally de% ded t#at = d d not want to %ause #er *urt#er d stress and n*ormed #er t#at per#aps t#e Ryle7s tube %ould be nserted w#en s#e s already n t#e operat on t#eatre) pr or to start ng t#e surgery8

>4C? 6#e * rst de*endant states n # s test mony t#at #e re%ogn sed t#e potent al %ompl %at on t#at t#e pat ent %ould #a,e w t#out t#e ryle7s tube and t#at s w#y #e %alled t#e se%ond de*endant to address t#e ssue at t#e operat on t#eatre w t# t#e pat ent8 /owe,er) be*ore s#e %ould attend to t) t#e se%ond de*endant was %alled away to attend to anot#er emergen%y %ase and t#e pat ent was le*t n t#e %are o* t#e t# rd de*endant 22 n so *ar as anest#es a was %on%erned8 6#e * *t# de*endant addressed t#e ssue o* t#e ryle7s tube w t# t#e pat ent at t#e re%o,ery area o* t#e operat ng t#eatre pr or to ndu%t on o* anest#es a8 6#e * *t# de*endant) w#o was t#e med %al o** %er ass st ng t#e t# rd de*endant) says t#at #e #ad e<pla ned to t#e pat ent t#at be%ause s#e was #a, ng ntest nal obstru%t on) a ryle7s tube needed to be nserted to dra n out t#e gastr % %ontent to redu%e t#e r sk o* asp rat on w#en s#e loses %ons% ousness8 /owe,er) a%%ord ng to t#e * *t# de*endant) t#e pat ent re*used and sa d t#at s#e would only allow t#e ryle7s tube to be nserted a*ter s#e was under general anest#es a8 >46? 6#e * *t# de*endant t#en n*ormed t#e t# rd de*endant t#at t#e pat ent #ad re*used t#e ryle7s tube nsert on8 6#e * *t# de*endant also states t#at #e #ad %ounseled t#e pat ent on t#e mportan%e o* t#e ryle7s tube> but t#e pat ent was stead*ast n #er re*usal and asked *or ts nsert on to be done a*ter s#e #ad lost %ons% ousness *ollow ng ndu%t on o* anest#es a8 6#en a de% s on was taken to do -ust t#at8 6#e %onse:uen%e was t#at t#e pat ent regurg tated large ,olume o* 1 !"# $% at %& # g#ly a% d % stoma%# %ontent t#at entered nto t#e pat ent7s resp ratory system and %aused damage to #er lungs and ult mately #er deat#8 6# s was desp te t#e anest#et % team tak ng all appropr ate measures to be prepared *or any e,ent o* regurg tat on or asp rat on8 >38? 6#e pla nt **7s pos t on s t#at aga nst t#e une:u ,o%al e, den%e o* t#e mportan%e o* t#e ryle7s tube) t#e * rst) se%ond) t# rd and * *t# de*endants #ad *a led to #a,e t nserted and t#at t# s s not %onsonant w t# t#e standard o* %are8 6#e pla nt ** subm ts t#at t#e * rst de*endant knew t#at t#ere was a real r sk t#at t#e pat ent would asp rate * s#e underwent anest#es a be*ore remo,al o* #er stoma%# %ontent) yet #e d d not ensure t#at t# s was done be*ore ndu%t on o* anest#es a8 6#e pla nt ** %ompla ns t#at t#e * rst de*endant %ould #a,e spoken to # m about t#e pat ent7s re*usal and t#at #e %ould #a,e persuaded t#e pat ent to #a,e t#e ryle7s tube nserted8 6#e pla nt **7s %ounsel subm ts t#at t#ere s no e, den%e o* t#e * rst de*endant?

4a) 4b) 4c) 4d)

n*orm ng t#e pat ent t#at t was , tally mportant to #a,e t#e ryle7s tube nserted to pre,ent asp rat on> ensur ng t#at t#e pat ent appre% ated t#e mportan%e and need *or t#e ryle7s tube nsert on and t#at t %ould poss bly sa,e #er l *e> assur ng t#e pat ent t#at #e %ould super, se t#e ryle7s tube nsert on * s#e w s#ed to #a,e # m present dur ng su%# nsert on> ne t#er d d #e tell t#at #e %ould make t#e nsert on # msel* and t#at #e would do so gently and as pa nlessly as #e reasonably %ould8

>34? =n s#ort) t#e pla nt ** argues t#at t#e * rst de*endant d d not make any attempts to allay #er *ear or %on%erns o* pa n and no e**ort was made to make #er as %om*ortable as #e poss bly %ould *or t#e nsert on o* t#e ryle7s tube8 6#ere*ore) t#e pla nt ** subm ts t#at t s w#olly %on%e ,able t#at

Page 11 t#e pat ent re*used t#e suggest ons to #a,e t#e ryle7s tube nsert on as s#e #ad a pre%on%e ,ed not on *rom e<per en%e t#at t would be pa n*ul and un%om*ortable8 6#e pla nt ** subm ts t#at?

