4 The deceased, Mdm Lee Lee Chan (“Mdm Lee”), was 59 years of age at her passing on 28 July 2011. The Plaintiff is the widower of Mdm Lee and is also the administrator of her estate. The Defendant, Dr London Lucien Ooi Peng Jin, is a Senior Consultant Surgeon at Singapore General Hospital (“SGH”) specializing in hepato-pancreato-biliary (“HPB”) surgery, ¹ ie, surgeries involving the liver, pancreas, and bile ducts.

5 On 4 July 2011, Mdm Lee underwent a Whipple operation performed by the Defendant to remove a tumour on the head of her pancreas. While under post-operative care, she suffered several complications, and passed away on 28 July 2011. ² Her final cause of death was as follows: ³

8 The pancreas is an organ located behind the stomach. At its head is the duodenum (ie, the first section of the small intestines) and the bile duct (ie, the tube joining the liver to the pancreas). ⁴

9 In a Whipple operation, the pancreatic head, the gallbladder, and part of the bile duct, stomach, and small intestines are removed. The remnants of the pancreas, bile duct, and stomach are then anastomosed (ie, reconnected) to the gastrointestinal tract to facilitate normal digestion and absorption of food. ⁵

11 In his Statement of Claim (Amendment No 2) (the “SOC”), the Plaintiff alleged that the Defendant: ⁶

12 At or around the beginning of the trial, the Plaintiff narrowed his claim to a single allegation, ie, that the Defendant failed to offer timely and appropriate care between the Whipple operation and two subsequent surgeries. ⁷

13 The Plaintiff submitted that by 7 July (POD3), Mdm Lee had suffered “an anastomotic leak of the anastomotic sites of the Whipple Operation”, ⁸ which the Defendant failed to investigate, diagnose, and treat timeously. By the time the anastomotic leak was diagnosed on 17 July, it had deteriorated severely. Thereafter, despite knowing of the anastomotic leak, the Defendant failed to manage Mdm Lee appropriately. Up until 24 July, he failed to investigate whether her fluid collections were adequately drained by the existing abdominal drains, and to intervene via a percutaneous drainage procedure (ie, inserting a small tube through the skin to drain fluid in the abdomen) into any undrained fluid collections. By the time the Defendant decided to perform a percutaneous drainage procedure on 24 July, Mdm Lee’s condition had become unsalvageable.

(a) Before 2300hrs on 16 July, it sufficed for the Defendant to have simply suspected, but neither investigated nor diagnosed, an anastomotic leak. In any event, his management and treatment of Mdm Lee would have been substantially the same even if she had been diagnosed with an anastomotic leak.

(b) Following the occurrence of an anastomotic leak at 2300hrs on 16 July, it was appropriate for the Defendant to have managed Mdm Lee with non-surgical measures. ⁹ She was too unstable for invasive intervention, whether in the form of a laparotomy (ie, opening up the abdomen to wash it out and close the disrupted anastomosis), or a percutaneous drainage procedure to remove the undrained fluids in the abdomen. ¹⁰ Hence, she was managed non-surgically to optimise her condition for the definitive intervention of a laparotomy.

20 On 7 July (POD3), Mdm Lee had amylase levels of 1,361U/L and 1,942U/L respectively in her right and left operatively-inserted drains. ²⁸ These levels were respectively 7.3x and 10.4x of her normal serum amylase level of 186U/L. ²⁹ Citing Claudio Bassi et al, “Postoperative pancreatic fistula: an international study group (ISGPF) definition” (2005) 138(1) Surgery 8 (the “Bassi Article”), the Plaintiff submitted that, in view of these results, the Defendant should have suspected or diagnosed an anastomotic leak. This was initially denied by the Defendant.

22 Based on her drain amylase level on 7 July, Mdm Lee had a POPF. Although Dr Mak accepted this, he did not equate the POPF with an anastomotic leak. He added only that the prognosis on 7 July was that the POPF would resolve spontaneously. ³⁰ The disputes between the parties were thus as follows:

23 The Plaintiff submitted that in the accepted medical literature, the terms “leak” and “POPF” are synonymous and interchangeable. Accordingly, Mdm Lee had by 7 July suffered from, and should have been diagnosed with, an anastomotic leak. He referred to the following passage from the Bassi Article (at p 10) to support his contention: ³¹

24 The Defendant submitted that the terms “POPF”, “anastomotic dehiscence”, and “anastomotic leak” are distinct. Even if Mdm Lee had a POPF on 7 July, she did not necessarily have an anastomotic leak. I set out the Defendant’s definitions of these terms: ³²

(a)  POPF: a leakage of pancreatic fluid into the abdominal cavity that results in drain output on or after POD3 with an amylase content of over 3x the serum amylase activity, without any indication of the mechanism by which the leakage actually occurred. ³³

(b) Anastomotic dehiscence: a rupture or disruption in an anastomosis (the PG anastomosis in Mdm Lee’s case) that results in a gap in the anastomosis through which contents of the stomach and pancreas can leak into the abdominal cavity. ³⁴

(c) Anastomotic leak: an anastomotic dehiscence that results in leakage of the contents of the stomach and pancreas into the abdominal cavity. ³⁵

Since a anastomotic dehiscence is the mechanism through which an anastomotic leak occurs, I will refer to both the complications of an anastomotic leak and an anastomotic dehiscence simply as a “Dehiscence”.

25 The Defendant claimed in his closing submissions that he had from POD3 (7 July) suspected a Dehiscence based on Mdm Lee’s elevated drain amylase level, even though there was no need to have documented it: ³⁶

26 This submission stood in stark contrast to the Defendant’s pleadings and evidence-in-chief. In the Defence, Mdm Lee’s elevated POD3 drain amylase levels were omitted entirely from the Defendant’s account of his observations and decisions from 4 to 16 July. ³⁷ This was even though the SOC had described the drain fluid amylase level of 1,361U/L (for the right drain) on 7 July, as a finding that “reflected a clear possibility of a pancreatic leak.” ³⁸

27 As chronicled in the Defence, Mdm Lee was first observed for indications of a Dehiscence late in the night of 16 July when she complained of sudden abdominal pain. ³⁹ An abdominal CT scan in the morning of 17 July showed a possible Dehiscence. ⁴⁰ Only thereafter was she “diagnosed” with “septic shock likely secondary to anastomotic leak”. ⁴¹ The Defendant then pleaded that “[o]n 17 July 2011, an anastomotic leak was suspected.” ⁴² This suggested that he did not even suspect a Dehiscence until 17 July.

