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Malayan Law Journal Reports/2012/Volume 4/Dennis Lee Thian Poh (the irst plainti is the hus!an" o #oh Pau $u ("e%ease"&& ' (rs ) Dr Mi%hael *amy ' +nor , -2012. 4 MLJ /01 , 22 Mar%h 2012 40 pages -2012. 4 MLJ /01

Dennis Lee Thian Poh (the first plaintif is the husband of Hoh Pau Yu (deceased)) & Ors v Dr Michael Sam & !nor
H"#H $O%&T ('%!L! L%MP%&) L!% ()) L!* + $","L S%"T *O S-..-./. O0 .11. .. March .1/. Civil Procedure -- Pleadings -- Parties bound by -- Plaintiffs in medical negligence suit pleaded specific causes of deceased patient's death -- Plaintiffs presented different case in court -Pleaded case not proven -- Whether court had no option but to dismiss suit -- Whether hospital where patient died vicariously liable for acts/omissions of consultant doctor -- Whether fact patient knew consultant was independent contractor and specifically chose him as her doctor released hospital from vicarious liability The "e%ease" in this a%tion2 a lawyer2 "ie" in hospital hours a ter she ha" gi)en !irth to her se%on" "aughter an" a ter a su""en onset o hea)y !lee"ing3 The "e%ease"4s hus!an" (4the irst plainti 4& an" her two %hil"ren (4the se%on" an" thir" plainti s4& !rought this a%tion against the %onsultant o!stetri%ian an" gynae%ologist (4the irst "e en"ant4& who ha" atten"e" to the "e%ease" an" the hospital (4the se%on" "e en"ant4& where the in%i"ent too5 pla%e3 They !rought the %laim as "epen"ants o the "e%ease" un"er s 0 o the 6i)il Law +%t 178/3 The plainti s4 %auses o a%tion against the "e en"ants were oun"e" upon allege" !rea%hes o "uty o %are an" o %ontra%t an" or negligen%e3 +s against the se%on" "e en"ant2 the plainti s %laime" it was lia!le or the a%ts an" omissions o the irst "e en"ant as it was un"er a non,"elega!le "uty to treat patients9 a "uty it %oul" not "is%harge !y "elegating the same to the irst "e en"ant un"er a %ontra%t or ser)i%es3 The irst "e en"ant "enie" the allegations an" %onten"e" he ha" a%te" in a%%or"an%e with what was legally e:pe%te" o him3 The se%on" "e en"ant "enie" it ha" negligently %ause" the "e%ease"4s "eath an" maintaine" that e)en i the irst "e en"ant was oun" to !e lia!le2 it woul" not !e )i%ariously lia!le as the irst "e en"ant was an in"epen"ent %ontra%tor3 The se%on" "e en"ant also "enie" it ha" !rea%he" any a%%epte" stan"ar" o %are in pri)ate hospitals in Malaysia3 ;n their amen"e" statement o %laim2 the plainti s plea"e" that what le" to or %ause" the "e%ease"4s "eath was 4massi)e post,partum haemorrhage (4PP#4& in the %ourse o in"u%tion4 o la!our or2 alternati)ely2 e:%essi)e !lee"ing "ue to a uterine tear3 The "e en"ants su!mitte" that the plainti s were !oun" !y their plea"ings an" %oul" not present a "i erent %ase in %ourt3 The irst,%ite" reason or the "eath2 the "e en"ants argue"2 was illogi%al as PP# !y its )ery "e inition was something that happene" a ter "eli)ery while in"u%tion was a pre, "eli)ery 4 M ! "#$ at "#4 pro%e"ure3 +s or the alternati)e reason plea"e"2 the "e en"ants sai" there was no e)i"en%e the "e%ease" ha" su ere" a uterine tear3 Held2 "ismissing the %laims with %osts<

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The plainti s were !oun" !y their plea"e" %ase on %ausation3 =hen there was a mar5e" "eparture rom the plea"e" %ase2 as was the %ase here2 the %ourt ha" no option !ut to "ismiss the %ase on that groun" alone (see paras 1/,10&3 The plainti s aile" to pro)e their plea"e" %ase that the "eath was %ause" !y PP# in the %ourse o in"u%tion or e:%essi)e !lee"ing "ue to a uterine tear3 PP# was !lee"ing in e:%ess o 800 mls within 24 hours o "eli)ery while in"u%tion was !e ore "eli)ery3 The plainti s4 e:pert %on%e"e" the %ontention was illogi%al an" agree" it %oul" not happen3 +s to the allegation o uterine tear2 the irst "e en"ant oun" no tear or rupture when he e:amine" the uterus9 neither "i" the histopathology report mention that the uterus was torn or rupture" (see paras 104(!& ' 41,44&3 The plainti s aile" to esta!lish that the se%on" "e en"ant ha" !rea%he" the appli%a!le stan"ar" o %are or pri)ate hospitals in Malaysia3 >o relia!le e)i"en%e was a""u%e" as to what was the appli%a!le stan"ar" o %are or pri)ate hospitals in Malaysia in the year 2000 whi%h the se%on" "e en"ant ha" !rea%he" (see paras 104(%& ' ?7&3 The se%on" "e en"ant was not )i%ariously lia!le or the irst "e en"ant4s a%ts an" omissions3 The "e%ease" an" the irst plainti ha"2 upon her a"mission to the hospital2 agree" to !e !oun" !y the se%on" "e en"ant4s %on"itions o ser)i%e one o whi%h was that all %onsultants at the hospital were in"epen"ent %ontra%tors whose instru%tions woul" !e %arrie" out !y the hospital an" its nursing sta 3 The "e%ease" ha" also spe%i i%ally %hosen the irst "e en"ant as her o!stetri%ian (see paras 104(e&2 71,74&3 The "e en"ants ha" not !rea%he" their "uty o %are to the "e%ease" nor %ause" or materially %ontri!ute" to her "eath3 The plainti s ha" not pro)en that the %ause o "eath was PP# that was not atten"e" to !y the "e en"ants9 rather the %ourt oun" the "e%ease" "ie" "ue to +mnioti% @lui" Am!olism (+@A& "espite the e orts ma"e !y the irst "e en"ant an" a team o me"i%al spe%ialists an" me"i%al support sta (see para 104("&&3

*i mati "alam tin"a5an ini2 seorang peguam2 meninggal "unia "i hospital !e!erapa Bam selepas "ia melahir5an ana5 perempuan 5e"uanya "an selepas !ermulanya pen"arahan yang !anya5 se%ara ti!a,ti!a3 *uami si mati (4plainti pertama4& "an "ua orang ana5,ana5nya (4plainti 5e"ua "an 5etiga4& mem!uat 4 M ! "#$ at "#% tin"a5an ini terha"ap perun"ing o!stetri5 "an pa5ar sa5it puan (4"e en"an pertama4& yang telah merawat si mati "an hospital (4"e en"an 5e"ua4& "i mana 5eBa"ian terse!ut !erla5u3 Mere5a mem!awa tuntutan se!agai tanggungan si mati "i !awah s 0+5ta Cn"ang,Cn"ang *i)il 178/3 Dausa tin"a5an plainti terha"ap "e en"an,"e en"an a"alah !erasas5an atas "a5waan pelanggaran 5ewaBipan !erhati,hati "an 5ontra5 "an 5erana 5e%uaian3 Terha"ap "e en"an 5e"ua pula2 plainti men"a5wa ia !ertanggungBawa! 5e atas per!uatan,per!uatan "an 5etinggalan, 5etinggalan "e en"an pertama 5erana ia a"alah "i !awah 5ewaBipan 4non,"elega!le4 untu5 merawat pesa5it9 5ewaBipan yang ti"a5 "apat "ilepas5an "engan mewa5il5an 5epa"a "e en"an pertama "i !awah 5ontra5 !agi per5hi"matan3 De en"an pertama mena i5an "a5waan,"a5waan terse!ut "an menegas5an !ahawa "ia telah !ertin"a5 mengi5ut apa yang "iamanah5an oleh un"ang,un"ang 5epa"anya3 De en"an 5e"ua mena i5an ia telah %uai "alam menye!a!5an 5ematian si mati "an menge5al5an huBahan !ahawa walaupun "e en"an pertama telah "i"apati !ertanggungBawa!2 ia ti"a5 a5an menBa"i lia!iliti )i5arius 5erana "e en"an pertama a"alah seorang 5ontra5tor !e!as3 De en"an 5e"ua Buga mena i5an !ahawa ia telah melanggar mana, mana stan"ar" penBagaan yang "iterima "i hospital,hospital swasta "i Malaysia3 Dalam penyataan tuntutan terpin"a mere5a2 plainti mempli"5an !ahawa apa yang mem!awa atau menye!a!5an 5ematian si mati a"alah 4massi)e post,partum haemorrhage (4PP#4& in the %ourse

Page 4 o in"u%tion4 atas se!a! !ersalin atau2 se!agai alternati 2 pen"arahan yang !erle!ihan 5erana 5oya5an "i uterine3 De en"an,"e en"an menghuBah5an !ahawa plainti a"alah teri5at "engan pli"ing mere5a "an ti"a5 "apat mem!entang5an 5es yang !er!eEa "i mah5amah3 *e!a! pertama 5ematian yang "inyata5an2 "e en"an,"e en"an !erhuBah2 a"alah ti"a5 logi5 5erana PP# melalui "e inisinya2 a"alah sesuatu yang !erla5u selepas !ersalin mana5ala in"u5si a"alah satu prose"ur pra,!ersalin3 Fagi alasan alternati yang "ipli"5an2 "e en"an,"e en"an menghuBah5an !ahawa tia"a !u5ti yang si mati telah mengalami 5oya5an pa"a uterine3 Diputus2an2 menola5 tuntutan,tuntutan "engan 5os<

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Plainti a"alah teri5at "engan 5es yang mere5a pli"5an atas 5ausa3 +pa!ila ter"apat satu penyimpangan yang 5etara "aripa"a 5es yang "ipli"5an2 seperti "alam 5es ini2 mah5amah ti"a5 mempunyai pilihan selain menola5 5es terse!ut atas alasan terse!ut sahaBa (lihat perenggan 1/,10&3 Plainti gagal mem!u5ti5an 5es yang mere5a pli"5an !ahawa 5ematian terse!ut "ise!a!5an oleh PP# "alam perBalanan in"u5si atau pen"arahan yang !erle!ihan "ise!a!5an oleh 5oya5an pa"a uterine3 PP# pen"arahan mele!ihi 800 mls "alam tempoh 24 Bam selepas !ersalin se"ang5an in"u5si a"alah se!elum !ersalin3 Pa5ar plainti sen"iri menga5ui huBahan terse!ut ti"a5 logi5 "an !ersetuBu ia ti"a5 !oleh !erla5u3 Fagi "a5waan 5oya5an pa"a uterine2 "e en"an pertama ti"a5 4 M ! "#$ at "#" menBumpai se!arang 5oya5an atau ruptur semasa "ia memeri5sa uterus9 laporan histopatologi Buga ti"a5 menye!ut !ahawa rahim 5oya5 atau ruptur (lihat perenggan 104(!& ' 41,44&3 Plainti gagal untu5 mem!u5ti5an !ahawa "e en"an 5e"ua telah melanggar stan"ar" !erhati,hati "i hospital swasta "i Malaysia3 Tia"a !u5ti yang !oleh "iBa"i5an san"aran !er5enaan apa5ah stan"ar" !erhati,hati yang terpa5ai "i hospital swasta "i Malaysia pa"a tahun 2000 yang telah "e en"an 5e"ua mung5iri (lihat perenggan 104(%& ' ?7&3 De en"an 5e"ua ti"a5 !ertanggungan se%ara )i5arius 5e atas per!uatan "an 5etinggalan "e en"an pertama3 *i mati "an plainti pertama telah2 apa!ila si mati "imasu55an "alam hospital terse!ut2 !ersetuBu untu5 teri5at "engan syarat per5hi"matan "e en"an 5e"ua "i mana semua perun"ing "i hospital a"alah 5ontra5tor !e!as yang arahannya a5an "iBalan5an oleh piha5 hospital "an 5a5itangan Bururawat3 *i mati Buga telah se%ara 5husus memilih oleh "e en"an pertama se!agai pa5ar o!stetri5 (lihat perenggan 104(e&2 71 ' 74&3 De en"an,"e en"an ti"a5 melanggar 5ewaBipan !erhati,hati mere5a 5epa"a si mati ataupun menye!a!5an atau se%ara material menyum!ang 5epa"a 5ematiannya3 Plainti ,plainti ti"a5 mem!u5ti5an !ahawa pun%a 5ematian a"alah PP# yang ti"a5 "irawat oleh "e en"an9 se!ali5nya mah5amah men"apati !ahawa si mati meninggal "unia a5i!at amniotic fluid embolism (4+@A4& walaupun usaha,usaha yang "i!uat oleh "e en"an pertama "an se5umpulan pa5ar,pa5ar peru!atan "an 5a5itangan so5ongan peru!atan (lihat perenggan 104("&&3

*otes @or %ases on parties !oun" !y plea"ings2 see 2(1& Mallal's &igest (4th A"2 2010 Reissue& paras /128,/1273 $ases referred to

Page 8 'ik Ming (M) *dn +hd , -rs v Chang Ching Chuen , -rs and another appeal -1778. 2 MLJ 0009 -1778. 1 6LJ /172 6+ (re "& 'n.alai 'mmal , 'nor v 'bdul /areem -17/7. 1 MLJ 222 @6 (re "& 'rulappan /annan v &r *uresh Chopra , -rs -2011. 1 6LJ //22 #6 (re "& +P0 0nternational 1inance td (formerly known as 'yala 1inance (2/) td) v 3engku 'bdullah 0bni *ultan 'bu +akar -2007. 4 MLJ ?212 6+ (re "& +ull and 'nother v &evon 'rea 2ealth 'uthority 22 FMLR 07 ("ist"& Cassidy v Ministry of 2ealth -1781. 1 +ll AR 8042 6+ (re "& Chester v 'fshar -2002. 1 +ll AR 8822 6+ (re "& &r Chin 4oon 2iap v 5g 6u /hoon , -rs and other appeals -177?. 1 MLJ 809 -177?. 1 6LJ 8112 6+ (re "& &r Wong Wai Ping , 'nor v Woon in *ing , -rs -1777. / 6LJ 212 #6 (re "& 4 M ! "#$ at "## 1arra. and another v /ing's 2ealthcare 52* 3rust and another -2007. +ll AR (D& 18?2 6+ ( oll"& 1oo 1io 5a v &r *oo 1ook Mun , 'nor -2000. 1 MLJ 8712 @6 (re "& 7imstern Corporation (M) *dn +hd , 'nor v 7lobal 0nsurance Co *dn +hd -17?0. 1 MLJ 1022 *6 (re "& 7old v 6sse8 County Council -1742. 2 DF 2712 6+ (re "& 2or *ai 2ong dan satu lagi lwn 9niversiti 2ospital dan satu lagi -2002. 8 MLJ 1/09 -2001. ? 6LJ 20?2 #6 (re "& echemanavasagar a/l * /aruppiah v &r 3homas 4au Pak Chenk , 'nor -200?. 1 MLJ 1182 #6 (re "& eung v Campbell -1778. (J >o 10 (not oll"& iau Mui Mui v &r : ;enkat /rishnan -1777. 1 6LJ 2002 #6 (re "& Munusamy v PP -17?0. 1 MLJ 4722 *6 (re "& 5ational !ustice Compania 5aviera *' v Prudential 'ssurance Co td -1771. 2 Lloy"4s LR /? (re "& Pekan 5enas 0ndustries *dn +hd v Chang Ching Chuen , -rs -177?. 1 MLJ 4/82 @6 (re "& :2+ +ank +hd (subsituting /wong 4ik +ank +hd) v /wan Chew 2oldings *dn +hd -2010. 2 MLJ 1??9 -2010. 1 6LJ //82 @6 ( oll"& :oe v Ministry of 2ealth -1784. 2 +ll AR 1119 -1784. 2 GF //2 6+ (re "& :ogers v Whitaker (1772& 108 6LR 407 (re "& :osenberg v Percival (2001& 208 6LR 414 (re "& *idaway v +oard of 7overnors of the +ethlem :oyal 2ospital and the Maudsley 2ospital , -rs -17?8. 1 +6 ?012 #L (re "& *istem Penyuraian 3rafik / +arat *dn +hd v /enny 2eights &evelopment *dn +hd , 'nor -2007. 1 MLJ ?079 -2007. 4 6LJ 802 6+ (re "& *tate 7overnment of Perak v Muniandy -17?/. 1 MLJ 4702 *6 (re "& Whitehouse v !ordan , 'nor -17?0. 1 +ll AR /802 6+ (re "&