5a) 5b) 5c)

t#e * rst de*endant merely le*t t#e nsert on o* t#e ryle7s tube to t#e nurses and surg %al tra nee w t#out # msel* attempt ng to per*orm t#e pro%edure> t#e se%ond de*endant d d not e,en see or assess t#e pat ent be*ore pass ng on #er on to t#e t# rd de*endant7s %are8 6#e se%ond de*endant mere %ommun %ated to t#e t# rd de*endant t#e l ttle t#at was sa d to #er by t#e * rst de*endant> t#e t# rd and * *t# de*endants also #ad *a led to nsert t#e ryle7s tube desp te #a, ng known t#at t would be re:u red to be done be*ore t#e operat on and *urt#er know ng t#at t#e pat ent #ad ,om ted about 20 1 !"# $% at %' t mes t#at day and t#ere*ore t was reasonably *oreseeable t#at s#e would regurg tate w#en s#e loses %ons% ousness8

>33? 6#us) t#e pla nt ** argues t#at t#e * rst) se%ond t# rd and * *t# de*endants #ad s mply not done enoug# to ensure t#at t#e ryle7s tube was nserted8 6#e pla nt **7s %ase s t#at * t# s pro%edure #ad been done) t would #a,e greatly redu%ed t#e %#an%es o* asp rat on and poss bly pre,ented #er deat#8 =n t#e % r%umstan%e) t#e pla nt **7s pos t on s t#at t#e * rst) se%ond) t# rd and * *t# de*endants were negl gent and #ad brea%#ed t#e r dut es n *a l ng to pro, de reasonable %are to t#e pat ent n not ensur ng t#at a ryle7s tube was nserted to remo,e and/or redu%e #er stoma%# %ontent w#en t#e pat ent was under t#e r %are8 >3:? 6#e de*endants on t#e ot#er #and say t#at t#e pat ent #ad pers stently re*usal to #a,e t#e ryle7s tube nserted e,en a*ter #a, ng been %ounseled about t#e r sk o* asp rat on86#e * *t# de*endant n # s e, den%e states as *ollows?
!r Azr n %ame down and we went to see #er aga n n t#e Re%o,ery Area and !r Azr n e<pla ned to #er t#at * s#e d dn7t #a,e a Ryle7s 6ube) s#e was at # g# r sk o* asp rat on w#en s#e was g ,en anest#es a and loses %ons% ousness8 /e also e<pla ned t#at t#e gastr % %ontents would enter t#e lungs and damage t#e lung t ssue and %ause lung damage e,entually8

6#e nurses w#o attended to t#e pat ent also ga,e e, den%e to t#e e**e%t t#at t#e pat ent #ad pers stently re*used all attempts to nsert t#e ryle7s tube8 >3@? 6#e de*endants say t#at t#ey #a,e done all t#at t#ey poss bly %ould n t#e *a%e o* t#e pat ent7s %ont nuous re*usal and #er * rm des re to #a,e t nserted only a*ter s#e #ad lost %ons% ousness n t#e operat ng t#eatre8 6#e de*endants argue t#at surgery to address t#e pat ent7s pr mary problem o* ntest nal obstru%t on #ad to be done on an emergen%y bas s8 6#e de*endant7s state t#at t would not #a,e been w se to wa t longer as t#e pat ent7s ad#es on %ol % %ould deter orate and be l *e t#reaten ng8 6#e de*endants %ontent t#at w# le t would #a,e been best * t#ere was a ryle7s tube pr or to t#e operat on) t#e re*usal o* t#e pat ent meant t#at t#ey #ad to go a#ead w t# anest#et % ndu%t on w t#out t#e ryle7s tube and #a,e t nserted mmed ately a*ter ndu%t on8 6#e t# rd and * *t# de*endants #ad also taken all ne%essary pre%aut on and preparat on to ant % pate regurg tat on8 6#e t# rd de*endant used t#e rap d se:uen%e ndu%t on $7R"=7+ te%#n :ue *or anest#es a8 6#e * *t# de*endant ass sted t#e t# rd de*endant n t#e ndu% ng o* anest#es a8 .ot# t#e med %al e<perts $P;2 and !;9+ agree t#at t#e R"= s t#e a%%epted te%#n :ue n su%# %ases8 6#e t# rd de*endant #ad a tra ned anest#et % nurse $7!;37+ on stand by to apply %r %o d pressure on t#e pat ent s#ould t#e need ar se8 6#e appl %at on o* %r %o d pressure s a te%#n :ue used dur ng anest#es a to pre,ent and/or arrest regurg tat on o* stoma%# *lu d and ts asp rat on nto t#e resp ratory system8 =n 1 !"# $% at %( *a%t !;3 d d mmed ately apply %r %o d pressure w#en t#e pat ent started to regurg tate unusually large amount o* stoma%# *lu d8 !esp te t#ese e**orts) t#e pat ent asp rated8 .ot# e<perts are n