28  The Defendant pleaded also that from 4 to 16 July, “[t]he volume of fluid drained from [Mdm Lee’s] abdominal drains, the fluid amylase levels, and the occasional pain were not unusual.” ⁴³ He stated also in his affidavit of evidence-in-chief (“AEIC”) that her drain amylase level on 7 July “was slightly elevated but was not unusual”. ⁴⁴ These were remarkable statements. The fluid amylase levels in [Mdm Lee’s] right and left drains on 7 July were respectively 7.3x and 10.4x her normal serum amylase levels (see [20] above). These far exceeded the [3x] threshold for identifying the existence of a POPF under the Bassi Article. Even Dr Mak described Mdm Lee’s drain amylase levels on POD3 as “high”. ⁴⁵

29 The Defendant stated further in his AEIC that amylase-rich pancreatic fluid spilt during the Whipple surgery “may not have been totally washed away during surgery … will persist for a few days post-operatively and … therefore be measureable or detectable in the abdominal drains.” It was thus “more relevant to monitor for a possible anastomotic leak through observing the colour and volume of the drain [fluids].” For Mdm Lee, “the colour of the drain fluid was not worrisome or suggestive of any form of anastomotic leak until 17 July”. ⁴⁶

30 In his oral evidence, the Defendant put forward two additional explanations for Mdm Lee’s elevated POD3 drain amylase level: (i) seepage of pancreatic fluid through the suture holes along anastomoses, and (ii) release of amylase-rich exudate due to pancreatitis or irritation of the pancreas. In support of these contentions, the Defendant cited Vladimir D Dugalic et al, “Drain amylase value as an early predictor of pancreatic fistula after cephalic duodenopancreatectomy” (2014) 20(26) World Journal of Gastroenterology 8691 (the “Dugalic Article”) at 8695. ⁴⁷

33 The benign explanations for Mdm Lee’s POPF put forth by the Defendant (at [31] above) did not assist him. As Dr Mak clarified, one would expect the benign explanations for an elevated drain amylase level to be “self-limited” and settle within a few days of a Whipple operation. ⁴⁸ The Bassi Article advocated conducting the drain amylase test for identifying a POPF “on or after [POD3] simply because one hopes that by the third day, you might exclude some of the other possible causes for amylase being present in the fluid.” ⁴⁹ This was also the view of Dr Nikfarjam, who opined that “stitch holes often seal up, and they don't persist beyond day 3. Anastomotic leaks, on the other hand, of any significance would persist.” ⁵⁰

36 First, the Defendant referred to Yi-Ming Shyr, et al, “Does drainage fluid amylase reflect pancreatic leakage after pancreaticoduodenectomy?” (2003) 27(5) World Journal of Surgery 606, which appeared to suggest that elevated drain amylase levels do not indicate a Dehiscence. ⁵¹ However, this article was written two years before the Bassi Article, and its findings had been considered by the authors of the Bassi Article when they formulated their definition of a POPF (at p 11, footnote 49). More importantly, the Defendant had in his submissions accepted the Bassi Article as authoritative. ⁵²

37 Secondly, the Defendant submitted that the Bassi Article was intended purely to facilitate comparative study of surgical experiences. ⁵³ However, the Bassi Article “suggest[ed] that use of [the] proposed definition of POPF will confirm its clinical value and allow accurate comparison of different surgical experiences” (at p 12). I note that the Defendant’s submissions quoted only the latter part of this sentence (which referred to the accurate comparison of surgical experiences), ⁵⁴ but omitted any reference to the former part of the sentence (which confirmed the “clinical value” of the ISGPF Test).

38 Thirdly, the Defendant relied on Daniel J Moskovic, et al, “Drain data to predict clinically relevant pancreatic fistula” (2010) 12 Journal of the International Hepato-Pancreato-Billary Association 472 to show that elevated drain amylase levels are not of themselves clinically significant. ⁵⁵ However, the Bassi Article ascribed no clinical significance to the bare fact of an elevated POD3 drain amylase level. Instead, it proposed a three-tier ex post facto grading of the clinical significance of a POPF, with Grade A having no clinical impact (see [46] below).

39 Finally, the Defendant suggested that the volume and colour of the drain fluids were more important indicators of a Dehiscence than an elevated POD3 drain amylase level (see [29] above). However, the Bassi Article had examined the diagnostic value of the volume and quality of drain output before formulating its objective test for a POPF/Dehiscence by reference to the POD3 drain amylase level (at p 11). This is not to say that the volume and colour of the drain fluid are unimportant, but only that the absence of drain fluid of a large volume or a sinister colour does not detract from the possibility of a Dehiscence when the requirements of the ISGPF Test (at [21] above) are satisfied.

41 I would add only that the Plaintiff’s oral elaboration of his opening statement added to the confusion. It conflated the criteria for identifying the existence of a Dehiscence with that for assessing its severity. I set out the statement of counsel for the Plaintiff, Mr Tan Chee Meng, SC (“Mr Tan”). ⁵⁶

42 Dr Nikfarjam opined that a Dehiscence could be identified from an elevated POD3 drain amylase level alone. He took the view that Mr Tan’s statement above, that “there are other criteria that one looks at to ensure that [the] possibility [of a leak] is minimised”, was more accurately a statement that the severity of a leak could not be determined solely based on an elevated POD3 drain amylase level. ⁵⁷

43 On the other hand, Dr Beckingham accepted that Mdm Lee’s elevated POD3 drain amylase level gave rise only to a suspicion, and not necessarily a diagnosis, of a Dehiscence. ⁵⁸

44 For this case, the distinction between a suspicion and a diagnosis of a Dehiscence is not material. Both of the Plaintiffs’ experts testified that a Dehiscence is the most frequent major complication after pancreatic surgery. ⁵⁹ Dr Mak acknowledged that a Dehiscence is the most severe cause of a POPF, “the one which we as surgeons are obliged to consider as our worst case scenario.” ⁶⁰ I find that it was thus unreasonable for the Defendant to fail to even suspect a Dehiscence based on Mdm Lee’s elevated POD3 drain amylase level. In doing so, he fell below the standard of care expected of him.

