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SINGAPORE: The Court of Three Judges on Wednesday (Feb 5) handed a 36-month suspension to a psychiatrist after earlier finding him guilty of professional misconduct.
In May last year, Dr Ang Yong Guan was found guilty of three charges of deviating from the relevant standards when prescribing various medications to a patient.
The case relates to a series of prescriptions for a patient named Quek Kiat Siong, who died four days after the last prescription was issued in 2012.
Dr Ang treated the patient for about two years for multiple conditions, including insomnia, depression, post-traumatic stress disorder and anxiety.
The final prescription, issued on Jul 31, 2012, consisted of a daily dose of 60mg of Mirtazapine, which exceeded the permitted maximum daily dosage of 45mg, as well as a daily dose of 25mg of Zolpidem Controlled Release - above the permitted maximum daily dosage of 12.5mg.
SENTENCING
The first two charges related to prescriptions issued between Feb 8, 2010, and Dec 31, 2011; and between Jan 1, 2012 and Jul 31, 2012.
Dr Ang had decided to switch between antidepressants without ensuring that each was continued for at least four to six weeks.
He had also allowed for long-term chronic use of benzodiazepines by prescribing a six-month supply to Mr Quek on Jul 31, 2012.
The court, comprising of Chief Justice Sundaresh Menon, Justice Belinda Ang and Justice Tay Yong Kwang, said in the judgment on Wednesday that the level of harm associated with the two charges was "closely linked to the severity of the potential harm which the patient could have suffered because of Dr Ang’s prescriptions".
In 2017, Mr Quek's sister filed a complaint against Dr Ang with the Singapore Medical Council (SMC). But a disciplinary tribunal acquitted him of professional misconduct and instead found him guilty of failing to provide professional services of the quality which is reasonably expected of him.
This was overturned last May by the Court of Three Judges, which said Dr Ang knew he had exceeded the applicable dosage limits and could not justify his decisions to deviate from the standards.
"Even though the SMC's case against Dr Ang is predicated on the potential harm which the offending prescriptions might have caused the patient – rather than any actual harm resulting therefrom – we find it difficult to ignore the fact that the level of potential harm associated with these prescriptions was severe," the judges said on Wednesday.
They added that the multiple benzodiazepine prescriptions entail a risk of central nervous system (“CNS”) depression, sedation, respiratory depression, and cardiovascular depression.
With the concurrent prescription of opioid analgesics, the risks are "of a similar nature, albeit of a greater magnitude" as it may disproportionately increase the CNS depressant effect of the respective medications and result in cardiorespiratory depression, hypotension, coma and death.
As a specialist and senior medical practitioner, Dr Ang would have been expected to demonstrate a greater degree of competence in managing the risks associated with his prescriptions, as compared to a general practitioner, said the court.
Even if Dr Ang "genuinely believed it necessary to go outside the bounds of accepted standards of treatment if the patient was to be able to live a normal life", it is difficult to excuse his failure to inform Mr Quek of the "real and severe risk of the treatment possibly ending his life altogether".
With the third charge, which related to the final prescription, the court found that the gravity of the potential harm was "severe".
"Despite the highly dangerous nature of this prescription, and despite being aware of the risks it entailed, Dr Ang proceeded to increase the dosages of these medications without any good reasons for doing so, and without obtaining the patient’s informed consent," said the court.
Dr Ang also failed to show that he had considered the potential for drug interactions and did not give an explanation on why the risks to the patient were worth taking.
"In our view, the lack of any explanation given for the increased dosages and the absence of thought given to how this might affect potential drug interactions is indicative that the last prescription could not even subjectively have been made with a genuine but mistaken concern for the patient’s interest."
"Instead, it suggested that there was no justification at all for the last prescription."
PLACED PATIENT IN "GRAVE DANGER"
Dr Ang was given a three-year suspension, with the first charge of 12 months and second charge of 10 months to run concurrently. He also received a 24-month suspension for the third charge, which will run consecutively.
In the judgment, the court noted that it was appropriate to run the first and second charges concurrently as the factual averments and medications involved thereunder were ultimately identical.
The third charge, which was the "most serious" of the three, was run consecutively as "it entailed a dramatic one-off increase in the prescriptions of Mirtazapine and Zolpidem CR well beyond the maximum dosage limits contained in the product inserts".
The court added that Dr Ang placed the patient in "grave danger" and "did not even appear to properly appreciate the gravity of so doing at the material time".
"This was completely unacceptable conduct that would harm public confidence in the medical profession."
On the issue of costs, Dr Ang had argued for legal costs to be S$50,000 while the SMC asked for S$147,000. The court ordered on Wednesday that Dr Ang pay S$100,000 in costs as the SMC had failed to establish many of the factual averments underlying the first two charges.
"We also observe that the averments concerning discontinuation of antidepressants, for which Dr Ang was not found liable, involved close scrutiny of the individual justifications behind each discontinuation," said the court.
Dr Ang is currently the assistant secretary-general for the Progress Singapore Party (PSP) and contested in the Marymount Single Member Constituency (SMC) during the 2020 General Election.
In response to CNA's query on Wednesday, a PSP spokesperson said that Dr Ang had informed the party in January that he would not seek re-election or participate in the upcoming General Election when his Central Executive Committee term ends next month.
The spokesperson added that the party accepts the court's decision and has no further comment.
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