Page 12 agreement t#at regurg tat on and asp rat on %an o%%ur e,en * %r %o d pressure s appl ed8 6#e appl %at on o* %r %o d pressure s not a *ull proo* met#od to stop asp rat on8 >3A? .ot# e<perts also agree t#at t#e presen%e o* ryle7s tube s not mandatory pr or to t#e ndu%t on o* anest#es a and t#at ts presen%e does not guarantee an empty stoma%# nor does t el m nate t#e r sk o* asp rat on all toget#er8 =n *a%t t#e pla nt **7s e<pert $7P;27+ #ad sa d t#at t#ere are nstan%es w#ere anest#es a s adm n stered w t#out ryle7s tube e,en w#en t s nd %ated8 P;2 sa d as *ollows?
.ut we do) as #a, ng sa d t#at) t#ey do #a,e pat ents put down w t#out Ryle7s tube8 .ut we %an7t #old # m aga nst or n *a,our o* t#at pra%t %e be%ause t#ere are ot#er r sks asso% ated *rom not #a, ng a Ryle7s tube 888 =* s#e st ll re*uses) t#en we7ll #a,e to take t#e ne<t step o* #a, ng a pat ent on my #and now) *ull stoma%#) no Ryle7s tube) =7ll be prepared8

>37? 6#e de*endant7s e<pert w tness !;9 #as e<pressed s m lar , ew8 /e sa d t#at t s a%%epted anest#et % pra%t %e to pro%eed w t# ndu%t on o* anest#es a w t#out * rst nsert ng a ryle7s tube n an at2r sk2o*2asp rat on pat ent8 6#e * rst de*endant n # s test mony sa d t#at n pat ents w t# ntest nal obstru%t on) t#e r sk o* asp rat on s always t#ere regardless o* w#et#er t#ere s a ryle7s tube or not8 =n *a%t) t#e * rst de*endant says t#at #e #as #ad %ases w#ere ntest nal obstru%t on pat ents #a,e d ed *rom asp rat on pneumon a e,en w t# ryle7s tube nserted8 .ot# t#e e<perts do not seem to #a,e d ,ergent , ews on t# s8 6#oug# t#e r sk o* asp rat on %ould be redu%ed * t#e ryle7s tube #ad been nserted and stoma%# %ontents dra ned) t#at does not mean t#at t#e r sk o* asp rat on %an be totally el m nated8 !;9 says t#at t#e r sk o* asp rat on s s gn * %ant n %ases o* ntest nal obstru%t on w t# or w t#out ryle7s tube8 >3B? My * nd ngs on t#e ssue o* t#e non2 nsert on o* t#e ryle7s tube pr or to ndu%t on o* anest#es a s as *ollows8 6#e pla nt ** argues t#at t#e * rst) se%ond) t# rd and * *t# de*endants #ad s mply not done enoug# to ensure t#at t#e ryle7s tube was nserted to remo,e and/or redu%e #er stoma%# %ontent w#en t#e pat ent was under t#e r %are8 6#e pla nt **7s %ase s t#at * t# s pro%edure #ad been done) t would #a,e greatly redu%ed t#e %#an%es o* asp rat on and poss bly pre,ented #er deat#8 =n t#e % r%umstan%e) t#e pla nt **7s pos t on s t#at t#e * rst) se%ond) t# rd and * *t# de*endants were negl gent and #ad brea%#ed t#e r dut es n *a l ng to pro, de reasonable %are to t#e pat ent8 >3C? 6#e de*endants on t#e ot#er #and say t#at t#e pat ent #ad pers stently 1 !"# $% at %1 re*used to #a,e t#e ryle7s tube nserted e,en a*ter #a, ng been %ounseled about t#e r sk o* asp rat on8 6#e * *t# de*endant n # s e, den%e states as *ollows?
!r Azr n %ame down and we went to see #er aga n n t#e Re%o,ery Area and !r Azr n e<pla ned to #er t#at * s#e d dn7t #a,e a Ryle7s 6ube) s#e was at # g# r sk o* asp rat on w#en s#e was g ,en anest#es a and loses %ons% ousness8 /e also e<pla ned t#at t#e gastr % %ontents would enter t#e lungs and damage t#e lung t ssue and %ause lung damage e,entually8

6#e nurses w#o attended to t#e pat ent also ga,e e, den%e to t#e e**e%t t#at t#e pat ent #ad pers stently re*used all attempts to nsert t#e ryle7s tube8 >36? 6#e de*endants say t#at t#ey #a,e done all t#at t#ey poss bly %ould n t#e *a%e o* t#e pat ent7s %ont nuous re*usal and #er * rm des re to #a,e t nserted only a*ter s#e #ad lost %ons% ousness n t#e operat ng t#eatre8 6#e de*endants argue t#at surgery needed to be done on t#e pat ent on an emergen%y %ase bas s8 Ie t#er t#e pla nt ** nor # s e<pert w tness $P;2+ %#allenged t# s prognos s8 >:8? = a%%ept t#e de*endants7 e, den%e t#at t would not #a,e been w se to wa t any longer to per*orm t#e surgery as t#e pat ent7s ad#es on %ol % %ould deter orate and be l *e t#reaten ng8 = also