45 I note that Dr Mak opined that “the possible [POPF] that was discovered on [7 July] was not directly related to the later anastomotic dehiscence” that the Defendant eventually diagnosed on 17 July (see [121] below). What Mdm Lee had on 7 July was a “transient or biochemical pancreatic fistulae” that settled spontaneously. Hence, “there was not any dehiscence of the [PG] anastomosis before 16th July”. ⁶¹ However, the Defendant did not mention a transient or biochemical pancreatic fistulae in his evidence. Besides, as Dr Beckingham explained (by reference to the Dugalic Article (at p 8697)), the concept of “a fistula that wasn't there to start with and then developing later … after the 5th post-operative day” was doubtful. ⁶² In any event, Dr Mak conceded that “it [was] difficult to determine, if the fistulae had closed by 16th July”. ⁶³ Accordingly, I do not accept the suggestion that Mdm Lee had on 7 July a [transient] POPF that settled shortly thereafter and that was unrelated to the Dehiscence diagnosed on 17 July. Instead, she likely had a Dehiscence from 7 July. Although this Dehiscence was not clinically significant on 7 July, it deteriorated and had become much worse by 16 and 17 July.

46 The Plaintiff’s pleaded case was that an abdominal CT scan should have been performed before 17 July to investigate Mdm Lee’s condition. ⁶⁴ Had it been done, it would have confirmed the existence of a Dehiscence and revealed a need for intervention: specifically, a percutaneous drainage procedure to drain the collections of fluid in the abdomen that were inadequately drained by the existing operatively-inserted drains.

47 As a result, Mdm Lee did not have an abdominal CT scan until 17 July, by which time it was “too late” for any intervention to have changed her outcome: ⁶⁵

50 Before any evidence was led on the first day of trial, the Defendant applied to amend his Defence to clarify that there would have been little change to Mdm Lee’s management even if a Dehiscence had been diagnosed before 17 July: ⁶⁶

52 Dr Beckingham testified that “the earliest point at which it would have been reasonable to consider further intervention would be 11 July, and probably the latest point at which we should have been considering it was 17 or 18 July.” ⁶⁷ Further, such intervention would have been performed only “on the assumption that you [have] do[ne] a CT scan which shows you something significant enough to warrant percutaneous drainage.” ⁶⁸ Although Dr Beckingham subsequently retracted his evidence that percutaneous drainage could have been performed as late as 17 or 18 July, he nevertheless refrained from criticising Mdm Lee’s management before 11 July. ⁶⁹

53 Dr Nikfarjam did not challenge Mdm Lee’s management prior to 11 July. From 7 to 8 July, despite her elevated POD3 drain amylase level, she had improved since her Whipple operation and was not unwell. ⁷⁰ It was thus reasonable for the Defendant to have managed her the way he did. ⁷¹ On 9 July, Mdm Lee experienced respiratory compromise (ie, breathing difficulties) and shortness of breath, ⁷² and drained “haemoserous” fluid. ⁷³ It was thus appropriate to have focussed on controlling these complications on 9 and 10 July. ⁷⁴

55 On 11 July, Mdm Lee’s breathing difficulties worsened. At 1205hrs, she was acidotic with an Arterial Blood Gas (“ABG”) level of pH7.290 (the “11 July ABG”). ⁷⁵ At 1600hrs, her abdomen was “slightly distended”. ⁷⁶ A chest X-ray showed bilateral basal atelectasis (ie, collapse of the lungs), and a right-sided pleural effusion (ie, shift of fluid into the chest) with free fluid around her liver. ⁷⁷ Her hands and feet were edematous, ie, swollen by the accumulation of fluid in the tissues. ⁷⁸ (I note that the British spellings of this adjective and its associated condition are respectively “oedematous” and “oedema”. I will however adopt the American spellings, “edematous” and “edema”, which were used in the medical notes for Mdm Lee, and in the parties’ evidence and submissions.) Her heart rate fell from 106 beats per minute (“bpm”) at 0900hrs to 80bpm at 1800hrs, but rose to 88bpm after 2200hrs. ⁷⁹ Her albumin level fell to 19g/L, down from 22g/L on 9 July. ⁸⁰ The Defendant ordered the pleural effusion to be treated with percutaneous drainage of the chest. ⁸¹ At about 1945hrs, a CT scan of the chest was performed to guide the insertion of a tube for that percutaneous drainage procedure (rather than to investigate Mdm Lee’s condition generally). The scan revealed free fluid in the right suphrenic space (ie, below the right diaphragm). ⁸² Notably, this scan was ordered not by the Defendant but by the radiologist who performed the percutaneous drainage procedure. ⁸³

57 On 12 July, 2,360ml of abdominal fluid was drained from Mdm Lee. ⁸⁴ Her ABG level was pH7.301 at 0213hrs (the “12 July 0213hrs ABG”) and pH7.323 at 1108hrs (the “12 July 1108hrs ABG”). ⁸⁵ She was acidotic but improving.

58 On 13 July, 2,500ml of abdominal fluid was drained from Mdm Lee. ⁸⁶

59 The Plaintiff submitted that by 11 July (POD7), Mdm Lee had deviated from the usual clinical course after a Whipple operation. ⁸⁷ The clinical signs and symptoms she displayed necessitated a CT scan of her abdomen to eliminate the possibility of a Dehiscence and to investigate whether further intervention was necessary. Additionally, the clinical indicators that emerged between 11 and 12 July should have heightened the Defendant’s suspicion of a Dehiscence, and alerted him to the need for such an abdominal CT scan. The Plaintiff highlighted 10 indicators when cross-examining the Defendant and Dr Mak, but referred to a total of 12 indicators in his submissions: ⁸⁸

60 The Defendant agreed, in cross-examination and in submission, that Mdm Lee had by 12 July displayed these 10 or 12 indicators. ⁸⁹ However, he testified that not all of the indicators persisted at the same time. Some had resolved, while others had been attributed to causes other than a Dehiscence. Once an indicator was accounted for, it was “dropped from the equation” and “we move[d] on.” ⁹⁰ Thus, it was incorrect to manage Mdm Lee by “tak[ing] the ten [or twelve] symptoms and signs and throw[ing] them into one time frame. That is not the way you practice medicine.” ⁹¹ I do not understand the Plaintiff’s experts to have been propounding a different approach. Nevertheless, the parties disagreed on the extent to which each indicator had resolved.