Page / Wu *iew 4ing t/a 1uh in +ud-7rafting Centre v 7unung 3unggal <uarry , Construction *dn +hd , 'nor -2011. 2 MLJ 19 -2011. 1 6LJ 4072 @6 (re "& 4ew Wan eong v ai /ok Chye -1770. 2 MLJ 1822 *6 (re "& Le3islation referred to 6i)il Law +%t 178/ s 0 A)i"en%e +%t 1780 ss 1012 1022 114(g& *harmini 5avaratnam (*iva &harma , 'ssociates) for the plaintiffs= &arryl 7oon (Maid>uara bt Mohammed with him) (:a.a? &arryl , oh) for the first defendant= &hinesh +haskaran (/ 5avinderan with him) (*hearn &elamore , Co) for the second defendant= Lau (ee Lan +4 5/6 This a%tion arose ollowing the "emise o Ma"am #oh Pau $u 4 M ! "#$ at "#@ (4"e%ease"4&2 a patient o the irst "e en"ant2 Dr Mi%hael *amy2 a %onsultant o!stetri%ian an" gynae%ologist ha)ing a pra%ti%e with a %lini% at the se%on" "e en"ant2 Hleneagles #ospital (DL& *"n Fh"3 The plainti s4 %laims against the "e en"ants are ma"e pursuant to s 0 o the 6i)il Law +%t 178/ as "epen"ants o Ma"am #on Pau $u ("e%ease"&3 The irst plainti 2 Dennis Lee Thian Poh is the hus!an" o Ma"am #oh Pau $u ("e%ease"& whilst the se%on" an" thir" plainti s2 the %hil"ren o the same are minors an" their %laim is ma"e through their ather an" ne:t rien"2 the irst plainti 3 There is no %laim !y the estate o Ma"am #oh Pau $u ("e%ease"&3 5.6 The plainti s4 %auses o a%tion against the irst an" se%on" "e en"ants are oun"e" upon an allege" !rea%h o "uty2 negligen%e an" !rea%h o %ontra%t3 The irst "e en"ant !asi%ally "enies the sai" allegations an" %onten"s that )is,a,)is the patient2 he has a%te" in a manner an" in a%%or"an%e with what is e:pe%te" o him in law3 The se%on" "e en"ant essentially "enies that ,, (i& it has !rea%he" any a%%epte" stan"ar" o %are in pri)ate hospitals in Malaysia9 (ii& it has negligently %ause" the patient4s "eath9 an" (iii& it is not )i%ariously lia!le e)en i the irst "e en"ant is oun" lia!le as the irst "e en"ant is an in"epen"ent %ontra%tor3 576 The trial o this a%tion pro%ee"e" on the "etermination o only the issue o lia!ility an" i lia!ility is esta!lishe"2 the issue o Iuantum o "amages will %onseIuentially !e "etermine"3 586 #a)ing %onsi"ere" the su!missions o the parties ; "ismisse" the plainti s4 %laims with %osts3 The reasons or the %ourt4s "e%ision are set out !elow3 PL)!D"*#S 596 The !ur"en o proo is on the plainti s to satis y the %ourt that on a !alan%e o pro!a!ilities<

1a) 1b) 1c) 1d)

the "e en"ants owe" them a "uty o %are9 the "uty o %are was !rea%he"9 the plainti s ha" su ere" "amages as a result o the sai" !rea%h9 an" %ausation ie that it was the "e en"ants4 !rea%h o "uty that %ause" the plainti s to su er the loss an" "amage3

(ss 101 an" 102 o the A)i"en%e +%t 17809 6ssentials of Medical aw !y $eo Dhee Guan ' 8 (rs (2004& at p 148&3

Page 0 4 M ! "#$ at "#A 5:6 #owe)er in the %ir%umstan%es o this %ase ; shall !e a""ressing the issue o %ausation irst rather than the !rea%h o "uty o %are issue2 the reason o whi%h will !e%ome apparent later3 5;6 ;t is trite that the plainti s !ear the !ur"en o pro)ing that the irst an" se%on" "e en"ants4 a%ts or omissions %ause" the patient4s "eath as opine" !y the @e"eral 6ourt in Wu *iew 4ing t/a 1uh in +ud-7rafting Centre v 7unung 3unggal <uarry , Construction *dn +hd , 'nor -2011. 2 MLJ 19 -2011. 1 6LJ 407 at p 421 @,H<
@or the plainti to su%%ee" in a %laim or negligen%e2 it is essential or him to pro)e among others that the inBury %ause" to him was "ue to the "e en"ant4s negligen%e3 3here must be a link between the wrongdoing and the damage caused= 3he burden of proving this link is upon the plaintiff ,, see +onnington Casting td v Wardlaw 3333 (Amphasis a""e"3&

5<6 The plainti s in para 1? o the amen"e" statement o %laim plea"e"<

The "e%ease" un"erwent the in"u%tion on or about BACD hours on 43113003 0n the course of the induction the deceased suffered massive post partum haemorrhage %ausing the "e%ease"4s "emise3 +lternati)ely2 the "e%ease" su ere" e8cessive bleeding "ue to a uterine tear2 whi%h le" to the "e%ease"4s "emise3 (Amphasis a""e"3&

5=6 Thus a%%or"ing to the plainti s themsel)es2 the patient4s "eath was %ause" !y either<

2a) 2b)

massi)e post partum haemorrhage (4PP#4& in the %ourse o in"u%tion9 or e:%essi)e !lee"ing "ue to a uterine tear3

5/16 +s highlighte" !y the se%on" "e en"ant it is signi i%ant to o!ser)e that the plainti s ha" 4 ull me"i%al an" legal input an" representation4 at the time they ma"e the a oresai" spe%i i% allegations regar"ing %ausation in the amen"e" statement o %laim3 This is !orne !y the ollowing<

3a) 3b) 2c)

the plainti s4 amen"e" statement o %laim was only "ra te" an" this suit was ile" on 21 +pril 20029 the "ra ting o the plea"ing was "one well a ter the plainti s ha" %onsulte" their e:perts2 Dr Lim Foon #oe (4P=24& whose report is "ate" 10 June 2001 an" Mr DJ Tu nell2 whose report is "ate" 10 May 2001 (4P=14&9 an" P=24s letter "ate" 1? May 2001 to P=1 (!un"le H p 1& in see5ing his 4opinion regar"ing the %ausation o the un ortunate patient4s "eath ollowing %hil"!irth4 state"<
4 M ! "#$ at "@D +s you 5now2 the hus!an" o the "e%ease"2 Mr Dennis Lee has as5e" me to prepare a report in or"er to initiate the litigation pro%e"ure against the (!stetri%ian an" the #ospital3

5//6 Learne" %ounsel or the irst "e en"ant similarly re erre" to para 1? o the amen"e" statement o %laim an" su!mitte" that they o!Be%te" to the %ase presente" !y the plainti s as it was not plea"e"3 The irst "e en"ant su!mitte" that it was %ommon groun" that the patient "i" not su er rom PP# "uring in"u%tion9 (ii& the patient %oul" not ha)e su ere" PP# "uring in"u%tion !e%ause !y "e inition2 PP# is a ter "eli)ery an" in"u%tion is !e ore "eli)ery3 5/.6 The se%on" "e en"ant hel" the same position an" su!mitte"<

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;n"u%tion is the pre,la!our perio" rom !e ore the onset o la!our to when la!our is esta!lishe"3 Post,partum haemorrhage on the other han"2 !y its )ery "e inition2 is an e)ent that o%%urs post,partum ie a ter "eli)ery3

5/76 ;n this %onne%tion ; in" the irst an" se%on" "e en"ants4 position in that it is impossi!le or the "e%ease"4s "eath to ha)e !een %ause" !y massi)e PP# in the %ourse o in"u%tion is %on irme" when Dr Lim (P=2& %on%e"e" that the plainti s4 %ontention was illogi%al an" there ore it %oul" not happen when it was put to him in %ross,e:amination an" ha" state" 4333 ;n"u%tion has not resulte" ;n the "eli)ery yet2 ;n"u%tion is only pre,;a!our e)ent3 333 -PP#. !y "e inition is post, partum so -it %annot !e that in the %ourse o in"u%tion the patient su ere" massi)e PP# %ausing the "eath.43 5/86 ;n relation to the alternati)e allegation o uterine tear2 ; in" this allegation is unwarrante" in that the e)i"en%e a""u%e" showe" the %ontrary as<

4a) 4b)

the irst "e en"ant2 the only eye witness who e:amine" the uterus himsel an" oun" no tear or rapture9 an" there is no mention that the patient4s uterus was either torn or rapture" in the histopathology report (!un"le D p 70&3

5/96 ;n a%t as early as 12 +pril 2011 learne" %ounsel or the se%on" "e en"ant registere" their o!Be%tion2 whi%h was a"opte" !y learne" %ounsel or the irst "e en"ant2 stating<
+ ter assessing the e)i"en%e o Dr Tu nell (P=1& an" to an e:tent the e)i"en%e in re,e:amination o Dr3 Lim2 ; in" that there is a signi i%ant "eparture rom the Plainti s plea"e" %ase3 @or a)oi"an%e o "ou!t2 ; will want it to !e re%or"e" our o!Be%tion at this stage3 =ill ta5e it up in su!mission3

4 M ! "#$ at "@B 5/:6 ;n the %ir%umstan%es ; wholly agree" with learne" %ounsel or the se%on" "e en"ant that the plainti s are un"ou!te"ly !oun" !y their plea"e" %ase on %ausation as hel" !y the @e"eral 6ourt in :2+ +ank +hd (subsituting /wong 4ik +ank +hd) v /wan Chew 2oldings *dn +hd -2010. 2 MLJ 1??9 -2010. 1 6LJ //8 at p 202 paras 11 an" 18 (MLJ&9 pp /07,/?0 paras 11 an" 18 (6LJ& that<
;t is a %ar"inal rule in %i)il litigation that the parties must a!i"e !y their plea"ings 333 The parties shoul" 5now !est as to what they want an" it is not or the %ourt to pursue a %a)alier approa%h to sol)ing their "ispute !y in)enting or %reating %ause or %auses o a%tion whi%h were not plea"e" in the irst pla%e 3333

5/;6 Parties must ne%essarily !e !oun" !y their plea"ings2 an" when there is a mar5e" "eparture rom the plea"e" %ase as is the %ase here2 the %ourt has no other option !ut to a"opt the time, honoure" prin%iple an" "ismiss the plainti s4 %ase on this groun" alone3 ( rele)an%e here also are the %ases o superior %ourts %ite" !y the irst "e en"ant namely2 'n.alai 'mmal , 'nor v 'bdul /areem -17/7. 1 MLJ 22 (*6&2 *tate 7overnment of Perak v Muniandy -17?/. 1 MLJ 470 (*6&2 7imstern Corporation (M) *dn +hd , 'nor v 7lobal 0nsurance Co *dn +hd -17?0. 1 MLJ 102 (*6&2 4ew Wan eong v ai /ok Chye -1770. 2 MLJ 182 (*6& at p 188 6,@ (le t %olumn&2 +P0 0nternational 1inance td (formerly known as 'yala 1inance (2/) td) v 3engku 'bdullah 0bni *ultan 'bu +akar -2007. 4 MLJ ?21 (6+& at p ?10 paras 2? an" 273 5/<6 ;n the e)ent ; err2 ; will now %onsi"er whether the plainti s ha)e pro)en their %ase as per the prereIuisite elements mentione" in para 8 a!o)e ha)ing regar" to the issues raise" !y the plainti s3 0!"L%&) TO )>PL!"* TH) &"S'S O0 "*D%$T"O* TO TH) P!T")*T

Page 7 5/=6 The plainti s su!mitte" that misoprostol or its tra"e name %ytote% is not li%en%e" or use in in"u%tion o la!our9 it is mar5ete" an" use" or the pre)ention an" treatment o pepti% ul%ers3 The letter rom HD *earie ' 6o2 the manu a%turer o %ytote% with the warning 4Drug =arning on Misoprostol4 was not e)i"en%e !e ore the %ourt3 #owe)er as pointe" out !y the plainti s the sai" +ugust warning letter was allu"e" to in e:h D113 =hat is signi i%ant is e:h D11 is a positi)e response rom +6(H (+meri%an 6ollege o (!stetri%ians an" Hynae%ologists& "ate" 10 >o)em!er 2000 on the sai" +ugust warning letter that<
The +6(H "o%ument strongly a irms e:isting +6(H opinion that misoprostol ,, a "rug manu a%ture" or treatment o gastri% ul%ers un"er the tra"e name 6ytote%J ,, %an !e use" sa ely an" e e%ti)ely o ,la!el or %er)i%al ripening an" la!or in"u%tion3