Page 13 a%%ept t#e de*endants7 %ontent on t#at w# le t would #a,e been best * t#ere was a ryle7s tube nserted pr or to t#e operat on) t#e pers stent re*usal o* t#e pat ent meant t#at t#ey #ad to go a#ead w t# anest#et % ndu%t on w t#out t#e ryle7s tube and #a,e t nserted mmed ately upon t#e pat ent los ng %ons% ousness8 >:4? =n t# s regard) = * nd t#at t#e t# rd and * *t# de*endants #ad also taken all ne%essary pre%aut on and preparat on to ant % pate regurg tat on8 6#e t# rd de*endant #ad used t#e R"= te%#n :ue *or anest#es a) w# %# s t#e a%%epted te%#n :ue *or ndu%t on o* anest#es a n su%# %ases and #e #ad a tra ned anest#et % nurse $!;3+ on stand by to apply %r %o d pressure on t#e pat ent s#ould t#e need ar se8 = a%%ept t#e e, den%e o* !;3 t#at s#e appl ed %r %o d pressure w#en t#e pat ent started to regurg tate8 /owe,er desp te #er e**orts) t#e pat ent asp rated8 >:3? 6#e *a lure to stop t#e regurg tat on o* stoma%# *lu d does not mean t#at t#e t# rd and * *t# de*endants were negl gent n t#e r %are or #ad not pro, ded t#e ne%essary and a%%eptable standard o* pro*ess onal %are8 = say so on t#e bas s o* t#e e, den%e o* bot# e<perts t#at regurg tat on and asp rat on %an o%%ur e,en * %r %o d pressure s appl ed8 6#ere*ore) t#e danger o* asp rat on s always t#ere w#et#er or not a ryle7s tube s nserted or %r %o d pressure appl ed8 >::? =n *a%t) bot# e<perts also agree t#at t#e presen%e o* a ryle7s tube s not mandatory pr or to t#e ndu%t on o* anest#es a and t#at ts presen%e does not guarantee an empty stoma%# nor does t el m nate t#e r sk o* asp rat on all 1 !"# $% at %= toget#er8 =n *a%t t#e pla nt **7s e<pert $P;2+ #ad sa d t#at t#ere are nstan%es w#ere anest#es a s adm n stered w t#out ryle7s tube e,en w#en t s nd %ated8 P;2 sa d as *ollows?
.ut we do) as #a, ng sa d t#at) t#ey do #a,e pat ents put down w t#out Ryle7s tube8 .ut we %an7t #old # m aga nst or n *a,our o* t#at pra%t %e be%ause t#ere are ot#er r sks asso% ated *rom not #a, ng a Ryle7s tube 888 =* s#e st ll re*uses) t#en we7ll #a,e to take t#e ne<t step o* #a, ng a pat ent on my #and now) *ull stoma%#) no ryle7s tube) =7ll be prepared8

>:@? 6#e de*endant7s e<pert w tness !;9 #as e<pressed s m lar , ew8 /e sa d t#at t s a%%epted anest#et % pra%t %e to pro%eed w t# ndu%t on o* anest#es a w t#out * rst nsert ng a ryle7s tube n an at2r sk2o*2asp rat on pat ent8 6#e * rst de*endant n # s test mony sa d t#at n pat ents w t# ntest nal obstru%t on) t#e r sk o* asp rat on s always t#ere regardless o* w#et#er t#ere s a ryle7s tube or not8 =n *a%t) t#e * rst de*endant says t#at #e #as #ad %ases w#ere ntest nal obstru%t on pat ents #a,e d ed *rom asp rat on pneumon a e,en w t# ryle7s tube nserted8 6# s e, den%e stands un%#allenged8 >:A? 6#oug# t#e r sk o* asp rat on %ould be redu%ed * t#e ryle7s tube #ad been nserted and stoma%# %ontents dra ned) t#at does not mean t#at t#e r sk o* asp rat on %an be totally el m nated8 !;9 says t#at t#e r sk o* asp rat on s s gn * %ant n %ases o* ntest nal obstru%t on w t# or w t#out ryle7s tube8 >:7? = * nd t#at n l g#t o* t#e abo,e e, den%e and %urrent med %al pra%t %e) t#e non2 nsert on o* t#e ryles tube pr or to ndu%t on o* anest#es a s a%%eptable med %al pra%t %e) so long as t#e med %al team s prepared *or poss ble e,entual ty o* asp rat on) as was t#e %ase #ere8 >:B? 1n t#e ssue o* w#et#er proper %onsent was obta ned *rom t#e pat ent and w#et#er t#e pat ent oug#t to #a,e been n*ormed o* t#e r sk o* deat# *rom asp rat on t s t#e pla nt **7s subm ss on t#at t#e de*endants d d not obta n proper %onsent *rom t#e pat ent n relat on to t#e surgery *or t#e *ollow ng reasons?