62 The Defendant in his oral evidence-in-chief attributed the pleural effusion to Mdm Lee’s low albumin level, which allowed fluid to leak out of her blood vessels and into the [third] space in her chest. ⁹² The fact that she had edema even of her extremities ⁹³ (see [55] above) reinforced the conclusion that the third-spacing was so extensive as to have caused the pleural effusion. ⁹⁴ This was exacerbated by her atelectasis, which had in turn been worsened by her lack of mobilisation. ⁹⁵ Given the absence of abdominal complaints, all indicators pointed to the chest – and away from the abdomen – as the source of the pleural effusion. ⁹⁶

63 Dr Mak accepted that a Dehiscence could contribute to fluid in the abdomen, which could in turn lead to a pleural effusion. ⁹⁷ Given Mdm Lee’s highly elevated POD3 amylase level, the pleural effusion could not have been due only to her low albumin state. The possibility of a Dehiscence must also have been addressed. ⁹⁸ However, any concerns about a Dehiscence were assuaged by the significant improvement in her clinical condition after her chest was drained. ⁹⁹

64 Dr Nikfarjam opined that on 11 July, the breathing difficulties increasingly experienced by Mdm Lee, coupled with the associated development of a significant pleural effusion, should have raised concerns of a significant intra-abdominal complication. Large pleural effusions rarely occur after a Whipple operation in a patient who, like Mdm Lee, has no significant pre-existing heart failure, chronic liver disease, malnutrition, or chronic kidney disease. ¹⁰⁰ However, Dr Nikfarjam then accepted that it was “reasonable to monitor what happens after 11 July to [determine] whether there might be a clinically significant anastomotic leak,” ¹⁰¹ and that on “12 and 13 July [Mdm Lee’s] clinical condition had improved after the drainage of the pleural effusion on the 11th." ¹⁰²

65 Dr Beckingham testified that the pleural effusion was caused by the presence of pancreatic fluid [from a Dehiscence] within the abdominal cavity, which "irritate[d] the pleural viscera directly above the diaphragm.” ¹⁰³ He cited Mark I van Berge Henegouwen et al, “Incidence, Risk Factors, and Treatment of Pancreatic Leakage after Pancreaticoduodenectomy: Drainage versus Resection of the Pancreatic Remnant” (1997) 185(1) Journal of the American College of Surgeons 18 at pp 21–23, which found that at least 48.3% (14 of 29) of patients with a Dehiscence developed a pleural effusion, and that a pleural effusion pointed to a Dehiscence.

66 Dr Mak explained that, statistically, the fact that 48.3% of patients with a Dehiscence developed a pleural effusion did not mean that there was a 48.3% chance that Mdm Lee had a Dehiscence by virtue of her pleural effusion. ¹⁰⁴ The study (at [65] above) considered only the incidence but not the cause of the pleural effusions in the patients studied. It was unreliable since pneumonia, infections of the chest or lung, and low albumin states were more common causes of a pleural effusion than a Dehiscence. ¹⁰⁵

67 In his AEIC, the Defendant attributed Mdm Lee’s 11 July ABG results to a “respiratory acidosis”. ¹⁰⁶ In his oral evidence-in-chief, however, he amended his explanation of the 11 July ABG results to a “metabolic acidosis possibly secondary to a respiratory cause”. ¹⁰⁷ He elaborated that while acidosis from a lung failure was “respiratory acidosis”, acidosis from a lung problem that impaired the transport of oxygen to the tissues and thereby caused the tissues to produce acid was “metabolic acidosis”. ¹⁰⁸

68 Dr Mak accepted that Mdm Lee had on 11 July suffered metabolic acidosis. The fluid that had accumulated in her chest from her pleural effusion made breathing difficult and prevented the lungs from getting enough oxygen to her tissues. The 11 July ABG result was “quite abnormal”. He thus “ha[d] to exclude various possibilities … for example, of infection and sepsis.” However, he remained “unsure simply on the basis of looking at this test result whether in fact that problem with breathlessness has also led and contributed to this abnormal state where her acidosis is.” ¹⁰⁹

69 Dr Nikfarjam dismissed any relation between the metabolic acidosis and the lungs. He explained that Mdm Lee’s partial pressure of carbon dioxide (PCO-2) levels, which would have increased if her lungs had been unable to fully expel the carbon dioxide in her body, had remained normal. ¹¹⁰ Since her lungs were working normally, they could not have caused the acidosis.

70 The Plaintiff submitted that the Defendant’s belated amendment of his evidence-in-chief (see [67] above) showed that he had “failed to apply his mind to properly evaluating the causes of the acidosis”. Instead, he had “jumped to the conclusion that it must have been a result of the pleural effusion at the time.” ¹¹¹ The metabolic acidosis indicated an intra-abdominal problem, which undermined attempts to localise the clinical indicators to a chest problem. ¹¹²

71 However, the significance of the 11 July ABG result was not fully borne out in the evidence of the Plaintiff’s experts. Dr Beckingham did not mention the 11 July ABG result in his evidence-in-chief or cross-examination, and discussed it only at the end of his re-examination when Mr Tan brought it to his attention. ¹¹³ Dr Nikfarjam agreed that Mdm Lee’s management on 11 July was appropriate, and that any differences between how he would have managed Mdm Lee and how the Defendant had in fact managed her constituted “an acceptable standard of variation.” ¹¹⁴

72 It was only after counsel for the Defendant, Ms Kristy Tan (“Ms Tan”), referred Dr Nikfarjam to the 11 July ABG results that he expressed concern about them. ¹¹⁵ Dr Nikfarjam explained that “if [he] had seen this blood test, [he] would have actually been more worried that there's an intraabdominal problem,” and “would have been more concerned that an imaging test should have been done on the 11th, of the abdomen.” ¹¹⁶ This was not convincing. If the 11 July ABG results were as important as he was belatedly making them out to be, he would not have neglected them earlier in his evidence.

73 Notably, the chest CT scan was performed only around 1945hrs on 11 July. Dr Nikfarjam conceded that, if the Defendant was unaware of the chest CT scan results, it was acceptable not to have ordered an abdominal CT scan despite the 11 July ABG result. ¹¹⁷ The Defendant testified during cross-examination that he saw the chest CT scan results only at 0730hrs on 12 July. ¹¹⁸ This was accepted by the Plaintiff. ¹¹⁹ By then, the 11 July ABG results had been superseded by the 12 July 0213hrs ABG results, ¹²⁰ which showed that the acidosis had improved significantly ¹²¹ after the chest drainage. The 12 July 1108hrs ABG results showed further improvement in the acidosis, ¹²² and both of the Plaintiff’s experts accepted that Mdm Lee was in a good and stable condition on 12 July. ¹²³

