SINGAPORE: A psychiatrist was found guilty of three counts of professional misconduct on Monday (May 13) for deviating from relevant standards when he prescribed various drugs to a patient.
These include prescribing medicines beyond the maximum doses indicated on the package leaflets.
Dr Ang Yong Guan’s case concerns a series of prescriptions for a patient named Quek Kiat Siong, who died four days after the last prescription was issued in 2012.
The cause of death was “multiorgan failure with pulmonary hemorrhage, due to mixed drug poisoning.
The concentration of drugs in his blood was found to be “elevated beyond therapeutic concentrations found in living subjects,” according to court documents.
Mr Quek’s sister lodged a complaint against Dr Ang with the Singapore Medical Council (SMC) in 2017.
However, a disciplinary tribunal acquitted Dr Ang of professional misconduct and instead found him guilty of failing to render professional services of the quality reasonably expected of him.
This was overturned by the Three-Judge Court on Monday, which said Dr Ang knew he had exceeded the applicable dose limits and could not justify his decisions to deviate from the standards.
The panel, comprising Chief Justice Sundaresh Menon, Justice Belinda Ang and Justice Tay Yong Kwang, will hear arguments at a later date on the appropriate sanctions to be imposed.
WHAT HAPPENED
Quek first consulted Dr. Ang on 8 February 2010, following a referral from another doctor.
For about two years, Dr Ang, who is also a member of the Singapore Progressive Party, treated Mr. Quek for multiple conditions including insomnia, depression, PTSD, and anxiety.
The patient had concurrent prescriptions for multiple benzodiazepines, concurrent prescription of benzodiazepines with opioid analgesics, as well as overdoses of Mirtazapine and Zolpidem Controlled Release.
Benzodiazepines are depressants that relieve anxiety. Mirtazapine is used to treat symptoms of depression, while Zolpidem is prescribed for insomnia.
One of the three charges relates to the final prescription issued on July 31, 2012.
It was for a daily dose of 60 mg of mirtazapine, which exceeded the maximum allowed daily dose of 45 mg, as well as a daily dose of 25 mg of Zolpidem Controlled Release. This was higher than the maximum allowed daily dose of 12.5 mg.
Mr. Quek died four days later.
JUDGMENT
Dr. Ang acknowledged that his nightly prescription of 60 mg of mirtazapine reached the edge of the kill range, but did not explain why he thought the risks to the patient were worth taking.
“The benefits of its prescription must outweigh or justify the risks assumed, and Dr Ang has not explained why that was so in this case,” the three-judge court said.
They added in the ruling that while prescriptions for Mirtazapine or Zolpidem Controlled Release in doses beyond their maximum prescribed levels presented little risk when taken alone, it should be noted that the patient was also taking several other medications simultaneously.
The other two charges refer to prescriptions issued between February 8, 2010 and December 31, 2011; and between January 1, 2012 and July 31, 2012.
Dr Ang’s decision to switch antidepressants without ensuring that each was maintained for at least four to six weeks was inconsistent with guidelines issued by the Ministry of Health.
He had also gone against guidelines on long-term chronic use of benzodiazepines by prescribing a six-month supply to the patient.
The court found some of its decisions to depart from the guidelines to be “objectively defensible,” while others were not.
In its ruling, the court said that while doctors can depart from the norms adopted by the medical profession, the burden is on them to show that their decisions are objectively justified in terms of risks and benefits.
The SMC’s disciplinary tribunal had refused to convict Dr Ang of professional misconduct, concluding that his decisions did not amount to a deliberate international deviation from standards of treatment.
He noted that the psychiatrist had shown care and concern for Mr. Quek and tried to live up to the standard expected of him.
But the Three-Judge Court ruled that “care and concern for a patient were irrelevant to a professional misconduct investigation.
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