6a)

t#e pat ent was not n*ormed by any o* t#e de*endants about t#e poss ble *atal %onse:uen%e o* anest#et % ndu%t on w t#out a ryle7s tube nserted and #er stoma%# %ontent empt ed or redu%ed pr or to ndu%t on8 Asp rat on %aus ng deat# and not -ust

Page 15 damage to #er lungs was %learly a mater al and n#erent r sk spe% * % to t#e pat ent7s t#en pre,a l ng med %al %ond t on> as a result o* t#e ndu%t on w t#out a ryle7s tube) s#e #ad asp rated and d ed o* asp rat on pneumon t s) a med %al %onse:uen%e w# %# was ent rely *oreseeable to t#e de*endants *rom t#e ,ery beg nn ng> and 1 1 !"# $% at & t#e * rst de*endant de% ded to pro%eed w t# surgery on t#e ,ery day #e #ad *ormed a de* n te op n on t#at surgery was ne%essary w t#out #a, ng * rst d s%ussed t#e same w t# t#e pla nt ** and n*orm # m o* t#e poss ble r sks and %onse:uen%es8

6b)

6c)

>:C? A%%ord ng to t#e pla nt **) t#e pat ent would not make any de% s on to go a#ead w t# surgery w t#out * rst #a, ng d s%ussed t#e same w t# # m8 6#e pla nt ** n # s test mony #ad stated t#at t#e * rst de*endant #ad *ull and personal knowledge t#at t#e pla nt ** was t#e one w#o made de% s ons w t# regards to t#e med %al treatment o* t#e pat ent8 =t was t#e pla nt ** w#o #ad spoken to t#e * rst de*endant be*ore #a, ng t#e pat ent trans*erred *rom 6emerlo# /osp tal to /DL8 A*ter t#e pat ent7s adm ss on and pr or to t#e * rst de*endant lea, ng *or Mala%%a to attend a %on*eren%e on 2E May 2010) t#e * rst de*endant #ad a *a%e to *a%e d s%uss on w t# t#e pla nt ** as to t#e pat ent7s med %al %ond t on and #e #ad n*ormed t#e pla nt ** t#at #e would n,est gate #er %ond t on *urt#er8 6#e * rst de*endant n # s test mony %on* rms some t# s assert on by t#e pla nt **8 6# s e, den%e %an be seen at p 1E@ o* t#e trans%r bed notes o* pro%eed ngs n t#e *ollow ng terms?
= #a,e # s telep#one number) and #e %alls me nterm ttently and #e a%tually %alled me *or t# s pat ent to be trans*erred under my %are) so t s only %ourteous *or me to %all # m to n*orm # m w#en t#e real de% s on was made *or t#e w *e to undergo t#e surgery8

>:6? 6#e * rst de*endant ask ng t#e pat ent to %all t#e pla nt ** on t#e p#one on t#e morn ng o* t#e ntended surgery and t#e * rst de*endant speak ng to t#e pla nt ** n*orm ng # m o* # s de% s on to per*orm t#e surgery on t#e pat ent *urt#er *ort * es pla nt **7s assert on n t# s regard8 6#e *a%t o* t#e matter s t#at n t#e sa d telep#one %on,ersat on) t#e * rst de*endant sa d not# ng to t#e pla nt ** about t#e n#erent dangers or r sks o* pro%eed ng w t# t#e surgery w t#out a ryle7s tube nserted8 6#e * rst de*endant #ad merely n*ormed t#e pla nt ** o* t#e need *or surgery and t#e %on,ersat on ended w t# t#e pla nt ** agree ng to t#e surgery8 =n *a%t) t#e pla nt ** d d not t# nk t#at t#e surgery #ad ser ous r sks and #e took # s t me to arr ,e at t#e #osp tal t# nk ng t#at t#e surgery would pro%eed r g#t a*ter t#e telep#one %all8 6#e pla nt ** *elt t#at t#ere was no need to see # s w *e be*ore s#e entered t#e operat ng t#eatre) as t#ere was no %ause *or %on%ern8 >@8? 6#ere s also no re%ord n t#e med %al %ase notes to s#ow t#at t#e pat ent #ad been ad, sed o* t#e n#erent and/or mater al r sks o* pro%eed ng w t# t#e surgery w t#out #a, ng #ad a ryle7s tube nserted or w t#out t#e stoma%# be ng empt ed o* ts %ontent8 =n *a%t) *rom t#e test mony o* t#e * rst de*endant) t s apparent t#at t#e pat ent7s %onsent *or t#e surgery as s#own n t#e %onsent *orm $at p 119 o* bundle .+ was not obta ned by t#e * rst de*endant but by # s 1 !"# $% at &1 surg %al tra nee) !r Leong on t#e n g#t be*ore t#e ntended surgery8 6#ere s no w tness to t#e s gnature o* t#e pat ent on t#e %onsent *orm8 6#e * rst de*endant assumes t#at !r Leong would #a,e e<pla ned t#e n#erent and mater al r sks o* t#e surgery but %annot be sure o* t#at8 =n any e,ent) !r Leong was not %alled as a w tness at tr al8 ;#at s e, dent *rom t#e * rst de*endant7s test mony s t#at w#en t#e pat ent s gned t#e %onsent *orm *or surgery) s#e d d so w t#out any ad, %e *rom t#e * rst de*endant w#o was #er pr mary do%tor and s#e d d so on t#e n g#t be*ore t#e * rst de*endant #ad made a de* n te de% s on to pro%eed w t# surgery8 6#e *ollow ng test mony o* t#e * rst de*endant dur ng %ross2e<am nat on s pert nent to t#e ssue?