74 The Defendant attributed the free fluid above the liver displayed by the 11 July chest CT scan to Mdm Lee’s low albumin state, which facilitated third-spacing in the abdominal cavity. The free fluid was of little concern because it could be drained by her existing abdominal drains. ¹²⁴ Dr Mak agreed with this assessment, ¹²⁵ and added that there was in fact no significant collection of fluid shown on the [albeit limited] set of images taken in the 11 July chest CT scan. ¹²⁶

76 Dr Beckingham referred only to a “2-to-3-cm rim of fluid around [Mdm Lee’s] liver which has not been drained”, but gave no evidence as to its significance. ¹²⁷ This fell short of establishing the Plaintiff’s submission that there was “significant fluid under her diaphragm”, ¹²⁸ particularly since Dr Nikfarjam had accepted that the free fluid above the liver could have been drained out by the existing abdominal drains. ¹²⁹

77 The Defendant gave evidence that haemoserous fluid was a very non-specific sign of a Dehiscence. It indicated only that blood had been mixed with serous fluid. ¹³⁰ The observations of haemoserous fluid between 9 and 11 July were not accompanied by any abdominal signs, except for a slight abdominal distension recorded at 1600hrs on 11 July that subsequently settled. ¹³¹ Further, the drain fluid became serous shortly thereafter. ¹³² Dr Mak echoed these observations, and emphasised that Mdm Lee’s abdomen would have exhibited signs of disquiet had there been a Dehiscence. ¹³³ The Plaintiff’s submissions did not refer to any evidence from his own experts on the issue of the haemoserous fluid.

78 The Defendant testified that low albumin was similarly a very non-specific sign of a Dehiscence. ¹³⁴ Although Dr Mak accepted that a suspicion of a Dehiscence had to be entertained if a low albumin state persisted, ¹³⁵ he attributed Mdm Lee’s low albumin state from 11 to 14 July to her “somewhat conservative” albumin supplementation of 100ml/day and to her continued fasting. ¹³⁶ He added that the steady rise in her albumin levels from 11 to 14 July pointed further away from a Dehiscence, which would have affected them adversely. ¹³⁷ Dr Beckingham accepted that a low albumin state was common after a Whipple operation because a patient would not have been fed for three to four days. ¹³⁸ Dr Nikfarjam testified only that low albumin was “a reflection of a patient becoming unwell … rather than a true cause”, ¹³⁹ and was “indicative of an inflammatory process that’s going on.” ¹⁴⁰

79 The Defendant explained that the slight abdominal distension would have been worrying only if it was accompanied by impaired bowel function, which could have suggested a collection of fluid in the space behind the lining of the abdominal cavity. ¹⁴¹ Mdm Lee had normal bowel functions, which Dr Nikfarjam accepted was reassuring. ¹⁴² Once again, the Plaintiff’s submissions did not refer to any evidence from his own experts on the issue of the abdominal distension.

82 As for Dr Beckingham, he had initially testified that it would have been reasonable to have performed percutaneous drainage – after a CT scan of the abdomen ¹⁴³ – as late as 17 or 18 July. Although he would have ordered an abdominal CT scan and percutaneous drainage on 11 July, ¹⁴⁴ it was reasonable not to have done so since Mdm Lee was getting better. Notably, this remained Dr Beckingham’s position even “assuming she has an anastomotic leak”. ¹⁴⁵

85 On 14 July, Mdm Lee had a low albumin level of 22g/L ¹⁴⁶ and drained “chylous” fluid. ¹⁴⁷ At 1000hrs, she complained of severe pain over a wound site, ¹⁴⁸ and received 75mg of Pethidine, a painkiller. ¹⁴⁹ At 1100hrs, she had pain with slight tenderness around her right drain site. ¹⁵⁰ At 1200hrs, she had mild abdominal pain with a soft abdomen and generalised tenderness on palpitation. However, she had no guarding, rebound tenderness, or peritonitis. ¹⁵¹ At 1347hrs, her C-reactive protein (“CRP”) value was 135mg/L while her WBC count was 11.53 x 109/L. ¹⁵² At 1620hrs, her pain had become “much better” and she was alert and comfortable. ¹⁵³

86 On 15 July, the colour of Mdm Lee’s drain fluid was “light haemoserous” at 0600hrs ¹⁵⁴ and “yellowish” at 1520hrs. ¹⁵⁵ Across the morning, she drained 1,510ml and 20ml of fluid from right and left abdominal drains respectively. ¹⁵⁶ At 0810hrs, she was alert, comfortable, and had no complaints of pain, normal parameters, and a soft and non-distended abdomen. ¹⁵⁷ At 1000hrs, she was well enough for physiotherapy, and performed ankle pumps and marched on the spot. ¹⁵⁸ When the Defendant saw her at 1320hrs, she was well and had no complaints. She took feeds and passed flatus. She drained serous fluid. ¹⁵⁹ At 1530hrs, she underwent another physiotherapy session. Three further physiotherapy sessions were then planned for 16 and 17 July. ¹⁶⁰

87 On 16 July, Mdm Lee had pain scores of 6/10 at 0930hrs and 3/10 at 1430hrs, but was alert and clinically well. ¹⁶¹ She underwent physiotherapy and did not complain of pain until 2035hrs. ¹⁶² Her drain fluids were “yellowish”. ¹⁶³

88 The Plaintiff submitted that, taken together, the clinical indicators that Mdm Lee exhibited pointed to a Dehiscence. As at 14 July, these included her elevated POD3 amylase level, her low albumin level, her elevated CRP and WBC values, her “chylous” fluid, and her abdominal disquiet. ¹⁶⁴ As at 15 July, Mdm Lee also displayed an inability to tolerate the soft foods that were commenced on 13 July, an elevated heart rate, and drain fluid of a high volume and light haemoserous or yellow colour. ¹⁶⁵ As at 16 July, Mdm Lee suffered from the aforementioned unexplained abdominal pain. The Plaintiff focused on the abdominal signs and “chylous” fluid on 14 July, the “yellowish” fluid on 15 July, and the unexplained abdominal pain on 16 July.

89 As mentioned (at [60] above), it was not unreasonable for the Defendant to have considered only the indicators that had persisted at a given point of time. Those that had been resolved or otherwise attributed to conditions other than a Dehiscence could be “left out [of] the equation.” ¹⁶⁶ Accordingly, I will once again examine the indicators in question individually, and then consider whether Mdm Lee’s management should have been changed in the light of all the indicators, viewed globally.

