SINGAPORE: A specialist in obstetrics and gynaecology has been suspended for 12 months for negligence linked to a 2013 surgery on a patient who later suffered a miscarriage when her uterus ruptured.
Dr Chen Yun Hian Christopher had performed a procedure on a patient known only as Ms C, who saw him to improve her chances of fertility, according to the grounds of decision by the Singapore Medical Council (SMC) Disciplinary Tribunal published on Tuesday (Sep 24).
Dr Chen made an “excessively wide” incision along the patient’s uterine wall, removing an “excessive amount” of healthy tissue and failed to close the uterine wall defect layer by layer, instead placing purse-string sutures and attempting to close the deeper defect by using “straight a needles”.
The veteran doctor, who is now 84, pleaded guilty to one charge of professional misconduct amounting to serious negligence.
He admitted to failing to meet the standard of care expected of him in performing a procedure on the patient. Another charge taken into consideration stated that he failed to obtain informed consent from the patient for the surgery.
WHAT HAPPENED
Dr Chen has been a specialist since 1998 and a registered medical practitioner since 1965.
At the time of the offence, he was practising at the Christopher Chen Centre for Reproductive Medicine, now known as the Advanced Centre for Reproductive Medicine – Fertility Clinic.
In January 2013, Ms C and her husband consulted Dr Chen for advice to improve her chances of pregnancy.
Dr Chen diagnosed the woman with adenomyosis – when the tissue that normally lines the uterus grows into the muscular wall of the uterus – and polycystic ovaries, which can cause hormonal imbalances and irregular periods.
He advised the patient to undergo a procedure to improve her chances of pregnancy, and the surgery took place in March 2013.
It involved an examination of the uterine cavity, removal of lesions and “cauterisation of endometriosis”, where tissue is removed by burning to treat a disease where tissue similar to the lining of the uterus grows outside the uterus.
After the surgery, Ms C continued to see Dr Chen for follow-up consultations to manage her heavy menstruation, as well as to undergo ultrasound scans for a more accurate estimation of ovulation dates to increase her pregnancy chances.
Around August 2014, Ms C realised she had conceived naturally. She continued to see Dr Chen until October 2014.
Around Oct 20, 2014, she suffered a uterine rupture and miscarried. She was in her early second trimester.
It was only in May 2016 that the SMC received a complaint from Ms C. She said the surgery performed by Dr Chen had resulted in her uterine rupturing during her pregnancy, and that he had not informed her of the consequences and risks of undergoing the procedure, including whether she would have to give birth via cesarean section.
THE INQUIRY
According to the grounds of decision, a “responsible and competent doctor” performing the surgery would have ensured that any incision made along the uterine wall to access the underlying module was small enough to avoid removing healthy tissue.
This was to preserve the healthy layers and ensure that the uterine wall defect could be closed without tension.
The uterine wall defect should also have been closed with “absorbable sutures” layer by layer.
Dr Chen agreed that he had deviated from this standard and that his conduct placed his patient at an increased risk of uterine rupture and miscarriage.
As a result, the patient suffered both the above and also has an increased risk of uterine rupture in future pregnancies. This was objectively “a foreseeable consequence” of Dr Chen’s misconduct, the judgment stated.
The SMC sought a suspension of between 24 and 30 months for Dr Chen, saying he was a highly experienced and senior doctor with close to 50 years’ experience as a medical practitioner and 15 years’ experience as a specialist at the time of the surgery.
SMC said a discount of only 50 per cent should be given for “some delay in prosecution”, attributing some delays to Dr Chen who asked for extensions to explain himself.
In explaining the delay of about six years and seven months since the notice of complaint in November 2016, SMC said the case involved “niche medical issues” and time was needed to find experts who were willing to be experts for SMC.
Many of the medical practitioners contacted by SMC declined to be involved, on the basis of conflict of interest which was “ostensibly due to the seniority and eminence” of Dr Chen. Eventually, SMC engaged an expert based overseas.
Dr Chen’s lawyers from Allen & Gledhill asked for not more than 10 months’ suspension, saying Dr Chen had believed that he was acting in the patient’s best interest.
However, he accepted with the benefit of hindsight that he “should have been more conservative by excising less myometrial tissue” and that he should have closed the uterine wall defect layer by layer.
Dr Chen believed that he had removed an appropriate amount of tissue and that using the purse-string stitch would benefit Ms C, by reducing surgical blood loss and resulting in less scarring and enabling faster recovery.
Dr Chen’s lawyers said he had no malicious intent towards the patient and was “not motivated by an intention to make financial or other personal gain”.
They added that Dr Chen, who is now 84, has been suffering from ill health after being diagnosed in 2015 with an abnormal heart rhythm. He has a pacemaker to manage his tachycardia, and his hypertension has reached high readings associated with the stress of the disciplinary proceedings, said the lawyers.
They argued that the lengthy lapse of time has resulted in hardship and distress to Dr Chen, who suffered a stroke in 2015.
After receiving the notice of complaint in 2016, he suffered such stress and anxiety that he was unable to maintain an active clinical practice and other doctors were brought in to take over his patients until the clinic no longer bore his name.
The risk of reoffending is low, as Dr Chen did not return to surgical practice after being assessed to be fit to perform clinical duties after his stroke, said the lawyers.
THE TRIBUNAL’S DECISION
The disciplinary tribunal said Dr Chen had performed the surgery in a manner which was “lacking in many aspects”. The way he closed the uterine wall defect was “entirely inappropriate” and caused irreparable harm to the patient.
The tribunal gave “very little weight” to the assertion that Dr Chen had honestly believed his use of purse-string sutures would benefit the patient, “given the extent of the departure from the acceptable methods”.
However, the tribunal found that this case “did not involve an abuse of trust and confidence for own personal gain”.
It found there was an inordinate delay in prosecution, saying the delay was “exceptionally long” even if SMC had difficulties obtaining expert opinion, without “cogent reasons to explain the delay”.
On top of the 12 months’ suspension, Dr Chen will be censured and will have to give a written undertaking to the SMC that he will not engage in the misconduct or any similar conduct again.
He will also have to pay the costs and expenses of the proceedings, including the costs of SMC’s solicitors.