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7 8 9 10 11 12 13 14

Gounsel? ;ould you agree or d sagree t#at at t#e po nt s#e s gned t# s %onsent *orm) s#e d d not know s#e was undergo ng a ma-or operat onK 1st !e*endant? = would d sagree be%ause = do trust !r Leong and = know #er8 Gounsel? = understand8 .ut you don7t know w#et#er s#e d d t) !o%tor8 1st !e*endant? = wouldn7t know *or sure8 Gounsel? Jou are assum ng t#at s#e d d8 1st !e*endant? Jes) = #ad to8 = #a,e to assume8 Gounsel? Jes8 Iow) =7m also putt ng t to you) !o%tor) t#at s#e only understood t#e mportan%e) t#e nature o* t#e operat on on t#e morn ng w#en you , s ted #er8 And t#at s w#y s#e %alled #er #usband and asked you to speak to # m8 1st !e*endant? Jes8

>@4? 6#e pla nt ** states t#at * t#ere #ad been proper ad, %e or warn ng *rom t#e * rst de*endant) #e would not #a,e allowed t#e surgery to pro%eed) unt l t#e r sk o* asp rat on *rom #er stoma%# %ontent #ad been attended to8 =n *a%t t was t#e pla nt **7s e, den%e t#at?
888 Ione o* t#e do%tors or anyone n /osp tal Duala Lumpur told me o* t#e mportan%e o* %lear ng my w *e7s stoma%# %ontent be*ore t#e operat on was %ondu%ted on #er8 = ne,er knew at t#at t me t#at #er stoma%# %ontent %ould enter #er lung w#en s#e was put to sleep or dur ng t#e operat on8 Ra-a .adrul be ng t#e do%tor n %#arge s#ould #a,e n*ormed me8

&urt#er) t#e pla nt ** states n # s w tness statement t#at?

=* = #ad known o* su%# danger) = would not #a,e allowed t#e operat on to go on8 = would #a,e persuaded my w *e to allow t#e do%tors to nsert t#e tube be*ore t#e operat on or be*ore s#e was put to sleep8 = would #a,e ns sted t#at t#e do%tors not per*orm t#e operat on unt l t#ey #a,e e<#aust ,ely attempted to nsert t#e tube or employed ot#er met#ods to remo,e #er stoma%# %ontents8 /ad = known o* t#e gra,e r sks n,ol,ed and #ad t#e #osp tal been unsu%%ess*ul n remo, ng #er stoma%# 1 !"# $% at &> %ontents be*ore t#e operat on) = would #a,e soug#t se%ond op n on) %#anged do%tors or #osp tal or soug#t treatment elsew#ere8 6#e *a%t o* t#e matter s t#at = was ne,er n*ormed8

>@3? 6#e * rst de*endant #ad also agreed t#at t was n%umbent upon # m to #a,e e<pla ned to t#e pla nt ** t#e mater al and n#erent r sks o* t#e surgery n t#e *ollow ng answers dur ng %ross2 e<am nat on $pp 23@2239 o* t#e notes o* pro%eed ng+8

15 16 17 18

Gounsel $P+? = am suggest ng to you !o%tor) t#at t#e onus s on you to #a,e e<pla ned t to # m *a%e to *a%e8 !o you agree w t# me or do you d sagreeK 1st !e*endant? Jes8 Gounsel $P+? JesK 1st !e*endant? "orry) yes8

&urt#er) at p 2A9 o* t#e notes o* pro%eed ng) t#e * rst de*endant says n %ross2e<am nat on?