90 The primary indicator relied upon by the Plaintiff was Mdm Lee’s abdominal disquiet on 14 July. I set out chronologically the observations on her abdomen, as recorded in her clinical notes. ¹⁶⁷

91 The Plaintiff submitted that the progression from severe pain at 1000hrs to generalised tenderness at 1230hrs should have alerted the Defendant to the possibility of a Dehiscence and the need for an abdominal CT scan. ¹⁶⁸ Although the pain apparently dissipated thereafter, the Plaintiff submitted that Dr Yeo’s observation of “pain much better than earlier today” at 1620hrs meant that the pain had resurfaced and that the underlying abdominal problem remained unresolved. ¹⁶⁹ I do not accept this contention. Those words did not mean that the pain had resurfaced, but that Mdm Lee had been getting better, not worse. The Defendant’s review of Mdm Lee at 1920hrs that evening, in which he observed that Mdm Lee was well with no complaints of pain, bear this out.

92 The Defendant accepted that unexplained abdominal pain accompanied by tenderness and guarding could point to a Dehiscence, ¹⁷⁰ but denied that Mdm Lee had such unexplained pain, generalised tenderness, or guarding.

(a) Mdm Lee’s abdominal pain at around 1000hrs was attributable to tugging on the right abdominal drain stitched to her skin. ¹⁷¹ She had localised the pain to her right drain site. ¹⁷² At 1100hrs, the Defendant examined her and found her abdomen soft and non-tender except for slight tenderness around the right drain site. ¹⁷³ Finally, X-rays of her chest and abdomen showed an absence of free air, which pointed away from bowel-abdominal communication. ¹⁷⁴

(b) The record of “generalised tenderness” at 1230hrs was inconsistent with the contemporaneous observations that Mdm Lee’s abdomen was “soft” with “0 guarding, 0 rebound, 0 peritonism”. ¹⁷⁵ Tenderness and guarding go together, except at the very onset of an abdominal problem. When tenderness has spread through the entire abdomen to give “generalised tenderness”, guarding must have followed. The discrepancy in the clinical records made it reasonable to have held off action. ¹⁷⁶ By the time the Defendant reviewed Mdm Lee at 1920hrs on 14 July, her pain issues had resolved, and her abdomen was soft and non-tender. ¹⁷⁷ Her abdomen remained soft and non-tender for the remainder of 14 July, and through 15 and 16 July.

93 Dr Mak testified that a Dehiscence would have irritated or inflamed the abdomen. However, Mdm Lee’s abdomen was soft and non-tender with no peritonism (ie, inflammation ¹⁷⁸ ). ¹⁷⁹ At 1030hrs, the clinical entry of “mild guarding” was contradicted by the observation that the abdomen was “soft”. The further observation of “0 rebound” reinforced the conclusion that there was no peritoneal irritation or other serious abdominal problem. ¹⁸⁰ At 1230hrs, the record of “no peritonism” in particular showed that the abdomen was well. ¹⁸¹

94 On the other hand, Dr Nikfarjam testified that on 14 July, Mdm Lee had “no right to have generalised tenderness at this point after surgery.” He stressed the importance of an observation of generalised tenderness, and concluded that in view of this, the Defendant should have ordered an abdominal CT scan. Although there was some inconsistency between the observations of “tenderness” and “0 peritonism” at 1230hrs, some of the abdominal signs could have been masked by the Pethidine that was administered at around 1000hrs. Moreover, “you would never want to be waiting for someone to develop peritonism before you act”; ¹⁸² particularly since Mdm Lee had developed abdominal pain that she did not have before. ¹⁸³

96 The observation of “generalised tenderness” was made by a junior doctor. ¹⁸⁴ As the Defendant testified, it could have been a product of unwieldy assessment technique. ¹⁸⁵ Further, it was undisputed that this observation was generally inconsistent with the contemporaneous observation, made by the same doctor, that Mdm Lee’s abdomen was “soft” with “0 guarding, 0 rebound, 0 peritonism”. ¹⁸⁶ More importantly, the Defendant had personally reviewed Mdm Lee at 1100hrs and 1920hrs, shortly after each disputed observation was recorded, and found her abdomen soft and non-tender. ¹⁸⁷ The review at 1920hrs, in particular, was carried out after all the effects of the Pethidine had worn off. ¹⁸⁸ The Defendant thus attributed the initial pain to tugging on the abdominal drains, ¹⁸⁹ and concluded that Mdm Lee’s abdominal signs showed no real cause for concern throughout 14 July. ¹⁹⁰

97 Abdominal fluid turns white and milky – ie, chylous – when the fat globules in the lymph vessels leak out into the abdomen. ¹⁹¹

98 The Defendant testified that the chylous fluid was attributable to the chyle from the fats in Mdm Lee’s soft diet on 13 July. If a Dehiscence had occurred at that time, Mdm Lee would have been in significant pain. Instead, she exhibited no such indicators at all. ¹⁹²

99 However, the Plaintiff’s experts opined that the amount of fat in the food that Mdm Lee had consumed on 13 and 14 July was insufficient to have produced a chyle leak. Dr Beckingham testified that chyle leaks are unheard of in pancreatic surgery. ¹⁹³ Hence, the term “chylous” in the clinical notes described only the appearance of the fluid. There was no other evidence of a chyle leak. ¹⁹⁴ Dr Nikfarjam added that the definitive test for a chyle leak is a triglycerides test for fat globules, ¹⁹⁵ which was not done. Instead, the Defendant simply diagnosed and treated the chylous fluid based on what he believed to be the characteristic appearance of chyle in the abdominal drains. ¹⁹⁶ This was misguided. The chylous fluid could in fact have been pancreatic fluid, which could present a similar appearance to the white colouration of chyle. ¹⁹⁷ The Defendant also conceded that the white colouration could have concealed pure pancreatic fluid, which was colourless. ¹⁹⁸

100 Two senior HPB surgeons separately recorded the observations of chylous fluid: Dr Wong Jen San at 0810hrs and the Defendant himself at 1100hrs. The former added that a dissection of a lymph node could have caused the increased chylous output. ¹⁹⁹ Dr Mak and Dr Ng Shin Yi testified that chyle has a distinctive appearance that experienced specialists can immediately identify. ²⁰⁰ As observed by the Plaintiff, 14 July was the only time when Mdm Lee’s drain fluid had a chylous appearance. ²⁰¹ Both parties agreed in the Glossary of Medical Terms that the Plaintiff tendered to the court that “chylous fluid” meant “[f]atty fluids with a white, creamy or milky colour from the lymphatic system ²⁰² [emphasis added]”. The Plaintiff could have put forward his own interpretations of term “chylous”, as he did for other entries in the Glossary. The fact that he did not do so reinforced the conclusion that Mdm Lee had only chyle in her drains.

