Dr Ang Yong Guan v Singapore Medical Council

Facts

Dr Ang Yong Guan, a senior psychiatrist with more than 36 years in practice, treated the late Mr Quek Kiat Siong between 8 February 2010 and 4 August 2012. His prescriptions did not comply with the applicable Ministry of Health guidelines, and his last prescription on 31 July 2012 gave Mirtazapine and Zolpidem CR above the maximum dosages in the product inserts. The patient died on 4 August 2012; the certified cause was multi-organ failure with pulmonary haemorrhage due to mixed drug intoxication. After his sister complained, a Disciplinary Tribunal convicted Dr Ang of three charges of failing to provide services of the expected quality and suspended him for 24 months, acquitting him of the alternative professional misconduct charges.

On cross-appeals in Originating Applications Nos 8 and 9 of 2023, the Court of 3 Judges, in an earlier liability judgment, convicted him instead of the three professional misconduct charges under s 53(1)(d) of the Medical Registration Act: concurrent prescription of multiple benzodiazepines, prescription of benzodiazepines while he knew the patient was taking opioid analgesics, and the final over-limit prescription. This judgment decided the sanction. The SMC's case was not that his prescriptions caused the death.

Issues

1. What levels of harm and culpability applied to each charge under the Wong Meng Hang framework.
2. Whether offender-specific factors, including his seniority and any inordinate delay in prosecution, warranted adjustment.
3. Whether the suspensions for the charges should run concurrently or consecutively, and what costs order to make.

Holding

The Court of 3 Judges set aside the tribunal's sentence and sentenced Dr Ang to a suspension of 36 months, with the censure and the written undertaking ordered by the tribunal to stand, and ordered costs of $100,000 in the SMC's favour.

Reasoning

Applying Wong Meng Hang v Singapore Medical Council and other matters [2019] 3 SLR 526, the court looked at potential harm. Combining benzodiazepines, and combining them with opioids, risked respiratory depression, coma and death, far graver than the addiction risks in the precedents Dr Ang relied on, so harm on the first two charges was mid-moderate. For the third charge, Dr Ang had conceded that 60mg of Mirtazapine went to the edge of the killing range, and the court could take the patient's death into account in assessing the risk; harm was at the low end of severe.

On culpability, a deliberate departure did not automatically put him at the top of the high range. There was no profit motive, unlike Singapore Medical Council v Wee Teong Boo [2023] 4 SLR 1328. But he had not weighed the risks, and he had not obtained the patient's informed consent to treatment carrying a real risk of death, which was not double counting because consent had not founded liability. That placed the first two charges at mid-medium. The final prescription, doubled without explanation or thought about drug interactions, showed blatant disregard and sat at the low end of high. Starting points were 18, 15 and 36 months.

His seniority and stature were aggravating, following Ang Peng Tiam v Singapore Medical Council and another matter [2017] 5 SLR 356, and his good record carried modest weight. No delay discount was given: absolute length alone does not show inordinate delay, he identified no unreasonable conduct by the SMC, and deterrence would have prevailed anyway. Contesting the charges was not lack of remorse.

The first two charges involved identical averments and ran concurrently; the third was a distinct, more serious act and ran consecutively. After a totality adjustment, the sentences became 12, 10 and 24 months. Costs were discounted because many averments were not proved.

From the judgment