19 20

Gounsel $P+? "o t would be natural) wouldn7t t) n t#ose % r%umstan%es) !o%tor) to #a,e d s%ussed #er %ase w t# t#e ne<t2o*2k n) w t# t#e pla nt **K 1st !e*endant? Jes8

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>@:? 6#e * rst) t# rd and * *t# de*endants #a,e agreed n t#e %ourse o* t#e r test mony t#at t#e pat ent was ne,er n*ormed nor %ounseled on t#e r sk o* deat# due to asp rat on dur ng ndu%t on o* anest#es a espe% ally w#en s#e #ad re*used t#e nsert on o* t#e ryle7s tube8 =n *a%t w#en t was suggested to t#e t# rd de*endant t#at t#e pat ent oug#t to #a,e been %ounseled n t# s regard) t#e t# rd de*endant a*ter a long pause agreed w t# %ounsel7s suggest on8 =n l g#t o* t#e t# rd de*endant7s own adm ss on t#at t#e pat ent oug#t to #a,e been %ounseled spe% * %ally on t#e n%reased r sk o* deat# *rom asp rat on * t#e ryle7s tube s not nserted) = * nd t#at t s n%umbent upon t#e * rst) t# rd and * *t# de*endants to #a,e %ounseled t#e pat ent on t#e n%reased r sk o* asp rat on and deat# *rom asp rat on w#en undergo ng t#e surgery w t#out t#e pr or nsert on o* t#e ryle7s tube and t#e empty ng o* t#e stoma%# %ontent8 >@@? 6#e &ederal Gourt n ,oo ,io Na7s %ase #ad stated %learly t#at t#e med %al pra%t t oner s 7duty bound by law to n*orm t#e pat ent w#o s %apable o* understand ng and appre% at ng su%# n*ormat on o* t#e r sk n,ol,ed n any proposed treatment so as to enable t#e pat ent to make an ele%t on o* w#et#er to pro%eed w t# t#e proposed treatment w t# knowledge o* t#e r sks n,ol,ed or de%l ne to be sub-e%ted to su%# treatment78 =n so de% d ng) t#e &ederal Gourt reasoned t#at e,en * e<press %onsent was g ,en n %onsent *orms) t#e ssues to 1 !"# $% at &$ be %ons dered are t#e r sks n,ol,ed n t#e med %al pro%edure n :uest on and w#et#er t#e pat ent #as been su** % ently warned o* su%# r sks8 >@A? /ere t#e *a lure o* t#e * rst) t# rd and * *t# de*endants to n*orm t#e pat ent o* t#e r sk o* deat# *rom asp rat on) n *a%t t#e n%reased r sk o* deat# be%ause o* #er *ull stoma%#) means t#at t#e pat ent #ad not been n*ormed o* a %r t %al r sk *a%tor t#at would #a,e been ne%essary *or #er to take nto %ons derat on n mak ng #er de% s on to pro%eed w t# general anest#es a and surgery8 = * nd t#at t#e * rst) t# rd and * *t# de*endants #a,e *a led to d s%#arge t#e r duty o* %are owed to t#e pat ent to duly to n*orm and ad, se t#e pat ent ade:uately and su** % ently o* t#e n#erent and mater al r sks o* pro%eed ng w t# t#e surgery and anest#es a w t#out t#e nsert on o* a ryle7s tube8 6#e * rst) t# rd and * *t# de*endants #a,e depr ,ed t#e pat ent o* su%# mater al n*ormat on and %aused #er to %onsent to t#e surgery and anest#es a w t#out #a, ng #er appre% ate t#e gra,e r sks n,ol,ed n t#e same8 >@7? 1n t#e ssue o* w#et#er t#e * rst de*endant owes a duty to t#e pla nt ** to n*orm # m o* t#e n#erent r sks o* t#e surgery and anest#es a my * nd ng s as *ollows8 1rd nar ly) n a do%tor pat ent relat ons# p) t#e duty o* %are s owed only to t#e pat ent8 /owe,er) t#ere are e<%ept ons to t# s general pr n% ple8 1ne su%# e<%ept on arose n t#e %ase o* 2urmit 3aur a4p #aswant .ingh + Tung .hin -ospital / 0nor 320124 5 MLJ 2@0 w#ere t#e / g# Gourt #eld t#at t#e %onsent o* t#e pat ent #ersel* was nsu** % ent as t#e %onsent o* t#e #usband was not obta ned *or a #ystere%tomy as re:u red under t#e %onsent *orm8 = %an see t#e ob, ous log % *or t#e #usband7s %onsent to be obta ned n %ases o* #ystere%tomy as t n,ol,es t#e -o nt reprodu%t ,e r g#ts o* #usband and w *e8 =n ot#er nstan%es) %onsent o* t#e ne<t o* k n may also be re:u red n s tuat ons w#ere t#e pat ent s n%apable o* g , ng %onsent or n%apable o* understand ng and appre% at ng t#e nature o* t#e proposed treatment and t#e r sk n,ol,ed8 " m larly) %onsent o* t#e spouse may be re:u red w#en t s e, dent t#at t#e pat ent s dependent on t#e spouse to make de% s ons n regards to t#e proposed med %al treatment or w#en t s e, dent to t#e do%tor t#at t#e de% s ons are be ng made -o ntly by bot# spouses n respe%t o* t#e treatment *or one o* t#e spouses8 >@B? /ere) e,en t#oug# t#e %onsent *orm does not re:u re t#e %onsent o* t#e pla nt **) t#e *a%tual matr < o* t#e %ase nd %ates t#at t#e * rst de*endant owed a duty to n*orm t#e pla nt ** o* t#e nature o* t#e surgery and t#e n#erent and mater als r sk o* t#e pro%edure) espe% ally n l g#t o* t#e pat ent7s re*usal to #a,e t#e ryle7s tube nserted8 6#e *a%t s t#at) t was t#e pla nt ** w#o made t#e de% s on to #a,e t#e pat ent trans*erred *rom 6emerlo# /osp tal to /DL to be attended to by t#e * rst de*endant and spoke to t#e * rst de*endant about t8 6#e * rst de*endant knew o* t# s and t#e