101 It was thus not unreasonable to have attributed Mdm Lee’s chylous fluid to a chyle leak, particularly when her drain fluid became serous again shortly after her diet was changed to manage the chyle leakage. ²⁰³

102 The Plaintiff submitted that the “light haemoserous” ²⁰⁴ and “yellowish” ²⁰⁵ colours of Mdm Lee’s drain fluid on 15 July “should have rang alarm bells.” ²⁰⁶ He referred to the Defendant’s evidence that “[a]ny time we see something that has been described differently, we will check”, ²⁰⁷ and to Dr Mak’s evidence that bile is yellowish and that a “mixture of bile and serous fluid can also turn yellowish.” ²⁰⁸

103 The Defendant testified that the change in the colour of drain fluid from “chylous” to “light haemoserous” at 0600hrs on 15 July was not in itself of concern. Only if the haemoserous colour had persisted would he have been worried. ²⁰⁹ By 0950hrs, however, the drain fluid had become “serous”. ²¹⁰ Similarly, concerns about the “yellowish” fluid observed at 1520hrs had been assuaged following Dr Yeo’s review of Mdm Lee that evening. The fluid had become “serous” and was of no concern. Dr Yeo did not see fit to record it. ²¹¹

104 Dr Mak added that bile is “golden yellow” or “intensely yellow”, rather than the “straw coloured faint yellow tinge” of normal serous fluid. ²¹² The absence of observations about the quality of the fluid (in particular, that the fluid was bilious), as opposed to simply the colour of the fluid, suggested that Mdm Lee did not have a Dehiscence. ²¹³

106 The Plaintiff submitted that the Defendant would have diagnosed a Dehiscence based on the significant abdominal pain in the morning of 16 July if he had been suspecting a Dehiscence. It was “blinkered” to have attributed the pain to “faecal loading”. ²¹⁴ The Plaintiff added in his reply submissions that the Defendant should have been alarmed because the residual pain (pain score 3/10) after Mdm Lee passed motion was “unexplained”. ²¹⁵

107 The Defendant testified that Mdm Lee’s pain score fell from 6/10 to 3/10 after she passed motion. ²¹⁶ The abdominal X-ray on 14 July had showed faecal loading. ²¹⁷ He thus concluded that faecal loading had caused the abdominal pain at 0625hrs. ²¹⁸ Dr Mak agreed that the passing of motion substantially resolved what appeared to have been severe abdominal pain. This suggested that the pain had not been caused by a Dehiscence or by significant inflammation or infection within the abdominal cavity. ²¹⁹

108 However, Dr Nikfarjam opined that faecal loading could not explain Mdm Lee’s abdominal concerns. ²²⁰ Further, it was worrying that she kept developing abdominal pain even while on antibiotics. ²²¹ Even so, Dr Beckingham accepted that faecal loading could have caused the pain, which was resolved upon the passing of motion. Mdm Lee had not passed motion from 14 to 16 July, and faecal loading was seen on the abdominal X-ray that was performed on 14 July. ²²²

109 The Defendant testified that Mdm Lee improved on 12, 13, and 14 July. This was incompatible with her having suffered a Dehiscence. ²²³ X-rays of her abdomen and chest showed that the operatively-inserted abdominal drains were in place and that there was no free air in the abdomen, which would have indicated a Dehiscence. ²²⁴ The fall in her WBC count from 26.26 x 109/L on 11 July to a near-normal 11.53 x 109/L on 14 July suggested an absence of on-going sepsis and infection in the abdomen. The maintenance of that WBC level from 14 to 16 July suggested further that Mdm Lee was quite well. ²²⁵

110 Dr Mak found that Mdm Lee’s stable global condition on 14 July was incompatible with that of a patient with a Dehiscence, who would have deteriorated. ²²⁶ Less risk-tolerant doctors might have considered an abdominal CT scan, but it was acceptable to have continued to observe Mdm Lee. ²²⁷ An abdominal CT scan was necessary only if she had had a fever, worsening abdominal pain associated with rebound tenderness and guarding, or drain fluid that was bilious or purulent. ²²⁸

111 Dr Nikfarjam opined that he would have ordered an abdominal CT scan in anticipation of performing percutaneous drainage, given the earlier abdominal pain and the observation of generalised tenderness on 14 July. It was unacceptable for the Defendant to have waited until Mdm Lee became unstable before conducting a CT scan, especially given her elevated POD3 drain amylase level. ²²⁹ However, Dr Nikfarjam then appeared to accept that the improvement in the pain on 15 and 16 July reduced the need for an abdominal CT scan. ²³⁰

113 The abdominal pain that Mdm Lee suffered initially in the morning of 14 July did not persist. The effect of the Pethidine that she had received at around 1000hrs that morning would have worn out after six hours. ²³¹ Yet she did not complain of further pain thereafter. The observation of generalised tenderness was inconsistent with the observation of “0 guarding, 0 rebound, 0 peritonism” (see [96] above). In any event, the Defendant in his subsequent review that evening did not observe any tenderness of the abdomen. Indeed, there was no subsequent observation of generalised tenderness on 14, 15, or 16 July.

114 As Dr Mak testified, a scan should be ordered only if there was a good reason for doing so, and not “just to look to see what things were like”. ²³² Moreover, as noted in Emmanuel Melloul et al, “Poor level of agreement on the management of postoperative pancreatic fistula: results of an international survey” (2013) 15 Journal of the International Hepato-Pancreato-Billary Association 307 at 312, there is “poor or no agreement” between HPB centres around the world as to the use of imaging strategies like CT scans in the management of POPF. Accordingly, I am of the view that the Defendant did not fall below the standard of care expected of him in his management of Mdm Lee from 14 to 16 July.