4 M ! "#$ at "@C This shows that me"i%ally the use o misoprostol is supporte" an" re%ommen"e" !y +6(H an" to "ate e)en =#( (=orl" #ealth (rganisation& an" @;H( (;nternational @e"eration o Hynae%ology an" (!stetri%s& re%ommen" the use o misoprostol or in"u%tion3 There ore it %annot !e sai" that the use o misoprostol as an in"u%tion agent is %ontrary to me"i%al opinion3 5.16 The plainti s %onten"e" that sin%e the la!our was in"u%e" on 8 >o)em!er 2000 whi%h is a ter the +ugust 2000 letter issue" !y the manu a%turer o misoprostol to physi%ians on the sa ety %on%erns in a")ising against the use o misoprostol in pregnant women2 Dr Mi%hael *amy2 the irst "e en"ant woul" !e "eeme" to ha)e noti%e o the warning letter an" there ore pro%ee"e" at his peril when he "e%i"e" to use misoprostol to in"u%e la!our on the patient2 M"m #o Pau $u on 8 >o)em!er 20003 5./6 +s %orre%tly su!mitte" !y the irst "e en"ant2 as the sai" warning letter per se was not in e)i"en%e an" it is not pro)en that the irst "e en"ant re%ei)e" any warning letter an" neither is it 5nown that the sai" letter was sent to Malaysia2 it woul" !e grossly un air to ma5e re eren%e to the sai" letter an" to "eem that the irst "e en"ant shoul" ha)e 5nown o its %ontents an" shoul" not use %ytote% or in"u%tion3 ?H)TH)& TH) DOS!#) %S)D 0O& "*D%$T"O* O0 L!(O%& ?!S !PP&OP&"!T) 5..6 The plainti s sought to rely on the (i& +6(H 6lini%al Management Hui"elines on ;n"u%tion o La!our2 +6(H Te%hni%al Fulletin >o 102 a summary o whi%h is oun" in the +meri%an @amily Physi%ian "ate" 18 July 2000 (+ppen"i: +&9 (ii& (!stetri% Cse o Misoprostol Vol 42 ;ssue 1 *eptem!er 2002 ;n"iana Perinatal >etwor5 !y Dr Dan *un5el (+ppen"i: F&9 an" (iii& *o%iety o (!stetri%ians an" Hynae%ologists o 6ana"a (*(H6& 6lini%al Pra%ti%e Hui"elines >o 1002 +ugust 2001 (+ppen"i: 6&3 +ll these three appen"i:es are anne:e" to the plainti s4 written su!mission3 The %ourt is o the )iew that these "o%uments %annot !e relie" on !y the plainti s as they were not re erre"/ten"ere" at the trial an" the "e en"ants nor their witnesses were ne)er allowe" to a""ress the same3 5.76 +s pointe" out !y the irst "e en"ant2 prior to 8 >o)em!er 2000 an" at the time the irst "e en"ant use" %ytote% on the patient2 the only su!stantial stu"y on the use o misoprostol was the pu!li%ation o the ;nternational Journal o Hyne%ology an" (!stetri%s in 177/ (e:h D12& whi%h was supporti)e o the use o misoprostol or in"u%tion/augmentation an" the "osage o 100 meg intra)aginally3 4 M ! "#$ at "@$ 5.86 The warning gi)en !y the manu a%turers o %ytote% (!un"le D p 71& %ontaine" in the pamphlet a%%ompanying the "rug is 46ytote% is %ontrain"i%ate" in pregnant women an" in women planning a pregnan%y as it in%reases uterine tone an" %ontra%tions in pregnan%y whi%h may %ause partial or %omplete e:pulsion o the pro"u%ts o %on%eption43 +s %orre%tly pointe" !y the irst "e en"ant what is signi i%ant is that an in%rease in uterine tone is ne%essary in !ringing a!out

Page 10 la!our9 as to the %onseIuen%es o %ausing 4partial or %omplete e:pulsion o the pro"u%ts o %on%eption42 it "i" not o%%ur in this instant %ase as the thir" plainti was "eli)ere" well3 ?!&*"*# O0 &"S'S !SSO$"!T)D ?"TH $YTOT)$ 5.96 The irst plainti 2 P=1 state" that the irst "e en"ant "i" not e:plain how the in"u%tion was to !e %arrie" out or what "rugs were going to !e use" or the in"u%tion an" "i" not e:plain any ris5s o in"u%tion o la!our or augmentation o la!our3 The plainti s %onten" no in ormation on the ris5s an" !ene its o using misoprostol or in"u%tion was pro)i"e" to the patient to ma5e an in orme" "e%ision whether to pro%ee" with the in"u%tion o la!our using misoprostol3 5.:6 ;t is not "ispute" %ytote% was use" in the augmentation o the patient4s la!our namely (i& 100 meg was irst inserte" per the patient4s )agina at 0320pm on 4 >o)em!er 2000 (ii& when +RM was e e%te" an" the hal ta!let o %ytote% (100m%g& %ame out together with the lowing liIuor 4almost inta%t42 a Iuarter ta!let o %ytote% (80 meg& was gi)en to the patient (=*P=1 G'+1?,17&3 5.;6 There was no warning o any material ris5 in relation to the use o %ytote% !e%ause in the year 20002 the me"i%al worl" was not aware o any material ris53 ;n 2000 there is no e)i"en%e that the me"i%al pro ession 5new o any material ris5 that is asso%iate" with the use o %ytote% or in"u%tion/augmentation o la!our3 Literature a""u%e" !y the plainti s were pu!lishe" a ter 2000 (see &r Chin 4oon 2iap v 5g 6u /hoon , -rs and other appeals -177?. 1 MLJ 809 -177?. 1 6LJ 811 (6+&9 :oe v Ministry of 2ealth -1784. 2 +ll AR 111 (Anglish 6ourt o +ppeal&3 (n the other han" misoprostol remains a re%ommen"e" "rug or the in"u%tion/augmentation o la!our !y @;H( (e:h D2/& an" =#( (e:h D20&3 5.<6 There is merit in the irst "e en"ant4s su!mission that there was no !rea%h o any "uty o %are owe" to the patient in not in orming o any material risk that may !e asso%iate" with the use o %ytote%<

5a)

5b) 3c)

2d)

the "uty the law imposes is the nee" to warn o material ris5 an" not Bust o any ris5 (see 1oo 1io 5a v &r *oo 1ook Mun , 'nor -2000. 1 MLJ 871 at p /01 where the @e"eral 6ourt a"opte" the test propoun"e" in :ogers 4 M ! "#$ at "@4 v Whitaker (1772& 108 6LR 407 at p 4?7 (#6 o +ustralia& an" ampli ie" in :osenberg v Percival (2001& 208 6LR 414 at p 4409 as there is e)i"en%e that the me"i%al worl" then "i" not 5now o any ris5 in the year 2000 or parti%ularly at the material time2 4 >o)em!er 2000 an" 8 >o)em!er 20009 D=14s e)i"en%e that %ytote% was %ommonly use" !y o!stetri%ians in Malaysia an" in the se%on" "e en"ant hospital2 pre,%ut ta!lets into hal)es (100m%g& an" Iuarters (80m%g& are store" in separate %ontainers an" ma"e rea"ily a)aila!le at the hospital4s la!our war"9 an" e)i"en%e o the irst "e en"ant4s e:pert witness2 Datu5 Dr +EiE2 a *r 6onsultant (!stetri%ian an" Hynae%ologist (D=1& that at that time an" in Malaysia there was no generally 5nown ris5 asso%iate" with %ytote% an" in 2000 no re%ommen"e" "osage or in"u%tion or augmentation o la!our an" in his written opinion state" that the 100m%g "osage use" !y the irst "e en"ant was not un%ommon an" there were no proto%ols issue" !y the Ministry o #ealth or any other authoritati)e !o"y in 2000 o its use or "osage or in"u%tion or augmentation o la!our (!un"le @ p 114&3

5.=6 The e)i"en%e re)eale" that the patient was an:ious to get on with the augmentation o her la!our as %oul" !e in erre" rom her response to the irst "e en"ant 4might as well2 might as well4 to augmentation o la!our3 The patient was a"mitte" on 4 >o)em!er 2000 at a!out 2317pm9 at a!out 8310pm ha" a slight show with wea5 %ontra%tions2 one %ontra%tion e)ery si: minutes lasting or 28 se%on"s (1</<28&9 ha" mil" tightenings an" the oetal hea" was note" to !e in the pel)i% !rim in"i%ating that the patient was in the early stages o pro%ess o la!our3 ;t was aroun" 0320pm

Page 11 when the option o augmentation was raise" !y the irst "e en"ant an" "is%usse" with the patient2 more than se)en hours o waiting !y the patient or la!our to progress (=*D=1 G'+ 7,11&3 There ore ; agree" with the irst "e en"ant it woul" !e spe%ulati)e whether the patient woul" ha)e "e%line" augmentation with %ytote% !e%ause o the possi!ility o uterine hyper%ontra%tility i she was tol" the re%ommen"e" "osage was 100 meg3 5716 The R6(H gui"elines (e:h P21& no "ou!t spea5s o the ris5 o uterine hyper%ontra%tility with the use o misoprostol whi%h %an lea" to oetal "istress or %er)i%al tears an" uterine rapture3 #owe)er none o these ris5s o%%urre" in this %ase as the plainti s ha)e %on%e"e" there is no oetal "istress an" the e)i"en%e showe" there was no %er)i%al tear or uterine rapture3 &"S' O0 D)!TH 0&OM HYP)&ST"M%L!T"O* O0 %T)&%S 57/6 The plainti s %onten"e" that the e)ents "uring an" a ter the in"u%tion 4 M ! "#$ at "@% o la!our resulte" in the patient4s "eath3 ; agree" with the irst "e en"ant4s su!mission that this %ontention is not tena!le as the %ourt was in orme" that the issue in this %ase is whether the patient "ie" o PP# or +@A (amnioti% lui" em!olism&2 a position ta5en e)en !y the plainti s4 e:perts an" o whi%h they testi ie" that the patient "ie" o PP#3 57.6 The plainti s4 %ontention that hyperstimulation rom using %ytote% %an %ause +@A is not a%%epta!le as (i& there was no su%h e)i"en%e a""u%e" an" (ii& e)en the plainti s4 e:pert2 P=2 e:presse" in his opinion (!un"le @2 p 0 para 431& that in i"enti ying the %ause o the massi)e o!stetri% haemorrhage lea"ing to the patient4s "emise un"er the hea"ing 443 6+C*+T;(>4 state"<
the ollowing "i erential "iagnoses ha)e to !e %onsi"ere"<

1a) 1b)
an" not %ytote%3

-+@A. with Disseminate" ;ntra)as%ular 6oagulation (D;6&9 -PP#. %ulminating in a Massi)e (!stetri% haemorrhage an" D;63

5776 The plainti s su!mitte" or the purpose o e:planation on ris52 it is not ne%essary or the plainti s to pro)e the %ause o "eath is !y PP# or +@A !ut it is su i%ient to show that it is a spe%ial or unusual ris5 or material ris5 o in"u%tion o la!our using misoprostol that it %an lea" to hyperstimulation (it "i" ta5e pla%e here& whi%h %an lea" to uterine atony (it o%%urre" here& an" su!seIuent D;V6 ("isseminate" intra )as%ular %oagulation& "ue to !loo" loss rom either PP# or +@A an" "eath3 5786 The a oresai" %ontention is untena!le3 Dr Lim (P=2& was o the )iew that there was uterine ta%hysystole hyperstimulation (rapi" %ontra%tions& !e ore the !irth o the !a!y whi%h was not appre%iate" !y the mi"wi)es an" these %on"itions ha)e the potential o %ausing "amage to the !a!y an" mother3 #owe)er the e)i"en%e showe" that the patient "i" not "ie rom hyperstimulation as (i& it is un"ispute" the !a!y4s oetal heart remaine" satis a%tory2 (ii& the patient4s %on"ition imme"iately a ter "eli)ery was also satis a%tory as photographs were ta5en with the !a!y an" (iii& the irst "e en"ant testi ie"<
#yperstimulation2 i signi i%ant2 woul" o ten result in uterine rupture2 %er)i%al tear an"/or oetal "istress3 ;n this %ase2 there was no uterine rupture2 there was no %er)i%al tear an" there was no e)i"en%e o oetal "istress (as %an !e seen rom the 6TH re%or"ings o the oetal heart&3 Thus the hyperstimulation in this %ase was not signi i%ant enough to %ause any "eleterious e e%t to either the Patient or the !a!y3 (=*D=1+ G'+ 1/&

4 M ! "#$ at "@"

Page 12 5796 The Iuestion !e ore the %ourt there ore is not shoul" the irst "e en"ant ha)e noti ie" the patient o the ris5 o hyperstimulation o the uterus that %oul" lea" to "eath3 ;t is or the plainti s to pro)e<

1.1 1.2 1.3 1.4 1.5 1.6

that there were 5nown material ris5s in the use o 6ytote%9 that there was a ailure to warn o those ris5s9 that the Patient i warne" o those ris5s2 woul" not ha)e agree" to the use o 6ytote% or augmentation9 that one o those 5nown material ris5s "i" a%tually o%%ur9 that ris5 le" to PP# (whi%h is the Plainti s4 %ase&9 an" that the Patient "ie" o PP#3

(*ee para 2? p 11 the irst "e en"ant4s su!mission in reply3& TH) L!? O* "*0O&M)D $O*S)*T 57:6 ;t is not "ispute" that the @e"eral 6ourt %ase in 1oo 1io 5a v &r *oo 1ook Mun , 'nor -2000. 1 MLJ 871 re%ognises that a me"i%al "o%tor has a "uty to "is%lose material ris5s asso%iate" with a treatment !eing gi)en3 The %ase o 1oo 1io 5a "i" not spea5 o 4in orme" %onsent43 The "uty to a")ise o material ris5s is a separate an" "istin%t "uty not relate" to %onsent an" or 4in orme" %onsent43 The %on%ept o 4in orme" %onsent4 is an +meri%an one as "istin%tly state" in the %ase o *idaway v +oard of 7overnors of the +ethlem :oyal 2ospital and the Maudsley 2ospital , -rs -17?8. 1 +6 ?01 %ite" !y the irst "e en"ant3 +t p ?742 the #ouse o Lor"s opine"<
The Buristi% !asis o the propose" su!stitution whi%h originates in %ertain state %ourt Buris"i%tions o the Cnite" *tates o +meri%a an" has oun" some a)our in mo"i ie" orm !y the *upreme 6ourt o 6ana"a2 appears to me2 with great respe%t2 to !e %ontrary to Anglish law3 ;ts oun"ation is the "o%trine o 4in orme" %onsent4 whi%h was originally !ase" on the assumption ma"e in C* 6ourt o +ppeals2 Distri%t o 6olum!ia 6ir%uit2 in Canterbury v *pence 4/4 @ 2" 0022 (where the %yni% might !e orgi)en or remar5ing it ena!le" a "e en%e un"er the *tate *tatute o Limitations to !e outmanoeu)re"2& that2 prima a%ie2 the %ause o a%tion in a %ase o surgery was trespass to the person unless 4in orme" %onsent4 to the parti%ular !attery in)ol)e" in the surgi%al operation %oul" !e pro)e"3 @rom a perio" long !e ore +meri%an in"epen"en%e this2 as ; ha)e pointe" out2 has ne)er !een so in Anglish law3 The rele)ant orm o a%tion has !een !ase" in negligen%e2 ie in assumpsit2 alone3

4 M ! "#$ at "@# ?H!T "S M!T)&"!L &"S' 57;6 The two authorities %ite" !y the plainti s (i& Meyer 6state et al v :ogers et al / 66LT(2"& 102 an" (ii& :eibl v 2ughes are 6ana"ian %ases an" "o not represent the law appli%a!le in Malaysia3 "S TH) !LT)&*!T",) &"S' O0 D)!TH 0&OM HYP)&ST"M%L!T"O* ! SP)$"!L O& %*%S%!L &"S' &)@%"&"*# D"S$LOS%&) 57<6 To support the %on%ept o 4spe%ial4 or 4unusual4 ris5 the plainti s %ite" the 6ana"ian %ases o eung v Campbell -1778. (J >o 10 an" Co.ocaru (7uardian 'd item) v +ritish Columbia Women's 2ospital an" this %on%ept is at o""s with the @e"eral 6ourt4s "e%ision in 1oo 1io 5a an" is not part o the Malaysian law3 @or the purposes o %ausation in relation to a")i%e2 the law appli%a!le is that propoun"e" in :osenberg v Percival in relation to the prin%iple in :ogers v Whitaker whi%h the @e"eral 6ourt a"opte" in respe%t o the a")ising o ris5s namely<