Page 19 trans*er took pla%e only a*ter t#e pla nt ** #ad a telep#one %on,ersat on w t# t#e * rst de*endant8 =t s also an und sputed 1 !"# $% at &% *a%t t#at t#e pat ent a*ter be ng n*ormed o* t#e surgery by t#e * rst de*endant #ad mmed ately %alled t#e pla nt ** on t#e p#one and #ad re:uested t#e * rst de*endant to speak to t#e pla nt ** about t8 6# s %learly nd %ates t#e dependen%e o* t#e pat ent on t#e pla nt ** to make t#e de% s on to pro%eed w t# mmed ate surgery8 6#e pla nt ** n # s e, den%e sa d t#at t#e * rst de*endant #ad merely n*ormed # m t#at emergen%y surgery #ad to be per*ormed on t#e pat ent w t#out n*orm ng o* t#e r sks o* t#e surgery8 6#e pla nt ** test * ed t#at #ad #e been told o* t#e r sks or t#at t#e pat ent was re*us ng t#e ryle7s tube and t#e attended n%reased r sks o* anest#es a under su%# %ond t ons #e would not #a,e agreed to allow t#e pat ent to undergo t#e surgery8 6#e pla nt ** sa d t#at #e made all med %al de% s ons relat ng to t#e pat ent and t#at t#e la%k o* su%# ad, se and n*ormat on meant t#at #e %ould not make an n*ormed de% s on and t#at t# s #as depr ,ed # m *rom tak ng a se%ond op n on8 6#e n,ol,ement o* t#e pla nt ** n t#e pat ent7s de% s on mak ng s ob, ous *rom t#e e, den%e8 6#e * rst de*endant sa d t#at #e does not d s%uss su%# matters o,er t#e telep#one) yet t#e * rst de*endant d d not re:uest t#e pla nt ** to see # m n person and e<pla n t#e mater al and n#erent r sks be*ore pro%eed ng w t# t#e surgery8 =n t#e % r%umstan%e) t would #a,e been prudent *or t#e * rst de*endant to d s%uss t#e pat ent7s med %al %ond t on and t#e proposed treatment and ts mater al and n#erent r sk w t# t#e pla nt ** be*ore t#e surgery8 =n t# s regard) t#e * rst de*endant adm tted t#at #e %ould #a,e done better8 >@C? =n t#e % r%umstan%e) = * nd t#at t#e * rst) t# rd and * *t# de*endants #a,e brea%#ed t#e duty o* %are and t#e pla nt ** #as su%%ess*ully pro,ed negl gen%e aga nst t#ese t#ree de*endants8 =n so *ar as t#e %ase aga nst t#e se%ond de*endant s %on%erned) = * nd t#at s#e #ad a ,ery l m ted role n t#e %are o* t#e pat ent and t#e med %al de% s ons t#at were taken8 6#ere s nsu** % ent e, den%e aga nst t#e se%ond de*endant to establ s# negl gen%e8 As su%# t#e %la m aga nst t#e se%ond de*endant s d sm ssed8 >@6? 6#e * rst) t# rd) and * *t# de*endants are employees o* t#e *ourt# de*endant w# %# owns and operates /DL t#roug# t#e M n stry o* /ealt#8 6#e , %ar ous l ab l ty o* a #osp tal *or t#e negl gen%e o* med %al pra%t t oners employed by t#e #osp tal s well stated by Lord !enn ng MR n 7oe + !inister of -ealth and 0nother Woolley + .ame 31EA54 2 F. @@ w#ere #e #eld?
6#e #osp tal aut#or t es are respons ble *or t#e w#ole o* t#e r sta**) not only *or t#e nurses and do%tors but also *or anest#et sts and surgeons8 =t does not matter w#et#er t#ey are permanent or temporary/res dent or , s t ng) w#ole or part t me8 6#e #osp tal aut#or t es are respons ble *or all o* t#em8

>A8? Hnder t#e % r%umstan%e) t#e *ourt# de*endant s , %ar ously l able *or t#e negl gen%e o* t#e * rst) t# rd and *ourt# de*endants8 =n t#e prem se) 1 !"# $% at && -udgment was entered *or t#e pla nt ** aga nst t#e * rst) t# rd) *ourt# and * *t# de*endants *or damages to be assessed and %ost to be borne by t#e * rst) t# rd) *ourt# and * *t# de*endants8 Claims against first< third< fourth and fifth defendants allowed? claim against second defendant dismissed;

Reported by A* : Mo#amad Ioor