SINGAPORE MEDICAL COUNCIL v DR LING CHIA TIEN
11 cases cited
Cited by 1 case
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Case Significance
In Singapore Medical Council v Ling Chia Tien [2024] SGHC 283, decided on 6 November 2024, the Court of Three Judges of the General Division of the High Court heard Originating Application No 1 of 2024, with Tay Yong Kwang JCA, Belinda Ang Saw Ean JCA and Judith Prakash SJ sitting and Belinda Ang Saw Ean JCA delivering the grounds of decision. The appeal was brought by the Singapore Medical Council against the decision of a disciplinary tribunal concerning the respondent, Dr Ling Chia Tien, who had faced 32 charges. The disciplinary tribunal found that 29 of the 32 charges were made out and imposed a term of 19 months' suspension. On appeal, which was on sentence alone, the Singapore Medical Council sought a suspension of 36 months on its primary case, with a fallback position of 30 months. After the hearing on 4 July 2024, the court dismissed the appeal, holding that a 19-month suspension was not manifestly inadequate and that the disciplinary tribunal's sanction was not disproportionate or out of line with relevant precedents, observing that the Council had significantly overstated its primary case.
Summary
SUPREME COURT OF SINGAPORE
06 November 2024
Case Summary
Singapore Medical Council v Ling Chia Tien [2024] SGHC 283
C3J/OA 1/2024
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Decision of the Court of 3 Judges of the General Division of the High Court (delivered by Justice Belinda Ang):
Outcome: The Court of 3 Supreme Court Judges dismissed the appeal and upheld the sentence of 19 months’ suspension.
Background to the appeal
1 C3J/OA 1/2024 was an appeal by the Singapore Medical Council (the “SMC”), against the sentence the disciplinary tribunal (the “DT”) imposed on Dr Ling Chia Tien (“Dr Ling”). Before the DT, Dr Ling faced 32 charges. The DT found that 29 out of the 32 charges were made out against Dr Ling and imposed a term of 19 months’ suspension. On appeal, the SMC sought a term of suspension of 36 months based on its primary case. In the alternative, the SMC sought a term of suspension of 30 months.
Facts
1 Dr Ling was a General Practitioner at Apex Medical Centre (Jurong) Pte Ltd (the “Clinic”). He graduated in 1983 and had been in practice for 40 years. At the material time, Dr Ling had three clinics with a total of five doctors working in them. There were three doctors working in the Clinic: Dr Ling, Dr Tay Sok Hoon (“Dr Tay”), and Dr Goh Miah Kiang (“Dr Goh”).
2 The Ministry of Health (the “MOH”) conducted an audit at the Clinic on 1 November 2016. The MOH officers obtained copies of 16 patient-medical records (the “PMRs”). At that time, the MOH was concerned about Dr Ling’s prescribing practice with respect to hypnotics or benzodiazepines, and his poor documentation of his patients’ medical records. The MOH reported its concerned to the SMC on 10 January 2017. The SMC referred the matter to the Complaints Panel on 25 May 2017. Dr Ling was informed of the appointment of a Complaints Committee on 14 November 2017 (the “First CC”).
3 The First CC issued a notice of complaint on 12 March 2017, and it requested a written explanation by Dr Ling. Dr Ling submitted his letter of explanation on 23 April 2018. Around 10 months later, on 19 February 2019, the First CC informed Dr Ling that it had ordered a formal inquiry to be held by a disciplinary tribunal. On the same day, the First CC informed the President of the SMC that it had discovered that Dr Ling had prescribed codeine-containing medications to five patients.
4 After about another 10 months, on 12 December 2019, the Investigations Unit of the SMC sent a second notice of complaint (the “Second Notice of Complaint”) to Dr Ling. This Second Notice of Complaint informed Dr Ling that a second Complaints Committee (the “Second CC”) had been appointed. The Second Notice of Complaint sought a written explanation from Dr Ling, which Dr Ling submitted on 3 February 2020. On 3 July 2020, the Second CC wrote to Dr Ling to inform him that it had ordered a formal inquiry to be held by a disciplinary tribunal.
5 Around nine months since the Second CC’s last correspondence, on 13 April 2021, the SMC’s solicitors served two Notices of Inquiry (“NOI(1)” and “NOI(2)”, respectively) on Dr Ling. The two NOIs contained a total of 32 charges that the SMC had preferred against Dr Ling in respect of 15 patients.