Page 11

6a) 6b) 4c)

4+t the irst le)el2 the ris5 must !e relate" to in a physi%al sense to the inBury that was su ere"49 4+t the se%on" le)el2 there must !e a %ausal %onne%tion2 in the legal sense2 !etween the ailure to warn o the material ris5 an" the o%%urren%e o the inBury49 an" 4;t reIuires the satis a%tion o 2 %riteria3 3he first criterion is a !rea%h o the "uty to warn o a material ris52 that ris5 ha)ing e)entuate" an" %ause"2 in the physi%al sense2 inBury to the patient3 3he second criterion is that2 ha" the warning !een gi)en2 the inBury woul" ha)e !een a)erte"2 in the sense that the rele)ant 4patient4 woul" not ha)e ha" the treatment in Iuestion43

57=6 +s regar"s the issue o %ausation2 in relation to the first criterion as to whether the allege" ris5 was asso%iate" with the inBury that is su ere" or is the su!Be%t matter o the %omplaint or %laim2 the answer is in the negati)e3 ; rest the reasons or this in"ing !ase" on what ; ha)e "is%usse" at paras 28 through to 18 a!o)e whi%h re)eale" that it is not the plainti s4 %ase that %ytote% %ause" the un ortunate "emise o the patient an" neither "i" the patient passe" away !e%ause o %ytote%3 5816 ;n relation to the second criterion o whether the patient woul" ha)e re use" the use o %ytote% ha" there !een some warning o ris5s2 as the patient is now "e%ease"2 it pro)es a "i i%ult issue to esta!lish3 Hrante" that the patient is a lawyer an" is intelligent2 ; in" P=14s e)i"en%e that i the patient was warne" o the ris5s2 she woul" ha)e re use" %ytote% is spe%ulati)e an" sel 4 M ! "#$ at "@@ ser)ing3 (n the other han" the irst "e en"ant was with the patient3 #e pro)i"e" her with the option o augmenting la!our an" he sai"< 4The patient was 5een to augment la!our as she was alrea"y a"mitte" into hospital an" in her own wor"s2 ; %learly re%all2 she sai" 4might as well2 might as well34 This e)i"en%e was un%hallenge" whi%h logi%ally means the patient woul" still ha)e opte" or augmentation with %ytote% e)en i tol" that uterine ta%hysystole may o%%ur with the use o %ytote% (ta%hysystole o%%urre" !e ore "eli)ery o the thir" plainti !ut "i" not %ause harm to either the patient or the thir" plainti as re erre" to in paras 11,14 a!o)e&3 58/6 +t its highest2 ; in" it %annot !e sai" on a !alan%e o pro!a!ilities2 that the patient woul" ha)e re use" augmentation !y the use o %ytote% i she was tol" o the ris5s asso%iate" with it (it is my in"ing that the irst "e en"ant has le" e)i"en%e in the year 20002 there is no e)i"en%e o any material ris5 asso%iate" with the use o %ytote% or in"u%tion/augmentation o la!our&2 gi)en that %ytote% is a "rug %ommonly use" or in"u%tion/augmentation o la!our an" remains a re%ommen"e" "rug or in"u%tion/augmentation o la!our !y @;H( an" =#( (as a""resse" in paras 172 212 24 an" 20 a!o)e&3 58.6 +s or the %ase o Chester v 'fshar -2002. 1 +ll AR 882 relie" on !y the plainti s2 it appears that the plainti s are appro!ating an" repro!ating when they ha" earlier ta5en the position that Anglish law is no longer appli%a!le in relation to the "uty to a")ise o material ris5s or ailure to so a")ise3 Fe that as it may2 in Chester v 'fshar2 the ris52 ner)e "amage an" paralysis materialise" an" %ause" the inBury whi%h was the su!Be%t matter o the suit3 ;n the instant %ase2 the patient "i" not "ie rom hyperstimulation an" neither o the e:perts in%lu"ing the plainti s4 e:perts ha)e postulate" this3 The %ase presente" the %ause o "eath as !eing either PP# or +@A3 PPH 5876 To reiterate the plainti s4 plea"e" %ontention is the patient4s "emise was %ause" !y (i& massi)e PP# in the %ourse o in"u%tion or (ii& e:%essi)e !lee"ing "ue to a uterine tear (see para 1? o the amen"e" statement o %laim in para /32 a!o)e&3 5886 The patient "i" not su er rom PP# "uring in"u%tion !e%ause !y "e inition2 PP# is !lee"ing in e:%ess o 800 mls within 24 hours o "eli)ery an" in"u%tion is !e ore "eli)ery3 P=22 Dr Lim Foon #oe2 the plainti s4 e:pert %on%e"e" that the %ontention is illogi%al an" agree" that it %annot happen3 Fase" on the plainti s4 plea"e" %ase2 the plainti s4 %laim is not ma"e out3

Page 14 5896 +s to the alternati)e allegation o uterine tear2 there is e)i"en%e to the %ontrary in that the irst "e en"ant e:amine" the uterus himsel an" oun" no 4 M ! "#$ at "@A tear or rapture3 The histopathology report supporte" his e)i"en%e as there is no mention that the patient4s uterus was either torn or rapture"3 OTH)& "SS%)S &)L!T)D TO PPH 58:6 The %ru: o Dr Lim4s opinion is the patient 4333 su ere" massi)e primary postpartum haemorrhage rom a uterine e)ent an" "e)elope" se)ere D;V6 ollowing this4 (!un"le @ p 7 para /37&3 !LL)#)D $O*T"*%O%S (L))D"*# O& AO*#O"*#A (LOOD LOSS 58;6 Dr Lim4s opinion is that 4while the uterus appeare" to !e %ontra%te"2 M"m #oh continued to bleed vaginally and this continued to be the case when she began to decompensate= =hen the (!stetri%ian arri)e" at 04102 she was gi)en an in usion o >ala"or2 whi%h is a prostaglan"in3 This is to 5eep the uterus %ontra%te"3 ;n spite o this2 M"m3 #oh continued to bleed vaginally34 333 4The %lini%al pi%ture was more %onsistent with hypo)olaemi% sho%5 rom a massive on-going blood loss34 (Amphasis a""e"3& (Fun"le @ p 7 para /3/2 p ? para 8303& 58<6 Dr Lim in %ross,e:amination e:plaine" that the %ause o the patient4s %ollapse 4333 ;t is %umulati)e !lee"ing lea"ing to #ypo)olaemia an" hypo:ia43 58=6 ; in" Dr Lim4s %on%lusion is in%onsistent with %ontemporaneous me"i%al re%or"s or the ollowing reasons<

7a) 7b) 5c)

Dr Lim ignore" the a%t that a%%or"ing to the me"i%al re%or"s a%ti)e !lee"ing ha" %ease" !y 1320am on 8 >o)em!er 20009 insu i%ient weight gi)en to the a%t that the irst "e en"ant le t aroun" 1310am on 8 >o)em!er 2000 a ter o!ser)ations o 4>o a%ti)e !lee"ing4 an" the patient4s uterus ha" %ontra%te"9 an" e)i"en%e rom Dato4 Dr Mohame" #assan (4D=84&2 the spe%ialist ;ntensi)ist that there 4was no e)i"en%e rom any o the re%or"s o any %ontinuous !loo" loss or 4ongoing4 !loo" loss43

!LL)#)D M!SS",) (LOOD LOSS 5916 ; in" there is no e)i"en%e o any massi)e !loo" loss e:%ept or the postulation !y Dr Lim3 59/6 Dr Lim4s estimates o !loo" loss !y the irst "e en"ant was that it was 4 M ! "#$ at "AD mu%h more than what the irst "e en"ant has estimate" an" thus there was massi)e !loo" loss3 The irst "e en"ant state" in his %lini%al notes that the !loo" loss was more than a)erage whi%h he e:plaine" meant !loo" loss o aroun" 280mls9 testi ie" orally the patient4s !loo" loss !e ore 4am on 8 >o)em!er 2000 to !e appro:imately 18038mls3 Dr Lim testi ie" a ully soa5e" pa" %oul" %ontain 200mls o !loo" an" a ully soa5e" in%ontinen%e pa" 800mls3 o the same3 #e e:plaine" his estimates were !ase" on his own e:periment "one !e ore he %ame to the %ourt o weighing the "ry pa"s9 soa5ing them with water an" reweighing an" the "i eren%e in grams woul" eIuate to milliliters amount o !loo"3 Thus in this pro%ee"ings Dr Lim estimate" the 1/4 pa" woul" hol" aroun" 180mls an" the K soa5e" in%ontinen%e pa" woul" hol" aroun" 128mls o !loo"3 59.6 #owe)er !ase" on in"ings o a paper !y M/s Fose2 Regan an" Paterson,Frown title" 4;mpro)ing the a%%ura%y o estimate" !loo" loss at o!stetri% haemorrhage using %lini%al

Page 18 re%onstru%tions4 (e:h D18&2 it is shown in Diagram F in e:h D18 (p 721& that a sanitary pa" 4saturate"4 %an only hol" 100mls o !loo" an" Diagram D in e:h D18 (p 721&2 an in%ontinen%e pa" soa5e" at 280mls3 ; agree with the su!mission o the learne" irst "e en"ant %ounsel that although the in%ontinen%e pa" in Diagram D is not ully saturate"2 one %annot %onten" !y loo5ing at the Diagram D that it %an hol" twi%e the amount as loo5ing at the Diagram D2 one %annot say that the in%ontinen%e pa" is only L saturate"3 5976 Dr Lim postulate" that perhaps there was a%%umulation o !loo" either in the uterus or the )agina whi%h is %on%eale"3 #owe)er this %ontention %an !e "e!un5e" !y the a%t<

8a) 8b) 6c)

there is no e)i"en%e o %on%eale" a%%umulation !ase" on the re%or"s a)aila!le9 the patient4s uterus was massage" !y the irst "e en"ant an" i Dr Lim4s %ontention is %orre%t2 it woul" ha)e lowe" out per )agina "uring the uterine massage9 an" i there was %on%eale" a%%umulation the patient4s uterus woul" ha)e !alloone" up an" it woul" !e noti%ea!le3

5986 Dr Lim %onten"e" that the patient was se)erely "e%ompensate" !e ore 4am on 8 >o)em!er 2000 in that the patient "isplaye" hypo)olaemi% symptoms whi%h ; in" is not supporte" !y any e)i"en%e3 The lui" !alan%e %hart (!un"le D p /7& showe" at 1340am the patient ha" urine output o 400mls9 e)en i one a%%ept that the 400mls was emptie" at 1340am (no 4 M ! "#$ at "AB e)i"en%e to this e e%t& this is not e)i"en%e o hypo)olaemia3 @%!*T"TY O0 (LOOD LOSS 5996 ; in" Dr Lim4s postulation o %ontinuous !lee"ing an" a%%umulate" !loo" within the patient4s )agina an"/or uterus is "e!un5e" in that there is no e)i"en%e o how mu%h !loo" the patient lost !e ore she woul" "e%ompensate an" !e in a state o se)ere sho%53 *ir +rul5umaran pro ere" a two, ol" e:planation whi%h is enlightening an" is repro"u%e"<

2a) 1

Dis%ussion ; woul" li5e to analyse the situation up to the point o ta5ing Ma"am #oh to the theatre3 The appro:imate !loo" )olume o an in"i)i"ual is a!out 1/12th o the weight in 5ilogram (si%&2 e:presse" in litres3 Ag a /0 5ilogram woman will ha)e 8 litres o !loo"9 others %onsi"er ?0 to 100 ml per 5g !o"y weight3 The pregnan%y weight o Ma"am #oh was /231 Dg when she atten"e" the antenatal %lini% on 0830/320003 +ased on this weight Madam 2oh's e8pected blood volume would be about % litres= 1or someone to collapse or to state that there was massive blood loss? one considers the loss of one blood volume within a C4 hour periodE the blood volume is considered as #F of ideal body weight= -ther definitions of massive blood loss for a woman to collapse include %DF of blood volume loss within $ hours or a rate of loss of B%Dml per minutes (Re eren%e ,, Page 83 Point 0 in Floo" trans usion in (!stetri%s ,, R6(H Hreen Top gui"elines >o 409 De% 20009 mo"i ie" July 200?&3 3wo or three litre blood loss within hours were not observed in Madam 2oh's case as this would have been obvious to the care giver= -ne should see e8cessive blood loss of at least roughly about 4DF to %DF of the blood volume to be in severe shock= 0n Madam 2oh's case 4D to %DF loss should be roughly about C to C=% litres? if we accept her blood volume to have been about % litres= There was a su""en %hange in the general %on"ition o M"m #oh ie su""en hypotension an" e:%essi)e !lee"ing within 20 minutes o the pre)ious o!ser)ation "espite the uterus !eing %ontra%te" +etween DC=4% hrs and D4=DD hrs no large volumes of fluid either crystalloids or colloids was given= 0f she had e8cessive bleeding it is likely the caregivers would have given large volumes of intravenous fluids= 3he staff would have also indentified e8cessive blood loss in e8cess of a litre= The atta%he" pi%torial %hart helps us to %onsi"er the appro:imate !loo" loss3 3here is nothing in the notes to suggest that the bed sheets were soaked in blood or the blood

3 4

Page 1/
was flowing on the ground from the bed= 0f that would have happened the staff would have noted that and called for help and then one could state PP2 was the case for the collapse=

1 5

4 M ! "#$ at "AC

+ased on the case notes? the assessment up to the time of Madam 2oh's collapse when there was severe bleeding at D4=DD hrs? there was no indication to suggest that she lost C itres of bloodE neither there was deterioration in her vital parameters Ge8cept her pulse rateH= #er general %on"ition deteriorated suddenly that %oin%i"e" with the e:%essi)e !loo" loss seen outsi"e3 #en%e2 some other mechanism other than bleeding must have precipitated her sudden collapse with a drop in +P to @%/%% mm 2g= The same me%hanism might ha)e triggere" hypotension an" the se)ere !loo" loss an" ; !elie)e that there was %oagulopathy setting in3 The %ollapse with re"u%e" !loo" low to the uterus woul" ha)e some in luen%e on the uterine %ontra%tions3 (Amphasis a""e"3& (Fun"le @2 pp 8,0&

6 1: 1:

Pulse an" !loo" pressure2 re erring toM ;t is ta5en !y the nursing sta 2 p47 going to p803 (n line 4 it states !loo" pressure 128/07 an" pulse was 1113 There was a Iuestion yester"ay whether they were a%%urate re%or"ings3 The usual pra%ti%e when there is an epi"ural is to ha)e a !loo" pressure %u 3 +n" the tu!e %an !e %onne%te" to a small ma%hine an" at the push o a !utton it will pro)i"e the pulse an" the !loo" pressure3 *o2 it is not "i i%ult to as%ertain the pulse an" the !loo" pressure soon a ter "eli)ery3 +s %ontemporaneously "es%ri!e"2 the mi"wi e has written her o!ser)ation ollowe" !y the !a!y4s +pgar s%ore (whi%h says 0/7& an" the su!seIuent line "es%ri!es the management o the !a!y3 4*u%tion 333 !a!y shown to mother4 all these in"i%ate what was "one soon a ter the "eli)ery3 +n" these o!ser)ations must ha)e !een "one "uring that time3 =henM *oon a ter "eli)ery3 +t 0140 on the same page2 again it says 128/07 an" on the ne:t %olumn the pulse 1112 there was "i i%ulty in !elie)ing that these 2 o!ser)ations %oul" !e i"enti%al an" ; !elie)e that it is !e ore this time an" %oul" ha)e !een i"enti ie" !e%ause the time inter)al might ha)e !een 20 or 10 minutes apart3 ; re er to a literature at P02 p173 0t would indicate that the rising pulse rate soon after delivery was certainly not due to blood loss and may have been due to her being unwell? vomiting= *o i at 01402 the pulse is still the same2 !ase" on this %hart2 when ; see the patient2 she was not an:ious2 or restless or agitate" or %on use"2 then it is unlikely that she had lost C B/C litres of blood in a concealed amount= &r Michael *amy at D$$D spoke to her and felt that she was talking and certainly she did not report these symptoms= =hen she %ollapse" at 04002 the nursing sta "i" not show that she was %ol" or pale an" %ol"3 ; you ta5e the urinary output2 the catheter was put at CC$D hours? and p"A of +undle & indicates that she had passed 4DDml of urine over a % hour period= 0t eIuates to @Dml per hour= During this 4 M ! "#$ at "A$ time a ter "eli)ery at 02802 she was given again %DDml of 2artmann's solution an" this shoul" not ha)e !een %ompletely run out at D$4D when the urinary output was 4DDml= There ore2 urinary output has not reduced as seen on the chart= 3herefore on general e8amination and based on the vital parameters? there was no indication she had C B/C litres of concealed blood= May ; ta5e you to p80 o Fun"le D2 the o!ser)ation at 0140 hours2 shows the mi"wi e has note" that the uterus was contracted and F pad soaked= 3hat suggests that some blood was coming out= 0f C B/C litres of blood was concealed in the uterus or vagina? the uterus would have been shifted very high up? it would then be larger in si>e to accumulate this C F litres of blood and this would have been spotted by the midwife who palpated the uterus to be contracted= 's a comparison my ady? (shows mineral water bottles? B=% and %DDml 8 C)? that would be the total amount of blood in the uterus? this amount would have shifted the uterus right up and the uterus would be ballooning up and the midwife would have felt when she palpated and said the uterus was contracted= *econdly? when she feels the uterus was firm and contracted? the chances that she would have pushed the blood and the blood dote from the uterus and vagina to the e8terior? to the outside= 3his was not observed here= *o? on general e8amination? based on the vital parameters? and on those clinical e8amination of the uterus? there was no suggestion there was concealed

2: 2:

Page 10
blood in the uterus or vagina at least till D$4D hours= &r *amy did his clinical e8amination at D$CD hours? and he left at D$$D hours= *o in the ne8t 4D minutes D$CD to D4DD? if C B/C litres were lost? it would not accumulate in the vagina or the uterus and it is likely to would have come out=

+t 0400 o!ser)ation2 it says !lee"ing PV NN2 it "oes not say there were any large %lots3 0f blood clots accumulated in the vagina for 4D minutes from D$CD to D4DD? one would have observed large clots coming out with the bleeding= 3he blood pressure dropping at D4DD to @%/%%? in my view along with the bleeding P; JJ points to a single pathology which is amniotic fluid embolism given rise to hypotension which causes hypo8ia to the uterus and the uterus starts bleeding in addition to coagulopathy because the amniotic fluid going into the respiratory system causes &0;C perpetuating the condition= (A)i"en%e,in,%hie 2 >(P o 12 +pril 2011 pp 10,203&

!LL)#)D SO%&$) O0 (L))D"*# 59:6 Dr Lim ne:t postulate" three possi!le sour%es o !lee"ing<
The most %ommon %auses o Primary Postpartum #aemorrhage are<

2i) 2ii) 1iii)

Cterine atony9

2
Trauma ,, Cterine rupture or %er)i%al la%eration9 an" Retaine" pla%enta3

4 M ! "#$ at "A4

59;6 +leeding from the atonic uterus ,, ;t is not "ispute" that ollowing "eli)ery the patient !le" more than a)erage3 The !lee"ing was per her )agina an" her uterus was atoni%3 The e)i"en%e o the irst "e en"ant2 D=22 sta mi"wi e *iti *alimeah an" the me"i%al re%or"s %omprising the nursing %are plan an" the irst "e en"ant4s %lini%al notes showe" that the patient4s atoni% uterus %ontra%te" a ter massage an" the appli%ation o "rugs an" there were se)eral entries in the nursing %are plan o 4no a%ti)e !lee"ing43 Dr Lim when %ross,e:amine" on paras /38 an" /3? o his opinion (!un"le @ p 7& sai" 4That the uterus massage" an" %ontra%te"2 that means goo" tone4 an" agree" that the uterus %ontra%te" to the massage an" 4that woul" "es%ri!e the goo" tone o the uterus43 There ore the allege" 4persistent !lee"ing4 %oul" not ha)e !een rom an atoni% uterus3 59<6 'lleged bleeding from a uterine rapture ,, There is no e)i"en%e !ase" on the %ontemporaneous me"i%al re%or"s ie (i& the irst "e en"ant who parti%ipate" in the hystere%tomy at aroun" 0318am on 8 >o)em!er 2000 sai" 4The patient4s uterus was inta%t ;t was %ertainly not torn or rupture"49 (ii& the irst "e en"ant state" 4there was no ree lui" or !loo" in the Patient4s peritoneal %a)ity49 (iii& unli5ely or an atoni% uterus to rupture or tear a ter "eli)ery an" no reason gi)en !y Dr Lim or this unli5ely phenomenon9 (i)& the histopathology report ma"e no in"ings as to any tear or rapture in the uterus3 59=6 'lleged bleeding from a cervical tear ,, There is no e)i"en%e o a %er)i%al tear as the irst "e en"ant sai" he oun" a 41st "egree )aginal tear whi%h he suture"43 Dr Lim state" in his opinion in !un"le @2 paras /302 /3? an" 11 with respe%t to the histopathology report 4there was a separate pie%e o tissue2 whi%h was the %er)i:43 an" 4This report appeare" )ery non,%ommittal 333 +lso2 a separate pie%e o tissue "es%ri!e" as 4%er)i:4 woul" suggest that there was a traumati% uterine e)ent an" ; eel that there was most li5ely a tear in the lower segment o the uterus43 The irst "e en"ant ma"e it %lear that that was part o the %er)i: that was le t !ehin" a ter the hystere%tomy !ut whi%h was noti%e" an" su!seIuently remo)e" (=*,D=1 G'+ 2/&3 There was no entry in the me"i%al re%or"s to the e e%t that there was a %er)i%al tear3

Page 1? 5:16 Dr Lim2 is a %onsultant o!stetri%ian an" gynae%ologist an" is %alle" !y the plainti to gi)e e:pert opinion3 #e has no personal 5nowle"ge o the a%ts2 "espite that he appears to %hallenge the histopathology report o the %onsultant pathologist in an area o me"i%al pra%ti%e he "oes not pro ess3 >either was the %onsultant pathologist %alle" !y the plainti 3 Thus the %ourt is not prepare" to 4 M ! "#$ at "A% gi)e any weight to Dr Lim4s e)i"en%e in this regar"3 ),)*TS !T 8!M 5:/6 ;t is the irst "e en"ant4s %ase that what happene" to the patient at aroun" 4am2 whi%h le" to her %ollapse2 the %alling o %o"e !lue2 the nee" or resus%itation an" the nee" or hystere%tomy were all the %onseIuen%es o an a%ute e)ent triggere" !y +@A an" whi%h le" to the "emise o the patient3 @or the %hronology o e)ents rom 4am on 8 >o)em!er 2000 onwar"s2 the %ourt grate ully a"opts the ta!le as per +nne:ure 4 atta%he" to the irst "e en"ant4s su!mission in reply as repro"u%e" !elow< 831132000 Time A)ent Re eren%e 0400 o Pt su""enly starte" to %ough "uring (1& >6P(p802 D, Trans%ript p882 D& (2& sponging2 spurts o !loo" %ame out rom DrM*4s Report (p7/2 D& (1& >urses4 Report )agina2 %ontinue" to ooEe hea)ily3 (2& (1& o Pt (p772 D& (4& Trans usion ReIuest @orm (p872 %omplaine" o !eing %ol"3 (2& o Flee"ing PVN D& (8& Postnatal (!ser)ation 6hart (p??2 D& N(1& o Dr M* in orme", =ill %ome3 (1& (1& o (/& >6P (p882 D& (0& Postnatal (!ser)ation Dr M* also or"ere" !loo" group an" 6hart (p8?2 D& %rossmat%h3 (2& (1& o Cterus massage", %ontra%te" when massage"3 (1& (2& (1& o l/) gela un"in 10 put up3 (1& (2& (1& (4& (8& o Dr 6hua in orme"3 (1& o FP ?8/889 Pulse 11? (2& (1& (4& (8& o FP ?8/489 Pulse 11? (/& (0& 0410 o Pt 6ollapse"3 (1& o O6o"e !lueO %alle"3 (1& (1& >6P(p802 D, Trans%ript p882 D& (2& 6PR (2& (1& (4& o Pallor noti%e"3 (0& o Dr 6hua orm (p??2 D& (1& Dr 6hua4s notes (p1/D , in orme"3 (1& (4& o Floo" reIueste"3 (/& o Pt Trans%ript p412D& (4& DrM*4s Report (p7/2 D& still ooEing3 (4& o FP?8/889P110(8& (8& Postnatal (!ser)ation 6hart (p8?2 D& (/& Trans usion Me"i%ine ReIuest @orm (p872 D& (0& >ursing Report (p772 D& 0418 o RM(9 Dr RaBa arri)es an" atten"s to Pt (1& 6ar"iopulmonary Resus%itation Re%or" with sta rom ;6C an" other war"s3 (1& (p??2 D& 0428 o Dr 6hua arri)es3 (1& (1& o >ote"< (2& , (1& 6ar"iopulmonary Resus%itation Re%or" La!oure" !reathing , pallorNN , semi (p??2 D& (2& Dr 6hua4s 6lini%al >otes (p1/2 D %ons%ious2 una!le to %ommuni%ate , FP , Trans%ript p412 D& (1& Dr M*4s report (p7/2 unre%or"a!le , (L& han" l/) gela un"ine an" D& nala"or , 02 a%e mas5 on2 A6H on o 20 H l/) %annula (R& orearm set up2 !loo" ta5en2 "rip set up3 (2& o Pt shut "own , har" to in" )eins3 (2& 0410 0448 o Dr M* arri)es3 (1& (2& o Pt su""enly stoppe" !reathing while !eing prepare" or ;6C trans er3 (2& o 6ar"ia% arrest3 A6H monitoring showe" i"io)entri%ular rhythm3 (2& o Pt intu!ate"3 (1& (2& (1& o A:ternal %ar"ia% massage starte" 4 M ! "#$ at "A" (1& 6ar"iopulmonary Resus%itation Re%or" (P??2 D& (2& >ursing Report (p772 D& (1& 6ar"iopulmonary Resus%itation Re%or" (p??2 D& (2& Dr 6hua4s 6lini%al >otes (pp1/, 102 D , Trans%ript p412 D& (1& Dr M*4s notes (p102 D , Trans%ript p112 D& (4& Dr Ru"y $eoh4s notes (p142D, Trans%ript p182 D&

Page 17 an" was %ontinue" or 20,10 min until sinus rhythm o!taine"3 (2& o Dr M* %alle" Dr Dewi (6onsultant 6ar"iologist& ' Dr Ru"y $eoh (6onsultant #aematologist& to assist3 (1& (8& o FP remaine" unre%or"a!le3 (1& (2& o 4 units whole !loo" trans use"3 (1& o @ollowe" !y / units o @resh @roEen Plasma3 (2& (1& o Pt was seen !y Dr Dewi3 (1& (1& (4& o Dr Dewi or"ers +PTT2 FC*A repeat !loo" group3 (1& (1& (4& o Pt was seen !y Dr Ru"y $eoh3 (2& (1& (4& o Pt was %lini%ally pale2 all pulses present3 (2& o Diagnosis was D;63 OD: D;6 (2& o De%ision ma"e to trans er Pt to the ;6C or urther management an" *ta!ilisation3 (1& (2& (1& o Flee"ingNNN3(1& o Pt arri)es at the ;6C a%%ompanie" !y Dr M*2 Dr 6hua2 Dr Dewi an" DrRu"y$eoh3 (1& (8& o (n arri)al2 pallor N NN2 un%ons%ious2 !lee"ing pro usely PV3 (1& o #aema%ell 8P 2 units an" li)er plasma 2 units2 rapi"ly trans use" o)er 10 minutes3 (1& o Pt pla%e" on )entilator an" emoral lines were set up3 (1& (2& o A6H showe" that Pt was in sinus ta%hy%ar"ia3 (2& (8& o Pt %ontinue" to !lee" NNN PV3(1&(2& o FP %oming "own3 (2& o *5in %ol" an" %lammy2 pallor NNNN2 not respon"ing to pain ul stimuli3 (4& (8& o Dr Dewi %ontinue" to assist in resus%itation an" sta!iliEation3 (1& o Dr Ru"y $eoh arrange" or !loo" an" !loo" pro"u%ts3 (1& o FP 180/089 #R 128 !pm (8& o Pt still ooEing rom uterus/)agina3 (2& o De%ision to trans er Pt to the (peration Theatre (O(@& or post partum hystere%tomy3 (1& (2& o Pt4s hus!an" (1st Plainti & in orme" o gra)ity o pro!lem o %ontinue" !lee"ing an" the nee" or an urgent laparotomy an" hystere%, tomy (4& o Ver!al %onsent o!taine"3 (4& o Datu5 Dr >i5 #ussein (6onsultant (!stetri%ian an" Hynae%ologist& %alle" to assist3 (2& o Pt trans erre" to (T as soon as (T was rea"y an" her FP was still Q 100 systoli%3 (2& o FP 110//49 Pulse ?03 (1& (0& o (peration starte"3 (1& o Pt4s %on"ition "eteriorate" rapi"ly in the (T3 (1& o A6H , se)ere !ra"y%ar"ia i"io)entri%ular rhythm3 (2& o 6PR initiate" an" %ontinue" throughout the operation3 (2& o Dr Dewi an" Dr Mohan"as

