[Update on Sep. 20, 2019, 4:25pm] This story was updated with a statement by Chief Executive Officer of Mount Elizabeth Hospital, Noel Yeo.

On Sep. 16, 2019 after a seven-day hearing, a state coroner revealed that the 2016 death of an elderly woman in a Singapore hospital was due to human errors and major lapses in protocol.

Some of these errors were oversights in part by the doctor, Sean Ng Yung Chuan.

Ng had been a practising orthopaedic surgeon since 2011.

Surgeon left for conference a day after patient's operation

Yuen Ingeborg, a Singapore permanent resident, was admitted into Mount Elizabeth Hospital on Nov. 1, 2016 to undergo knee replacement surgery.

The surgery is a fairly common one among older folks, used to treat pain and disability in the knees typically caused by arthritis.

According to The Straits Times, hundreds of patients in Singapore undergo the operation each year.

Following the operation, Yuen appeared fine, and Ng continued to observe her for recovery and post-surgery care.

First human error

The first human error, the coroner said, came when Ng left for a medical conference in Tokyo on Nov. 2, without handing the case over to another specialist, something which the coroner described as "injudicious" and "short-sighted".

It was during Ng's absence when complications arose.

Second human error

In the evening of Nov. 2, a nurse found that Ingeborg's left foot -- on the leg which was operated on -- was cold, and the patient was reportedly in much pain.

The nurse alerted a resident medical officer, Jeffrey Mah, who was unable to find a pulse in the leg, reported CNA.

Unable to contact Ng as he was overseas, Mah sought help from another orthopaedic surgeon, Chin Pak Lin, who had assisted during Yuen's surgery.

Chin discovered that during the operation, Ng had unknowingly severed an artery and a vein, leading to internal bleeding and restricted blood flow to the leg, causing it to feel cold to the touch.

This was the second in a string of human errors which eventually led to Yuen's death.

Emergency operation

An emergency operation was then conducted successfully, but the patient's condition continued to deteriorate.

Chin then decided to amputate Yuen's leg above the knee to save her life.

However, Yuen entered cardiac arrest, and subsequently died of multi-organ failure on Nov. 7.

Patient's children questioned medical professionals' expertise

The coroner stated that Yuen's children were not satisfied with the care their mother received at the hands of the nurses and the specialists, reported CNA.

Yuen's children were "unhappy" that Ng chose to leave Singapore so soon after the operation, and was not around to assist when complications arose.

They also doubted the nurses' abilities and competencies.

Nurses competencies doubted

Yuen's daughter reportedly pointed out twice that her mother's leg felt been icy cold, but the nurse responded that that was normal, ST reported.

Nurses also said that they could feel a weak pulse in Yuen's leg, when this had likely been impossible considering the blood vessels were severed.

Other surgeons from Singapore General Hospital stated during the inquiry that complications with the artery in the knee were very rare.

They affirmed that the nurses who had felt a "weak pulse" had probably pressed down too hard with their fingers, and were instead feeling their own pulses.

Surgeon cut short trip when patient's condition worsened

Regarding the Tokyo conference, Ng had reportedly told Yuen about it and suggested performing the surgery after the event.

However, Yuen had apparently been insistent on undergoing the surgery before the event, but did not reveal why.

Ng told the coroner that before he left, "everything was fine", and he was not told that Yuen's lower leg was feeling cold.

Nurses then informed him that Yuen was experiencing numbness in her leg while he was in Tokyo.

Ng subsequently called another anesthetist to assist.

The anaesthetist told Ng to continue with his trip, reported CNA.

When Yuen's condition worsened though, Ng cut his trip short to return on Nov. 5.

Other lapses in medical standards

Ng told the coroner that he left for the conference as there had been no post-surgery complications at the time.

Yuen's children also wanted to know if the injury to the blood vessels had been detected earlier, whether Yuen might have had a higher probability of survival.

Ng was unable to comment if that would have made any difference.

Other lapses in standards

Another lapse in standards was that Ng had failed to make notes of Yuen's condition at the time of the reviews on Nov. 1 and Nov. 2, instead documenting them after he returned from Tokyo.

This clearly flouted Singapore Medical Council guidelines.

According to CNA, Ng's notes displayed a "dire lack of details" and were "unreliable", which made it difficult for medical experts to ascertain if proper post-operative care had been administered.

The nurses' notes were also found to be "brief" and sometimes "inaccurate".

Review of protocols

The coroner added that despite the best intentions of medical professionals involved in the care of Yuen, there were gaps in the medical care issued, and Ng's actions had went "beyond mere human error".

"It demonstrated a clear departure from the standards expected of a physician who had primary care of a post-surgery patient."

Following this incident, the coroner suggested a policy where proper guidelines are in place for a handover, and "that a doctor delivering primary care to a post-surgery patient, must arrange for another doctor to cover him if he is going to be unavailable".

In a statement by Chief Executive Officer of Mount Elizabeth Hospital Noel Yeo, Yeo said that action had also been taken against Ng:

"Stern and appropriate action was taken against the doctor immediately after the hospital concluded its internal investigations, and he was served with an eight-month suspension. A report was also made to the Singapore Medical Council."

Since April 2018, Mount Elizabeth Hospital has reviewed nursing protocols for post-surgery care of knee replacement surgeries.

Top photo by Mount Elizabeth Hospital via Google Maps