6 At the start of the first tranche of proceedings on 7 February 2022, Dr Ling initially pleaded guilty to 11 charges. However, Dr Ling subsequently gave evidence that some entries in the PMRs were made by Dr Goh and Dr Tay when they saw the patients. The DT directed Dr Ling to provide the SMC with amended and supplementary transcripts of the PMRs. This led to various amendments to the charges, and the corresponding schedules in NOI(1) and NOI(2) on 15 July 2022. Dr Ling amended his plea at the start of the second tranche of proceedings on 29 August 2022 and only pleaded guilty to five charges.
7 During the second tranche, on 6 September 2022, the SMC’s solicitors wrote to the DT to inform the DT that there were 69 missing entries from the schedules to the NOI(1) and NOI(2). These entries were PMRs within the charge periods that were previously left out. The SMC raised this matter during the hearing on 7 September 2022 and sought the DT’s permission to replace the schedules with the corrected ones that included these additional entries. Dr Ling objected to the late amendment to the charges. He submitted that he should not be subjected to having to revisit 69 additional entries without the opportunity to properly consider every one of them. The DT allowed the application and directed that Dr Ling be given sufficient time to consider and address the additional entries in the Schedules.
8 On 4 November 2022, the SMC wrote to the DT seeking to amend the charges again with a corrected version of the dosages for some of Dr Ling’s prescriptions. At the start of the third tranche, on 14 November 2022, the SMC submitted that Dr Ling had provided certain clarifications on the dosages of some prescriptions – the amendments reflected those clarifications. Dr Ling did not object to the amendments, and the DT allowed them.
9 The DT grouped the 32 charges into four categories: (a) Documentation Charges; (b) Benzodiazepines Prescription Chagres; (c) Benzodiazepine Referral Charges; and (d) Codeine Prescription Charges. The DT found that 29 out of the 32 charges (including the five charges Dr Ling pleaded guilty to) had been made out and imposed a term of suspension of 19 months. The SMC appealed against the DT’s decision on sentence.
Decision on appeal
10 The SMC did not give satisfactory justification for the enhanced sentences it sought on appeal: at [69].
Benzodiazepine Prescription Charges
11 The SMC was not able to show that there was actual harm to any of the patients due to the prescriptions. The burden of proving actual harm was on the SMC, which it failed to discharge: at [76].
12 The Court upheld the DT’s finding that the harm was in the upper range of the “slight category”: at [76] and [88].
13 The evidence supporting the SMC’s contention, that the patients’ therapeutic dependence created a potential for more serious harm in the future, was sparse: at [77].
14 The opinion of Dr Gomathinyagam Kandasami (“Dr Kandasami”) had no evidential value in respect of the Benzodiazepine Prescription Charges. Dr Kandasami’s report was based on Patient 14’s consumption of codeine for cough related symptoms and not for benzodiazepines. Assuming the same opinion could equally apply to prescriptions of benzodiazepines for the same patient, the opinion would not assist the SMC. Dr Kandasami reported that the patient had no features of “Opioid [Codeine] Use Disorder or addiction”. Furthermore, Dr Kandasami caveated that he “would not be able to comment on whether prescribing codeine for her cough related symptoms was appropriate or whether she continues to require codeine prescriptions”: at [78].
15 Dr Kandasami’s opinion that the patient in question was likely to have developed therapeutic dependence did not immediately mean that there was significantly greater harm or potential harm caused: at [78].
16 The facts did not reveal a high frequency or number of prescriptions such that there would have been an increased potential of harm. There was no pattern of prescriptions or a correlation between the time gap between successive visits and the number of prescribed tablets. This suggested that Dr Ling had not been feeding patients’ dependence or addictions: at [79].
17 Three out of six patients were over the age of 65 by the time the prescriptions started. These three patients would potentially be exposed to an increased risk of harm. However, the caution in the 2008 CPG had to be viewed with the DT’s finding that the 2008 CPG allows for some clinical leeway for the long-term use of benzodiazepines in limited instances: at [82].
18 There was a lack of assessment in the sense explained in Ang Yong Guan v Singapore Medical Council and another matter [2024] SGHC 126 at [84] behind Dr Ling’s concomitant prescriptions: at [86].