0810 0880

1& >6P(p802D, Trans%ript p88& (2& Dr M*4s report (P0/2 D& (1& >urses4 report (p1002 D& (1& >6P(p812D, Trans%ript p882 D& (2& Dr Ru"y $eoh4s notes (P143D, Trans%ript p182 D& (1& Dr M*4s report (P7/2 D& (4& >urses4 Report (P1002 D& (1& >6P(p812D,Trans%ript p882 D& (2& DrM*4s Report (p7/2 D& (1& >urses4 Report (p1002 D& (1& >6P (pp81,822 D , Trans%ript p882 D& (2& Dr 6hua4s notes (p102 D , Trans%ript pp41,422 D& (1& Dr 6hua4s notes (p172 D , Trans%ript P423D& (4& DrM*4s Report (p7/2 D& (8& >urses4 Report (P1002 D& (/& >6P(p882 D&

0/18 0/20

0000

4 M ! "#$ at "A# (1& >6P(p822 D, Trans%ript p882 D& (2& DrM*4s notes (p112 D , Trans%ript p112 D& (1& Dr 6hua4s notes (p172 D , Trans%ript p422 D& (4& Dr M*4s notes (p482 D , Trans%ript p4/2 D& (8& Dr M*4s report (p702 D& (/& +naestheti% Re%or" (pp/8,//2 D& (0& 6lini%al 6hart (p012 D&

0018

(1& (peration Re%or" (P082 D& (2& +naestheti% Re%or" (pp/8,//2 D& (1& Dr 6hua4s notes (p172 D , Trans%ript p412 D& (4& Dr 6hua4s notes (p402 D , Trans%ript p412 D& (8& DrM*4s notes (p112 D , Trans%ript p112 D&

Page 20 (6onsultant +naesthetist& %alle" in to assist3 (1& o Pt %ontinue" to !e resus%itate" while hystere%tomy was per orme"3 (4& o #ystere%tomy per orme" !y Dr M* ' Dr >i5 #ussein3 (4& (8& o (R& ;nt ilia% artery an" (L& ;nt ilia% artery ligate" !y Dr Lee *ing #ong an" Dr 6hang Ding =ee (!oth 6onsultant Heneral *urgeons&3 (4& o +%ti)e 6PR %ontinue" or QV+ hrs3 (4& o Pt unre)i)a!le espe%ially a ter V@ set in3 (4& o FP unre%or"a!le3 (1& (2& o Resus%itation stoppe"3 Pt pronoun%e" "ea" on (T ta!le3 (1&(2&(4&(8& 6ause o "eath< D;V6 2R to +mnioti% @lui" Am!olism 6ar"iogeni% *ho%5 (/& (0& o Dr M* an" Dr 6hua spo5e to the 1st Plainti to o!tain %onsent or3 post mortem3 (1& o The 1st Plainti agree" that i it (D;V6 2R to +@A& was the %lini%al Oiagnosis o the ? 6onsultants in)ol)e"2 he "oes not want post mortem3 (1& o The 1st Plainti re use" a post mortem3 (1& o Pt4s !o"y returne" to war"2 last o i%e per orme"2 !o"y sent to mortuary (1& (2& (1&

0710

(1& (peration Re%or" (p082 D& (2& Dr 6hua4s notes (p402D, Trans%ript p412 D& (1& Dr M*4s notes (p482 D , Trans%ript p4/2 D& (4& Dr M*4s Report (p702 D& (8& >urses4 Report (P1002 D& (/& Dis%harge *ummary (p0/2 D& (0& Death 6erti i%ate (P1013D&

0748

(1&>6P(p822 D,Trans%ript p882 D& (2& >urses4s Report (p1002D& (1& Dr M*4s Report (p702 D& 4 M ! "#$ at "A@

5:.6 (n the "i eren%e !etween PP# an" +@A2 Pro essor Tu nell (4P=14& in e:amination,in,%hie he state"<
;n 5eeping it rele)ant to the %onte:t o this %ase2 PP# presents with !lee"ing whi%h will %ontinue or a perio" o time an" there is %ollapse3 +@A will present with %ollapse an" then !e%ause o the nature o the pathology2 the !lee"ing will %ome a ter the %ollapse3 *o the seIuen%e is the opposite way roun"3 *o the 5ey "etermination is whether there is !lee"ing an" then %ollapse or %ollapse an" then !lee"ing3

5:76 The plainti s su!mitte" that the %on%lusion o the plainti s4 e:perts that the D;V6 su ere" !y the patient was a result o massi)e unre%ognise" !loo" loss an" not "ue to a su""en e)ent o +@A is !ase" on the a%t that the e:%lusion %riteria or entry into the CD Register o +@A is that it e:%lu"es woman with maternal haemorrhage as the irst presenting eature in whom there was no e)i"en%e o early %oagulapathy or %ar"io,respiratory %ompromise3 ;n this regar" ; agree" with the su!mission o the irst "e en"ant that this e:%lusion %riteria "oes not apply in this present %ase as there was no !lee"ing !e ore the patient4s 0400 episo"e o !lee"ing an" there was early %oagulapathy or %ar"io,respiratory %ompromise3 5:86 ;n this instant %ase ; in"<

9a) 9b)

there is no e)i"en%e o any massi)e !loo" loss nor was there a%%umulation o !loo" either in the uterus or the )agina whi%h is %on%eale" as postulate" !y Dr Lim as a""resse" in paras 40 through to 88 a!o)e9 an" there was early %oagulapathy or %ar"io,respiratory %ompromise as the patient was %lini%ally "iagnose" o D;V6 !y the irst "e en"ant an" Dr 6hua (D=4&2 the %onsultant anaesthetist in atten"an%e as soon as they saw the patient shortly a ter 0400 (=*D=1 G'+ 21 an" in %ross,e:amination o D=1 10 May 2011 >(P p 21/9

Page 21 =*D=4 G'+ 183 6oagulapathy was %on irme" !y la! e:amination at 0/82 (!un"le D2 ra"iometer results P 00&3 5:96 ;n this %onne%tion the irst "e en"ant urge" the %ourt to regar" P=14s e)i"en%e as )ery unsa e3 +s or P=14s e)i"en%e2 ; %onsi"ere" that when he %on%lu"e" the %ause o "eath o the patient is PP# rather than +@A2 he "i" not get the ull a%ts o the %ase3 P=1 %on irme" un"er %ross,e:amination that<

10a) his e:pert me"i%al report (!un"le @ pp 21,2/& was !ase" entirely on an eight page" 10b)
"o%ument prepare" !y P=2 o 4the %lini%al summary o the %ase 333 -en%losing. the intensi)e %are re%or" o in)estigations an" the histology o the uterus349 he was not shown any me"i%al re%or"s as at the time he wrote the report2 his un"erstan"ing was P=2 was see5ing his a")i%e !e%ause o his spe%i i% 4 M ! "#$ at "AA e:pertise to ensure that the )iew he (P=2& is gi)ing was a PP# rather than +@A an" his un"erstan"ing as an e:pert is he %oul" re)ise his opinion i anything rele)ant !e%omes a)aila!le an" so it was routine pra%ti%e or him to write a preliminary repot whi%h he %oul" re)iew or urther in ormation9 that his theory o the )olume o the patient4s !loo" loss !y 0400 woul" !e in the or"er o two litres9 he was una!le to answer "ire%tly whether there is any e)i"en%e o !loo" note" in the re%or" e:%ept to reply 4>ot as mu%h as 2 litres2 !ut a!sen%e o e)i"en%e is not e)i"en%e o a!sen%e in this %ase49 he agree" that with the loss o two litres o !loo" !y 04002 one woul" e:pe%t the pulse rate to rise9 he le t the "ispute on the similar entries o FP o 128/07 an" pulse rate o 111 at 0248 an" 0140 to the "etermination o the %ourt9 agree" that at 0140 there was an entry that the patient ha" urine output o 400ml ( rom 1040 when the %athether was inserte" (!un"le D p /7&9 an" agree" that i all the urine was passe" a ter the !irth that it is less li5ely that she woul" ha)e ha" %ontinuous !lee"ing3

7c) 3d) 1e) 1f) 1g) 1h)

')Y !LL)#!T"O*S O0 *)#L"#)*$) !#!"*ST TH) S)$O*D D)0)*D!*T 5::6 +ssuming the plainti s ha)e su%%ess ully esta!lishe" a !rea%h o "uty o %are on the part o the se%on" "e en"ant (whi%h ; hol" has not !een pro)en an" to !e "is%usse" herea ter&2 ; shall now "eal with the allegations o negligen%e against the se%on" "e en"ant2 some o whi%h ; ha)e a""resse" earlier as the se%on" "e en"ant a"opte" the su!mission o the irst "e en"ant where)er appli%a!le3 Competence of DW6 (Siti Salimeah bt Shafiee) 5:;6 The plainti s essentially su!mitte" that the mi"wi)es were in%ompetent as (i& they aile" to monitor the patient properly2 (ii& they "i" not re%ognise there was %umulati)e ongoing !loo" loss in the patient2 (iii& "i" not ha)e su i%ient s5ills to re%ognise the se)erity o the !lee"ing (i)& aile" to re%ognise %on%eale" haemorrhage an" ()& "i" not %on)ey rele)ant in ormation to Dr Mi%hael *amy on %umulati)e ongoing !loo" loss an" in%rease in pulse rate3 4 M ! "#$ at #DD 5:<6 The se%on" "e en"ant4s sole witness2 *iti *alimeah !t *ha iee (4D=/4&2 who retire" in 20022 was the senior mi"wi e on "uty at the material time (7pm on 4 >o)em!er 2000&3 ;n terms o her

Page 22 Iuali i%ations an" e:perien%e as a mi"wi e2 D=/ in e:amination,in,%hie (=*D=/ G'+ 2 to 8& testi ie"<

3i) 3ii) 2iii) 1iv) 1v)

she ha" Iuali ie" in 1701 as a nurse an" in 1700 as a mi"wi e9 she ha" wor5e" in o!stetri%s in the la!our war" at the Duala Lumpur #ospital or / years !e ore Boining the 2n" De en"ant9 she ha" "eli)ere" o)er 102000 !a!ies an" "ealt with many %ompli%ate" %ases2 in%lu"ing %ases in)ol)ing post,partum haemorrhage9 she ha" more than 20 years4 e:perien%e in the year 20009 an" she ha" !een traine" to2 among others2 monitor patients or a!normal signs2 in%lu"ing signs an" symptoms o hea)y !lee"ing an" signs o patients going into hypo)olemi% sho%52 an" to ta5e appropriate a%tion3

5:=6 #owe)er as %orre%tly pointe" out !y learne" %ounsel or the se%on" "e en"ant2 there was no %hallenge !y the plainti s in respe%t o this aspe%t o her testimony3 +s su%h ; agree with the se%on" "e en"ant that the plainti s are "eeme" to ha)e a%%epte" that D=/ was a %ompetent2 e:perien%e" mi"wi e %apa!le o i"enti ying symptoms an" signs o PP# an" ta5ing appropriate reme"ial a%tion ('ik Ming (M) *dn +hd , -rs v Chang Ching Chuen , -rs and another appeal -1778. 2 MLJ 0009 -1778. 1 6LJ /17 at p /42&3 5;16 The plainti s %onten"e" that there is la%5 o %lose monitoring o the patient an" a la%5 o appre%iation o the uterine hyper stimulation2 rapi" la!our in the last hour prior to "eli)ery an" "i" not in orm the same to Dr Mi%hael *amy3 5;/6 ;n %ross,e:amination2 when as5e" why ha)ing agree" that entry 0118 4Patient ha" one episo"e o type ;; "ip42 !un"le D p 77 an" p ?/ D=/ showing the patient ha" a 6TH tra%ing whi%h was 4luar !iasa42 D=/ e:plaine"<
+< *aya ti"a5 mem!eritahu tapi meman"ang5an %ontra%tion !egini2 5ita a5an mem!uat assessment "ahulu "an tengo5 tahap %ontra%tions a"alah %uma "alam 10mmhg "an 5ea"aan ini ti"a5 memu"arat5an pesa5it ataupun 5epa"a !ayi3

5;.6 +s or the %ase o 2or *ai 2ong dan satu lagi lwn 9niversiti 2ospital dan satu lagi -2002. 8 MLJ 1/0 at pp 101,101 -2001. ? 6LJ 20? at pp 211,214 %ite" !y the plainti s2 ; in" !ase" on the e)i"en%e o %onstant monitoring et% 4 M ! "#$ at #DB allu"e" to in this instant %ase2 there was no negligen%e pro)en on the part o D=/3 Continuous post-partum bleeding 5;76 (n the night in Iuestion D=/ ha" personally monitore" the patient4s %on"ition an" "espite !eing %hallenge" that there was %ontinuous !lee"ing whether %on%eale" or re)eale"2 she stoo" her groun" that there was none as is e)i"ent rom her testimony2 wherein she2 inter alia2 state"<

4i)

+< 6atitan 4Floo" loss Q a)erage4 -Fun"le D p38? 4Postnatal (!ser)ation 6hart4. !erma5su" !ahawa si,men"iang a"a !er"arah !erle!ihan "ari 5e!iasaan sewa5tu melahir5an ana53 *aya ti"a5 !erapa ingat Bumlah anggaran se!enar 4)olume4 "arah yang si,men"iang telah hilang sewa5tu itu2 a5an tetapi saya pasti )olume "arah yang telah hilang %uma !erle!ihan se"i5it "ari 5e!iasaan sahaBa3 Ji5a pen"arahan simen"iang !erle!ihan "an merisau5an2 saya pasti su"ah men%atat5an 4!lee"ing NN349 *aya ta5 setuBu -si men"iang mung5in 5ehilangan "arah se!anya5 2 liter "an 5emung5inan !era"a "alam 5ea"aan 4hypo)olaemi% sho%54 se!elum pu5ul 4300 pagi yang ti"a5 mung5in "i5esan oleh Bururawat.3 *aya merawat si,men"iang pa"a hari

4ii)

Page 21
terse!ut sehingga si,men"iang "ihantar 5e ;6C "an saya ti"a5 ampa5 si,men"iang 5ehilangan "arah sehingga 2 liter3 *aya Buga pasti tahu Bi5a si,men"iang a"a !er"arah se!anya5 2 liter2 5erana su"ah pastinya 4in%ontinen%e pa"4 "an pa" a5an !erlumuran "arah "an pa",pa" ini harus "itu5ar 5erap 5ali3 Dalam 5es ini hanya S pa" !asah "engan "arah !er%ampur lo%hia pa"a pu5ul 1340 pagi "an pu5ul 4300 pagi 1 pa" (iaitu pa" yang sama& "an S in%ontinen%e pa" !asah "engan "arah !er%ampur lo%hia3 *aya Buga masih ingat selepas si,men"iang melahir5an ana5nya iaitu "ari pu5ul 2348 pagi hingga pu5ul 1340 pagi2 5ea"aan iEi5al si,men"iang "iperi5sa oleh saya3 *i,men"iang ti"a5 !era"a "alam 5ea"aan 4hypo)olemi% sho%54 ataupun !era"a "alam 5ea"aan yang mem!im!ang5an se!elum pu5ul 4300 pagi3

3iii)