19 The mere fact of concomitant prescriptions was not sufficient to warrant the finding of a much higher level of harm as advocated by the SMC. The SMC still bore the burden of showing that the use of the specific prescriptions caused either an increased potential or actual harm. The SMC failed to show either: at [87].
20 Even if the court had accepted the SMC’s submission that the level of harm was “moderate”, it would not have been sufficient to warrant appellate intervention on any of the four grounds set out in ADF v Public Prosecutor [2010] 1 SLR 874 at [17]: at [89].
21 The court agreed with the DT’s finding that Dr Ling’s culpability fell within the medium category: at [90] and [95].
22 The case of Singapore Medical Council v Wee Teong Boo [2023] 4 SLR 1328 (“Wee Teong Boo”) did not serve as a good comparison to the present case because it was dissimilar: at [92].
23 It was undisputed that Dr Ling did not make the inappropriate prescriptions for improper financial gain. Instead, Dr Ling appeared to hold strong patient-centric view. Notwithstanding Dr Ling’s misunderstanding of the extent to which he could exercise his clinical judgment, in his view, he was acting in what he considered to be in his patients’ best interests. But his beliefs, as noble as they might be, did not justify his departure from the applicable standards in the manner and to the extent to which he did: at [93]–[94].
24 The starting point sentence for each Benzodiazepine Prescription Charge should be 11 to 12 months’ suspension: at [96].
Benzodiazepine Referral Charges
25 The applicable sentencing framework should be applied individually to each set of charges. The SMC could not simply allow the assessment of one set of charges to “piggy-back” on another set of charges: at [100].
26 In many cases, however, there would be similar facts that would present themselves when assessing the two types of charges, as was the case with the Benzodiazepine Prescription and Referral Charges. The need to separate the analyses for the two sets of charges should nevertheless remain at the front of the court’s mind: at [101].
27 It did not follow that the inappropriate prescriptions of benzodiazepines to the elderly patients meant that the failure to refer those patients cause a similar extent of harm: at [102].
28 The core of the matter was that the SMC’s submission did not address the nub of the Court’s query – if there was indeed harm suffered by the failure to refer, why did none of the patients step forward to complain or reflect signs of addictions? The absence of an answer to that question weighed against the SMC’s suggestion that the mere failure to refer was ipso facto sufficient to warrant a sentence similar to that imposed for the Benzodiazepine Prescription Charges: at [102].
29 The Court observed that Singapore Medical Council v Dr Tan Kok Jin [2019] SMCDT 3 did not lay down a rule that a 50% discount must be applied to the sentences for a charge relating to the failure to refer vis-à-vis a corresponding charge for an inappropriate prescription. There is no bright line rule on how the two types of charges – referral and prescription charges – should generally be treated in relation to one another: at [104]–[105].
30 The harm was slight and the culpability was medium: at [106].
31 The duration of suspension of four months per Benzodiazepine Referral Charge was appropriate: at [103] and [106].
Codeine Prescription Charges
32 The initial starting point sentence for each Codeine Prescription Charge should be nine months’ suspension: at [107].
33 The level of harm would have been lower than in the case of Benzodiazepine Prescription Charges because there was little evidence as to the potential or actual harm that could be caused by the prolonged prescriptions of codeine-containing medications: at [108].
34 The SMC’s submission based on Dr Kandasami’s report was rejected: at [108].
35 There was no standard that codeine could not be repeatedly prescribed for cough beyond three weeks and more so if the cough lasted beyond eight weeks. There was little, if anything, that clearly indicated that the prolonged prescriptions of codeine-containing medications would have likely caused harm to Dr Ling’s patients: at [108].
36 There was insufficient evidence to show that elderly patients would face an additional risk of harm from codeine-containing medications. There was insufficient evidence as to the effect of the admixtures of codeine, and antihistamines and steroids used by Dr Ling. The Harm was in the slight category but lower than that for the Benzodiazepine Prescription Charges: at [109].
37 Dr Ling’s culpability was in the medium category: at [110].
38 The SMC’s reliance on Wee Teong Boo was inappropriate: at [111].
39 The starting point sentence was a term of suspension of nine months for each Codeine Prescription Charge: at [112].
Documentation Charges
40 The sentencing framework from Wong Meng Hang v Singapore Medical Council and other matters [2019] 3 SLR 526 should rightly apply to the Documentation Charges too. Nevertheless, the DT adopted the approach in Singapore Medical Council v Mohd Symsul Alam bin Ismail [2019] 4 SLR 1375 (“Mohd Syamsul”) because precedent cases have not applied the Wong Meng Hang framework. On appeal, neither party contended that the Wong Meng Hang framework should apply. The court, thus, proceeded on this issue with reference to Mohd Syamsul: at [113].
41 The duration of suspension should be three months for each Documentation Charge: at [115] and [117].
42 There should not be an uplift of one month for each Documentation Charge on the basis that Dr Ling’s decision to contest the charges reflected a lack of remorse. The act of contesting charges is not ipso facto ground for finding a lack of remorse which could aggravate the sentence: at [116].
Application of a one-third discount for delay in investigation and/or prosecution
43 The Court applied a one-third discount to the starting point sentences given the delays involved in the prosecution of the matter before the DT, which were found to be inordinate: at [118] and [135].
44 For a delay to be inordinate, it must be unusually long and inexplicable on reasonable grounds. The reference to a “significant” delay must also be a reference to an “inordinate” delay: at [120].
45 As suggested in Wong Poon Kay v Public Prosecutor [2024] 4 SLR 453 at [77], the defendant ordinarily bears the burden of proving that there was an inordinate delay in the prosecution and that the delay resulted in real injustice or prejudice to the defendant: at [120].
46 As for the computation of the length of the delay, this is fact-specific. It would be difficult to justify any strict rule on which delays the court must consider. Instead, the inquiry necessarily has to be a holistic one, taking into account the context of the proceedings and complexity of the case: at [122].
47 The application of a sentencing discount is not meant to be a purely arithmetic endeavour. It would be artificial to rely on merely the absolute length of the delay to find the corresponding discount that should be applied. A tribunal or a court should, for instance, consider, amongst other things, the reasons for the delay, whether the reasons proffered were defensible, and the effect that the delay would have had on the offender: at [123].
48 The reference to “investigations” in Ang Peng Tiam v Singapore Medical Council [2017] 5 SLR 356 does not refer strictly to delays up to the point in time before the start of DT proceedings. A court may, in an appropriate case, even consider the delays during DT proceedings that were occasioned by the SMC’s far from seamless approach to prosecuting the matter. This was one such case. The introduction of the 69 amendments to NOI(1) and NOI(2) during the second tranche of proceedings could be considered by the Court: at [124].
49 The Court was satisfied that the cumulative delays were inordinate, that Dr Ling had not contributed to the delays, and that Dr Ling had been prejudiced by those delays: at [135].
50 Applying the one-third discount, the aggregate sentence was 19 months’ suspension: at [137]–[138].
This summary is provided to assist in the understanding of the Court’s grounds of decision. It is not intended to be a substitute for the reasons of the Court. All numbers in bold font and square brackets refer to the corresponding paragraph numbers in the Court’s grounds of decision.
What was the outcome in Singapore Medical Council v Ling Chia Tien [2024] SGHC 283?
The Court of Three Judges dismissed the Singapore Medical Council's appeal on sentence, holding that the 19-month suspension imposed by the disciplinary tribunal was not manifestly inadequate. The tribunal had found 29 of the 32 charges against Dr Ling Chia Tien made out.
What suspension did the Singapore Medical Council seek in [2024] SGHC 283?
The Singapore Medical Council sought a suspension of 36 months on its primary case, with a fallback position of 30 months, against the 19-month suspension imposed by the disciplinary tribunal. The Court of Three Judges dismissed the appeal, finding the Council had significantly overstated its primary case.
Statutes Cited
s 53(2)(b)
Cases Cited (11)
SG (1)
SLR (10)
[2002] 1 SLR(R) 1024 [2010] 1 SLR 874 [2017] 4 SLR 66 [2017] 5 SLR 356 [2019] 3 SLR 526 [2019] 4 SLR 1375 [2020] 4 SLR 790 [2023] 4 SLR 1328 [2024] 3 SLR 1547 [2024] 4 SLR 453
Referenced in
Statutes interpreted in this judgment
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Judgment
Read the full judgment on the official Singapore Courts portal.
Read on eLitigationSource: eLitigation ([2024] SGHC 283)