+< Pa"a le!ih 5urang pu5ul 4300 pagi2 Puan +smah memanggil saya "an mem!eritahu saya !ahawa apa!ila "ia se"ang 4sponging4 si,men"iang2 si,men"iang ter!atu5 "an mula !er"arah !erle!ihan3 *aya terus masu5 5e Fili5 Fersalin untu5 memeri5sa si, men"iang3 *aya "apati si,men"iang !er"arah !erle!ihan3 Te5anan "arah Batuh 5e ?8/88 "an "enyutan na"i si,men"iang a"alah 1103 *aya terus menele on Dr3 Mi%hael *amy "an mem!eritahunya apa yang terBa"i3 Dr3 Mi%hael *amy mengarah5an saya untu5 4group "an %ross,mat%h4 "arah si,men"iang3 *aya Buga mem!eri5an 1 pint Hela un"in 5epa"a si,men"iang atas arahan Dr3 Mi%hael *amy3 *aya Buga mem!eritahu Dr3 6hua a5an 5ea"aan si,men"iang3 *i,men"iang masih !er"arah "an 5elihatan pu%at3 *aya mem!eri5an o5sigen 5epa"a !eliau3 *aya %u!a untu5 mengam!il sample "arah "ari 4 M ! "#$ at #DC si,men"iang untu5 %ross,mat%h tetapi salur "arah !eliau telah 4%ollapse"43 *aya memanggil 4%o"e !lue4 pa"a le!ih 5urang pu5ul 4310 pagi3 RuBu5 m/s 80 "an 823 ;5atan Do5umen 4D43 (see also D=/ >(A 20 June 2011 pp 10,1?2 p 4/2 pp 80,81&3

5;86 The plainti s urge" the %ourt to !e 4slow to %on%lu"e that the la%5 o re%or"ing o in ormation %orro!orates the "e en"ants4 )ersion that the "eath was %ause" !y +@A an" "oes not support the plainti s4 )ersion that (patient4s& "eath was "ue to PP#4 sin%e (i& the e)ent too5 pla%e 11 years ago an" the mi"wi e has a"mitte" that she ille" the re%or"s retrospe%ti)ely !e ore han"ing the patient o)er to the nurses at the ;ntensi)e 6are Cnit (;6C& an" (ii& as the "o%uments are in the "e en"ant4s possession2 the plainti s were una!le to )eri y them3 5;96 ; oun" that D=/ has pro ere" a reasona!le e:planation as to why the 4Laporan 4>ursing 6are PlanO (!un"le D p 47& whi%h is the 4turutan peristiwa yang !erla5u "ari 2348 pagi hingga /318 pagi4 was written a ter the patient was sent to ;6C !e%ause 4-D.itulis "engan segera pa"a masa itu 5erana saya periu serah5an laporan ini 5epa"a Bururawat,Bururawat "i ;6C "engan se%epat mung5in untu5 tin"a5an lanBut mere5a !er5enaan "engan rawatan si,men"iang3 (leh itu saya ti"a5 sempat untu5 menulis laporan mengi5ut masa,masa tertentu "an mengi5ut turutan peristiwa yang !erla5u 333 -mana5ala. 4Laporan "i mu5asurat 7? "an 77 a"alah laporan yang "i tulis !e!erapa hari selepas 5eBa"ian terse!ut3 (leh itu saya mempunyai masa untu5 menulis "engan terperin%i mengi5ut masa,masa yang tertentu34 5;:6 ;t is un"erstan"a!le when Dr 6hua state" that he was 4una!le to write notes "uring time o %are an" resus%itation4 an" 4-h.en%e notes written in %hronologi%al or"er as a%%urate as possi!le a ter "eath o patient4 as he was %on ronte" with an emergen%y situation an" was o%using an" prioritising his attention to the %are an" management o the patient then3 5;;6 Hrante" that there is no issue o a!ri%ation an" %on%o%tion arising an" gi)en the lapse o time sin%e the in%i"ent o%%urre" an" the matter was hear" an" gi)en that lapses o memory "o o%%ur with the passage o time2 surely the %ontemporaneous re%or"s in%lu"ing %lini%al notes an" entries o nurses in the nursing %are plan2 are a!solutely )ital when assessing the %ause o "eath o the patient3 ( echemanavasagar a/l * /aruppiah v &r 3homas 4au Pak Chenk , 'nor -200?. 1 MLJ 118 at pp 122,21&3 Time taken to respond to event of heavy bleeding 5;<6 The plainti s %onten"e" that sin%e the se%on" "e en"ant "i" not ha)e 4 M ! "#$ at #D$

Page 24 written proto%ols "ealing with PP# in the year 20002 this amounte" to some orm o negligen%e3 ; a%%epte" the se%on" "e en"ant4s su!mission that this %ontention %annot !e sustaine" or the ollowing groun"s3 @irstly2 the testimony rom irst "e en"ant4s three e:perts2 D=22 D=4 an" D=8 (Dato4 Dr Mohame" #assan +ri & that the a!sen%e o written proto%ols "i" not %ompromise the patient4s %on"ition<

5i)

D=2 testi ie" that while it is important to ha)e proto%ols2 it is more important to ta5e appropriate a%tion with or without proto%ols3 *ee D=2 >(A 14/4/2011 p322?3 D=2 also testi ie" that2 ta5en as a whole2 the mi"wi)es an" "o%tors who ha" atten"e" to the "e%ease" ha" a%te" appropriately on the a%ts o this %ase3 *ee D=2 >(A 14/4/2011 p32483

1. 1. 10 5ii) 2. 2. 3. 3.

$ou were also as5e" !y %ounsel or the Plainti a!out the ne%essity or proto%ols or the management o PP#3 My Iuestion is this3 Would you agree that taken as a whole? the midwives and the doctors who attended to this patient acted appropriately on the facts of this CaseK 4es? 0 agree= (Amphasis a""e"3&9

D=1 ha" testi ie" as ollows< ; there is no su%h proto%ol2 "o you suggest that the %onsultants in)ol)e" an" the nurses an" the M( woul" there ore not !e a!le to %ompetently manage the Patient when she %ollapse" shortly a ter 0400M My La"y2 ; "i" not suggest that at all3 =oul" that !e the %aseM Protocols and guides are guidelines= 0n the absence of these guidelines? doctors by training will be competent to handle emergencies whether it is an obstetrics emergency? road traffic accidents? it is our .ob= 0 do not go around rushing asking for guideline before 0 treat patients= 0t would look Iuite comical= *ee D=1 >(A 24///2011 p3110 ' 11?3 6an ; re er you to Fun"le D2 page 773 *tarting at 04002 a num!er o things happene"3 ;t says2 4During sponging2 patient su""enly starte" to %ough an" spurts o !loo" %ame 4 M ! "#$ at #D4 out rom )agina an" %ontinue" ooEing hea)ily3 Cterus %ontra%te"3 ;/V Hela un"in gi)en2 Dr *amy or"ere" group an" %ross mat%h3 Hi)en what is state" in the re%or"s2 you will confirm that the response of the midwives and those attending to the Patient was entirely appropriate= 4es My ady= (*ee D=1 >(A 24///2011 p3 100& (Amphasis a""e"3&9 ; ta5e you to p11 again2 the 2n" paragraph3 46are ul %ross mat%he" !loo" a)aila!le or trans usion within 10 minutes43 46lini%ians must !e aware o the %apa!ility o their !loo" !an5 regar"ing timing2 type an" amount o !loo" pro"u%ts a)aila!le in emergen%ies3 Hoo" %ommuni%ation with !loo" trans usion ser)i%e is essential3 >ature o emergen%y an" amount o !loo" pro"u%ts must !e stresse"34 #ere the a%ts o our %ase2 %ross mat%he" !loo" was not supplie" within 10 minutes3 +s ; ha)e sai"2 this is the author4s opinion2 it )aries "i erent parts o the worl" an" "i erent part o !loo" !an5ing ser)i%es3 $ou %annot ta5e the stan"ar" o one uni)ersity hospital in +meri%a or Anglan" an" try an" apply it in Malaysia3 ; it is the stan"ar" then the Ministry o #ealth woul" gi)e gui"elines that !loo" must !e a)aila!le within 10 minutes3 ; must stress that paragraph 2 also states that %lini%ian must !e aware o the %apa!ilities o the !loo" !an5 regar"ing timing an" type3 *o it is not !eing a!solute3 *o the paragraph there is with %on"itions3 Paragraph also states goo" %ommuni%ation with trans usion ser)i%e is essential3 +n" in this %ase2 the haematologist was present at 08803 +nywhere in the worl" you won4t get a haematologist at 08803

4.

1. 4. 5.

5.

11

Page 28 5;=6 *e%on"ly2 as aptly pointe" out !y the se%on" "e en"ant2 the opinions o the e:perts are !orne out in the seIuen%e o e)ents that o%%urre"<

6i) 6ii) 4iii)

(n%e the "e%ease" starte" to !lee" at 4am2 she was atten"e" to imme"iately !y D=/ who shortly therea ter soun"e" 6o"e Flue when the "e%ease" %ollapse"3

4 M ! "#$ at #D%

The "e%ease" was therea ter promptly atten"e" to !y the 6o"e Flue team2 whi%h %onsiste" among others o the resi"ent me"i%al o i%er2 nurses rom the ;ntensi)e 6are Cnit an" D=/3 *u!seIuently2 the "e%ease" was treate" !y D=12 D=12 a haematologist2 two general surgeons2 a %ar"iologist an" two anaesthetists3 The a)aila!ility o 6onsultants rom se)eral iel"s in the early hours o the morning on a *un"ay spea5s )olumes o the %are o ere" !y the 2n" De en"ant3

5<16 Thir"ly2 there is no %ausal lin5 !etween the a!sen%e o a written proto%ol an" the patient4s "eath whi%h was %ause" !y +@A is !orne out in the e)i"en%e o D=2 un"er %ross,e:amination !y the plainti s4 %ounsel<

1: 3:

; put it to you that i there ha" !een a proto%ol2 it4s pro!a!le that a sa e o!stetri%s pra%ti%e woul" ha)e !een %omplie" with an" this patient woul" not ha)e su ere"2 this patient woul" not ha)e "ie" my la"y2 ; thin5 ;4ll Bust %ut it short3 My La"y2 e)ery maternal "eath is a trage"y39nfortunately? there are some which we are unable to avoid and once classic e8ample is '16 which leads to Iuick succession of events of cardiac dysfunction? &0;C and bleeding which aggravate each other and causes the difficulty when tackling the situation= *ee D=2 >(A 14/4/2011 p322? ' 227 (Amphasis a""e"3&3

Time taken to respond to obtain and transfuse blood 5</6 The plainti s argue" there was a "elay in trans using the patient with !loo"3 ; "o not in" there is merit in this %ontention or the ollowing reasons<

11a) !loo" was groupe" an" %ross,mat%he" within an hour an" this is not unreasona!le 11b)
gi)en the patient4s )eins ha" %ollapse" an" there was "i i%ulty "rawing !loo" as per the testimony o Dr 6hua (4D=44&2 (>(A 1/ June 2011 p 4?9 an" e)en Dr Lim (4P=24& agree" that the "e%ision to or"er or %ross,mat%he" !loo" at 0400 hours was %orre%t an" that it woul" ta5e an hour to %ross,mat%h the !loo" (>(A / De%em!er 2010 pp 17,40&3

5<.6 The plainti s %onten"e" that the patient ought to ha)e !een gi)en (,negati)e !loo" imme"iately3 This %ontention is untena!le as it has ignore" the ollowing e)i"en%e<

7i)

D=1 an" D=4 !oth testi ie" that (,negati)e !loo" was not rea"ily 4 M ! "#$ at #D" a)aila!le in pri)ate me"i%al %entres in the year 20002 or or that matter e)en to"ay3 D=4 testi ie" that !loo" is only a)aila!le rom the >ational Floo" Trans usion 6entre2 an" that pri)ate hospitals are not allowe" to ha)e their own !loo" "onation "ri)e (D=4 >(A 213/32011p37?&3

+ similar sentiment is share" !y D=8 who state"<

Page 2/
+< ;n my e:perien%e as an in)entionist ; ha)e oun" that ( negati)e !loo" is not usually a)aila!le at short noti%e3 A)en when it is a)aila!le2 it is o ten in insu i%ient Iuantities or any signi i%ant !loo" loss in an a"ult3

7ii) 5iii)

D=4 %on irme" that less than 2P o the population has Rhesus D,!loo" type an" part o that less than 2PF is (,negati)e3 A)en P=2 agree" to this statement3 There ore it is impossi!le or a pri)ate hospital to ha)e a su i%ient amount o (,negati)e !loo" a)aila!le at all material times3 D=8 testi ie" (i& that gi)ing !loo" is rarely the irst line o response2 (ii& when the patient4s !loo" pressure %ollapses2 the irst line o treatment is to rapi"ly in use %rystalloi"s an"/or %olloi"s as was "one in this instant %ase an" (iii& that e)en i the !loo" was a)aila!le at 4310a3m3 it woul" not ha)e a)oi"e" the su!seIuent %ar"ia% arrest in the patient whi%h was %ause" !y +@A (>(A 213/32011 p3 1?9 pp317 an" 40&3

(&)!$H O0 D%TY O* TH) !$$)PT)D ST!*D!&D O0 $!&) ,"S-!-,"S TH) S)$O*D D)0)*D!*TB 5<76 =ithout preBu"i%e to my in"ings in respe%t o the allegations o negligen%e raise" !y the plainti s against the se%on" "e en"ant2 ; shall now %onsi"er the issue o whether the plainti s ha)e "is%harge" their onus o esta!lishing that the se%on" "e en"ant has !rea%he" the stan"ar" o %are reIuire" o pri)ate hospitals in Malaysia 4with a high "egree o pro!a!ility43 ( Whitehouse v !ordan , 'nor -17?0. 1 +ll AR /80 %ite" in 'rulappan /annan v &r *uresh Chopra , -rs -2011. 1 6LJ //2 (#6& at p /0/&3 5<86 ;n this regar" !e ore %onsi"ering whether the se%on" "e en"ant has !rea%he" the stan"ar" o %are2 it is in%um!ent or the plainti s to irst pro)e what e:a%tly the stan"ar" o %are was in pri)ate hospitals in Malaysia in the year 20003 @rom P=2 an" P=12 the ollowing is gathere" o their lo%ation o me"i%al pra%ti%e<

12a) 1.
P=2 pra%tise" or only our years in Malaysia (17?1,17?8& (18 years prior to the patient4s "eath& in a Ho)ernment hospital (Cni)ersity #ospital& an" therea ter %ontinue" his pra%ti%e a!roa" rom 17?8 till to"ate (e:h P1,P=14s 6V&9 P=2 %on irme" in %ross,e:amination2 sin%e 17?82 apart rom CD 4 M ! "#$ at #D# he pra%tise" in >ew Tealan" !ut not in Malaysia9 neither has he pra%tise" in any pri)ate hospital in Malaysia9 P=2 a"mitte" that his testimony is !ase" on his pra%ti%e in hospitals in CD9 an" P=2 %on irme" that he has no irsthan" 5nowle"ge o the %on"ition in %ar"ia% me"i%al %entres in Malaysia relating to the storage o !loo"2 as to what !loo" is 5ept on site2 o site et%3

1.

1. 1.

1 12b) P=1 state" he has ne)er wor5e" in Malaysia an" his e)i"en%e is !ase" on
pra%ti%es a"opte" in hospitals in Anglan"3 5<96 Fase" on the a oresai" e)i"en%e in my assessment P=2 an" P= 1 are not %ompetent to testi y on what %onstitutes the stan"ar" o %are reIuire" o pri)ate hospitals in Malaysia as an e:pert witness<

13a) 4shoul" pro)i"e in"epen"ent assistan%e to the %ourt !y way o o!Be%ti)e un!iase"
opinion in relation to the matters in "ispute49 an"

Page 20

13b) 4shoul" ma5e it %lear when a parti%ular Iuestion or issue alls outsi"e his e:pertise4
(5ational !ustice Compania 5aviera *' v Prudential 'ssurance Co td -1771. 2 Lloy"4s LR /? at p ?1&3 5<:6 (n !ehal o the "e en"ants2 the ollowing e)i"en%e was gathere" rom D=22 D=1 an" D=8 (e:pert witnesses& an" D=1 an" D=4 ( a%tual witnesses&<

14a) D=2 (Pro essor *ir * +rul5umaran& agree" that it woul" not !e appropriate to
automati%ally a"opt the green top gui"elines (o whi%h he is the author& to pri)ate hospitals in Malaysia2 thus there is a Iuali ier on pagel para 1 last senten%e whi%h rea"s 4Re%ommen"ations may !e less appropriate or other settings where a%ilities2 resour%es an" routine pra%ti%e "i ers43 D=2 "i" not in" the management o the patient to !e wanting (>(P 14 +pril 2011 pp 1/0,1/12 107,1?0&9 D=4 (Dr 6hua& testi ie" that the a!sen%e o a written proto%ol "i" not in any way Beopar"ise the health an" sa ety o the patient as 4This is the a%%epte" way we pra%ti%e43 This is the way we ha)e !een taught to respon" to emergen%ies3 6all primary "o%tor2 %all or help an" institute resus%itati)e measures while waiting or the rest to respon"34 D=8 (Dato4 Dr Mohame" #assan +ri & testi ie"<
+s ; ha)e sai"2 this is the author4s opinion2 it )aries "i erent parts o the worl" an" "i erent part o !loo" !an5ing ser)i%es3 $ou %annot ta5e the stan"ar" o one uni)ersity hospital in +meri%a or Anglan" an" try an" apply it in Malaysia3 ; it is the stan"ar" then the Ministry o #ealth woul" gi)e gui"elines that !loo" must !e a)aila!le within 10 minutes3 ; must 4 M ! "#$ at #D@ stress that paragraph 2 also states that %lini%ian must !e aware o the %apa!ilities o the !loo" !an5 regar"ing timing an" type3 *o it is not !eing a!solute3 *o the paragraph there is with %on"itions3 Paragraph also states goo" %ommuni%ation with trans usion ser)i%e is essential3 +n" in this %ase2 the haematologist was present at 08803 +nywhere in the worl" you won4t get a haematologist at 08803 *ee D=8 >(A 21///2011 p40'41&3

14b)

8c)

5<;6 Fase" on e)i"en%e o the "e en"ants4 witnesses2 ; agree" with the su!mission o the se%on" "e en"ant that 4one %annot lay "own stan"ar" o %are or pri)ate hospitals in Malaysia purely !y re eren%e to stan"ar" o %are or pri)ate hospitals in Anglan"2 6ana"a or +ustralia2 parti%ularly where the Malaysian Ministry o #ealth itsel has not seen it it to "o so43 5<<6 The plainti s relie" on the %ase o +ull and 'nother v &evon 'rea 2ealth 'uthority 22 FMLR 07 to argue that a ailure o a hospital to ha)e a sa e o!stetri% system in pla%e woul" !e tantamount to negligen%e as is the %ase against the se%on" "e en"ant3 The %ase %an !e "istinguishe" as it is !ase" on the pra%ti%es in the CD whi%h %annot !e simply transpose" to this %ountry3 ;n any e)ent2 D=1 has testi ie" that it was not the stan"ar" pra%ti%e in pri)ate hospitals in Malaysia to ha)e an o!stetri%s me"i%al o i%er in the year 2000 an" D=2 (>(A 14 +pril 2011 p 244& an" D=1 (>(A 24 June 2011 p 77& %on irme" this to !e so3 5<=6 There ore ; %on%lu"e there is no relia!le e)i"en%e as to what is the appli%a!le stan"ar" o %are or pri)ate hospitals in Malaysia in the year 2000 whi%h the se%on" "e en"ant has !rea%he"3 (n this groun" alone the %ourt is entitle" to "ismiss the %laims o the plainti s3 ,"$!&"O%S L"!("L"TY 5=16 The plainti s argue" that (i& P=1 an" the patient "i" not ha)e 5nowle"ge o the pri)ate %ontra%tual arrangements !etween the irst an" se%on" "e en"ants an" (ii& in any e)ent the se%on" "e en"ant owe" the patient a non,"elega!le "uty meaning that the se%on" "e en"ant woul" !e lia!le or the a%ts an" omissions o the irst "e en"ant as the se%on" "e en"ant is un"er

Page 2? a non,"elega!le "uty to treat patients whi%h %annot !e "is%harge" !y "elegating it to a %onsultant (the irst "e en"ant& un"er a %ontra%t o ser)i%es3 ( Cassidy v Ministry of 2ealth -1781. 1 +ll AR 8042 iau Mui Mui v &r : ;enkat /rishnan -1777. 1 6LJ 2002 &r Wong Wai Ping , 'nor v Woon in *ing , -rs -1777. / 6LJ 21 were %ite" !y the plainti s&3 5=/6 ;n the %ase o 1arra. and another v /ing's 2ealthcare 52* 3rust and another -2007. +ll AR (D& 18? (%ite" !y the se%on" "e en"ant&2 the Anglish 4 M ! "#$ at #DA 6ourt o +ppeal a ter re erring to the %ase o 7old v 6sse8 County Council -1742. 2 DF 2712 Cassidy4s %ase an" :oe v Ministry of 2ealth -1784. 2 GF // state" that that<
there were two s%hools o thought as to whether a hospital owes a personal non,"elega!le "uty to pro)i"e its patients with s5il ul treatment an" as to whether it is lia!le or the negligent a%ts an" omissions o those who pro)i"e treatment2 whether they are employees o the hospital or engage" !y it as in"epen"ent %ontra%tors3 The ma.ority view was that the hospital was lia!le !e%ause it is )i%ariously lia!le or the negligen%e o its employees3 +ut ord 7reene M: in 7old and &enning ! in Cassidy and again in :oe founded liability on the wider basis that the hospital is liable for the negligence of those who administer treatment in its hospital? regardless of their employment status 333 it now seems %lear2 ollowing suggestions !y Denning LJ (in the %ase o Cassidy& an" a su!seIuent "e%ision !y the #igh 6ourt o +ustralia2 that health authorities are un"er a personal2 non,"elega!le "uty to see that %are is ta5en in pro)i"ing treatment2 analogous to the non,"elega!le "uty owe" !y an employer to his employees 333 an" it has sin%e !een "e%i"e"2 in a%%or"an%e with this prin%iple2 that a health authority whi%h %ontra%ts out ser)i%es to an in"epen"ent %ontra%tor is lia!le or any ault e:hi!ite" !y the latter3 2owever? the limits of this principle should be noted= 0t does not apply where an authority enters into a private arrangement to supply services by contractL nor? it is submitted? does it apply to negligence on the part of a consultant or surgeon specifically chosen by the patient= (Amphasis a""e"3&

5=.6 =hen %ross,e:amine" !y the se%on" "e en"ant4s %ounsel2 the irst "e en"ant (4D=14& state" he was an in"epen"ent %ontra%tor an" was not a salarie" employee3 5=76 Cnli5e what the plainti s seem to %onten" that they ha)e no 5nowle"ge o the pri)ate %ontra%tual arrangements !etween the irst an" se%on" "e en"ants2 there is the e)i"en%e to the %ontrary in that the patient upon a"mission to the se%on" "e en"ant hospital on 4 >o)em!er 2000 ha" signe" a%5nowle"ging that she has rea" an" re%ei)e" a %opy o (the %on"itions o ser)i%e atta%he" to the registration orm (!un"le D pp 1,1&& an" 4irre)o%a!ly agree to !e !oun" an" %omply with the %on"itions o ser)i%e43 Li5ewise her hus!an" the irst plainti 2 has 5nowle"ge o the same %on"itions ha)ing signe" as guarantor (!un"le D p 1& where he2 inter alia2 4agree to !e !oun" !y all the a!o)e %on"itions43 +n" one o the 46on"itions o *er)i%e4 (!un"le D p 2& at para 4 rea"s<
4 #(*P;T+L 6(>*CLT+>T* +ll %onsultants in this #ospital are in"epen"ent pra%titioners an" it is the responsi!ility o the %onsultant to o!tain the patient4s %onsent when reIuire" or me"i%al or surgi%al treatment an" pro%e"ures3 The instru%tion o the %onsultants will !e %arrie" out !y the #ospital an" its nursing sta 3

4 M ! "#$ at #BD 5=86 @urther the e)i"en%e re)eale" that the patient has spe%i i%ally %hosen the irst "e en"ant as her o!stetri%ian an" she has engage" the irst "e en"ant hersel where 4the patient was intro"u%e" to (the 1st De en"ant& !y her ol"er sister34 (>(A D=1 12 +pril 2011 p ?&3 5=96 Thus !ase" on the a)aila!le e)i"en%e ; am satis ie" that the e:%eption allu"e" to in 1arra.4s %ase applies an" the se%on" "e en"ant is %orre%t in su!mitting that the "o%trine o non,"elega!le "uty is inappli%a!le3 OTH)& M!TT)&S

Page 27 Witnesses of fact not called as itnesses!

5=:6 ; am o the )iew that the plainti s4 in)o%ation o s 114(g& o the A)i"en%e +%t 1780 against !oth the irst an" se%on" "e en"ants with respe%t to the non,%alling o Dr +nne Tay (pathologist&2 Dr RaBa (resi"ent me"i%al o i%er&2 Dr Ru"y $eoh (haematologist&2 operating theatre nurses2 mi"wi e +smah an" the !loo" !an5 representati)es as witnesses is unwarrante"3 The reasons are as ollows3 5=;6 =ith regar" to Dr +nne Tay2 sin%e it is the plainti s who are suggesting that the histopathology report is in%omplete or ina%%urate2 it is or the plainti s to %all the sai" "o%tor i they wish to su!stantiate their allegation that there %oul" ha)e !een a uterine rapture whi%h was not "o%umente"3 5=<6 Dr RaBa4s in)ol)ement has !een "o%umente" in the nursing %are plan an" report on the patient !y the nurses on "uty an" his presen%e is unne%essary3 5==6 Mi"wi e +smah4s role is %omparati)ely minor as oppose" to Mi"wi e +smah who was a material witness an" was with the patient rom 2100 hours2 !e ore the "eli)ery until the patient was sent to the ;6C at 0/00 hours2 8 >o)em!er 20003 @urther "uring this perio" o time she was the mi"wi e who ma"e the entries in the nursing %are plan (!un"le D pp 47,81 an" trans%ript in !un"le D pp 81,88&3 5/116 The e)i"en%e o the operating theatre nurses is irrele)ant3 5/1/6 ;n my )iew the e)i"en%e o Dr Ru"y $eoh4s an" the !loo" !an5 representati)es are not material as there is ample e)i"en%e rom D=12 D=1 an" D=4 in respe%t o the a)aila!ility o !loo" at the material time in the hospital3 ;n any e)ent sin%e the issue o a)aila!ility o !loo" is an issue raise" !y the plainti s the onus is upon them to %all these persons as witnesses i they "eeme" it ne%essary3 4 M ! "#$ at #BB 5/1.6 @inally this is not a %ase where the "e en"ants are withhol"ing or suppressing e)i"en%e an" there ore s 114(g& is inappli%a!le (Munusamy v Public Prosecutor -17?0. 1 MLJ 472 (*6& at p 474 paras F,6 le t %olumn2 *istem Penyuraian 3rafik / +arat *dn +hd v /enny 2eights &evelopment *dn +hd , 'nor -2007. 1 MLJ ?079 -2007. 4 6LJ 80 (6+& at p ?2 para /02 Pekan 5enas 0ndustries *dn +hd v Chang Ching Chuen , -rs -177?. 1 MLJ 4/8 (@6& at pp 402 an" 817 at paras / an" #,; respe%ti)ely&3 Comments on the defendants" e#perts and evidential value 5/176 ; in" the "e en"ants4 e:pert witnesses are e:perts in their own area o e:pertise who a%te" pro essionally "espite the )igorous %ross,e:amination3 + ter assessing their e)i"en%e )is,a,)is whate)er rele)ant %ontemporaneous "o%uments or me"i%al literature re erre" thereto !y them ; ha)e no reason to "ou!t their %re"i!ility3 $O*$L%S"O* 5/186 Cn"ou!te"ly the "eath o the patient was a traumati% an" tragi% e)ent3 #owe)er !ase" on the oral an" "o%umentary e)i"en%e2 the me"i%al literature an" the law2 this %ourt has no other option !ut to "ismiss the plainti s4 %laims with %osts to !e ta:e" unless otherwise agree" as ; in" on a !alan%e o pro!a!ilities<

15a) on the plea"ings alone2 there is a material "eparture rom their plea"e" %ase9 15b) the plainti s ha)e aile" to pro)e their plea"e" %ase in that the patient4s "eath was
%ause" !y PP# in the %ourse o in"u%tion or e:%essi)e !lee"ing "ue to a uterine tear9

Page 10

9c) 4d)

2e)

the plainti s ha)e aile" to esta!lish that the se%on" "e en"ant has !rea%he" the appli%a!le stan"ar" o %are or pri)ate hospitals in Malaysia9 e)en i ; were to err on item (%& in relation to the se%on" "e en"ant2 the "e en"ants ha)e not !rea%he" their "uty o %are to the patient an" %ause" or materially %ontri!ute" to her "eath3 The plainti s ha)e not pro)en there was massi)e ongoing !loo" loss that was not noti%e" !y the irst or se%on" "e en"ants or neither was there %on%eale" !lee"ing that was not re%ognise" !y the irst or se%on" "e en"ants3 ;n short the plainti s ha)e not pro)en that the %ause o the patient4s "eath was PP# that was not atten"e" to !y the "e en"ants9 rather it is this %ourt4s in"ing that the patient "ie" "ue to +@A whi%h too5 pla%e shortly a ter 4am on 8 >o)em!er 2000 an" as me"i%al literature "is%loses patients who su ere" a %ar"ia% arrest the per%entage o sur)i)al is ?P3 Thus in this instant %ase the patient su%%um!e" to +@A "espite the e orts ma"e !y 4 M ! "#$ at #BC the irst "e en"ant an" team o me"i%al spe%ialists an" me"i%al support sta in the wee hours o the morning o 8 >o)em!er 20009 an" on the Iuestion o )i%arious lia!ility in relation to the se%on" "e en"ant2 e)en i the irst "e en"ant is negligent (whi%h ; hol" otherwise&2 the se%on" "e en"ant is not )i%ariously lia!le or the irst "e en"ant4s a%ts an" omissions3 Claims dismissed with costs=

Reporte" !y +sho5 Dumar