115 At 2300hrs on 16 July, Mdm Lee complained of a sudden intense pain over her abdominal region (pain score 8/10). ²³³ She was “screaming” in pain. ²³⁴ Her right and left abdominal drains drained 2,775ml and 330ml of fluid respectively. She received 50mg of Pethidine, but continued to describe pain “everywhere in the abdomen” (pain score 8/10). ²³⁵

116 At 0050hrs on 17 July, Mdm Lee exhibited abdominal “tenderness”. At 0130hrs, she complained of abdominal pain and a tender lower abdomen. Believing that a Dehiscence had occurred, Dr Ng Shu Li made an order to “KIV CT Abdo[men] if symptoms persist” in respect of a Dehiscence. ²³⁶

117 At 0900hrs, Dr Yeo observed that Mdm Lee had deteriorated and that her abdominal tenderness had persisted. An ABG test showed severe metabolic acidosis of pH7.187 requiring correction by bicarbonate infusion. ²³⁷ As the Defendant was not at work on 17 July (Sunday), Dr Yeo informed him of these findings over the telephone. ²³⁸ Given that Mdm Lee was in severe abdominal pain but had no severe kidney problems or breathing difficulties, the Defendant believed that the acidosis was likely due to an intra-abdominal cause. He thus “instructed Dr Yeo to arrange for an urgent [abdominal] CT scan to investigate if there was any anastomotic leak which may be the cause of a suspected intra-abdominal sepsis.” ²³⁹

118 At 1230hrs, a CT scan of Mdm Lee’s chest, abdomen, and pelvis (the “17 July Abdominal CT Scan”) was performed. It confirmed a Dehiscence and revealed collections of fluid. The scan report stated: ²⁴⁰

119 At 1300hrs, Mdm Lee was moved to the High Dependency Unit (“HDU”) for monitoring and for stabilisation via correction of her acidosis. ²⁴¹

120 By 1320hrs, the Defendant had arrived at SGH, reviewed Mdm Lee, and diagnosed her with a “delayed pancreatic dehiscence”. ²⁴² After a discussion with Dr Ng Shin Yi, the consultant intensivist at the SICU on 17 July, the Defendant moved her to the SICU for resuscitation at 1530hrs. ²⁴³

124 As an aside, I will first address the Plaintiff’s submission that the Defendant should, in line with his approach of managing Mdm Lee conservatively, have performed a repeat drain amylase test to “track the ‘improvement’” of her POPF. ²⁴⁴ This must have referred to the period from 8 to 16 July, ie, between the emergence of the POPF on 7 July and the 17 July Abdominal CT Scan that confirmed a Dehiscence. Relying on the opinions of Dr Nikfarjam and Dr Mak, the Plaintiff contended that the Defendant should have performed a repeat drain amylase test to assess “whether [the POPF on 7 July] had resolved spontaneously or if alternative management was required.” ²⁴⁵ However, the evidence of Dr Nikfarjam and Dr Mak did not go that far. Dr Nikfarjam opined that a repeat drain amylase test should have been performed only if the Defendant believed that the POPF had resolved and intended to remove the existing drains. ²⁴⁶ Similarly, Dr Mak observed that “there are no recommendations for routine follow-up evaluation of the amylase” of a patient with a POPF in order to determine the existence of a Dehiscence. ²⁴⁷ I note that Dr Beckingham did not appear to have given any evidence on the subject. In my view, since the Defendant did not intend to remove Mdm Lee’s abdominal drains, there was no need for him to have performed a repeat drain fluid amylase test.

125 I set out the relevant portions of the Defendant’s AEIC on his plan for Mdm Lee from 17 July: ²⁴⁸

126 The Defendant submitted that it was reasonable and appropriate to have managed Mdm Lee non-surgically on and after 17 July, and such management did in fact improve her sepsis. ²⁴⁹ From 17 to 19 July, he held off a laparotomy, a further abdominal CT scan, and a percutaneous drainage procedure because of Mdm Lee’s unstable condition and because her existing drains were managing the free fluid collections seen on the 17 July Abdominal CT Scan. ²⁵⁰ From 20 to 23 July, he held off a laparotomy because non-surgical management was continuing to improve Mdm Lee’s condition, and he held off an abdominal CT scan and percutaneous drainage because the additional benefits that they promised were outweighed by the risks involved. ²⁵¹ On 24 July, however, he ordered an abdominal CT scan because of the increase in Mdm Lee’s WBC count and the appearance of feculent matter in her abdominal drains, and then decided to perform percutaneous drainage of the loculated collections revealed on the scan. ²⁵² Nevertheless, before the percutaneous drainage could be performed, it was superseded by a decision to operate on Mdm Lee, on which I will elaborate later (at [156]–[159] below).

127 It is clear to me from the Defendant’s AEIC and oral evidence at trial ²⁵³ that, from 17 July, he had wanted to perform a laparotomy but could not do so because Mdm Lee was haemodynamically unstable. The intensivists had to resuscitate and stabilise her first. This was also the evidence of Dr Ng Shin Yi ²⁵⁴ and Dr Ang, ²⁵⁵ who were the consultant intensivists at the SICU on 17 July and from 18 to 25 July respectively. However, it was less clear whether, after Mdm Lee’s condition had improved by 19 July, the Defendant had been continuing to wait for an opportune time to perform the laparotomy, or had changed his mind and had been deferring the laparotomy to see whether her condition would improve to such an extent as to render a laparotomy unnecessary. As it turned out, this lack of clarity was not material, as I will explain later.

128 As for the Plaintiff’s case, I reiterate that it was Dr Beckingham’s evidence that 17 or 18 July was the latest time for intervention via a percutaneous drainage procedure (after an abdominal CT scan) or a laparotomy (see [52] above). Thereafter, any such intervention would not have “made a difference to the outcome in [Mdm Lee’s] case.” Dr Beckingham maintained this position throughout the trial. ²⁵⁶

129 As for Dr Nikfarjam, he opined that if percutaneous drainage was not performed on 17 July, it should have been performed “on the 18th, 19th, 20th, 21st, 22nd, 23rd, till the day [Mdm Lee] had surgery.” ²⁵⁷

Ms Tan pressed Dr Nikfarjam to give a more specific time-frame for the performance of percutaneous drainage. However, he maintained that the time-frame was simply after Mdm Lee “had gone into the intensive care, was intubated, was given some inotropic supports and was having blood pressure maintained” in the afternoon of 17 July. ²⁵⁸ This was vague.

130 The Plaintiff’s submissions were no better. He first alleged that the Defendant should have “included [as part of his treatment plan], a plan for percutaneous drainage to drain the source of [Mdm Lee’s] abdominal sepsis as soon as she was resuscitated and stabilised.” ²⁵⁹ Since Mdm Lee was undergoing resuscitation and stabilisation from 17 to 19 July, the earliest opportunity for percutaneous drainage was 20 July. Yet, in the very next paragraph of his submissions, the Plaintiff criticised the Defendant for not ordering a CT scan, in order to perform percutaneous drainage, “prior to 24 July”. ²⁶⁰ This was too sweeping an allegation as it ignored the fact that Mdm Lee was undergoing resuscitation and stabilisation from 17 to 19 July.

131 Another sweeping submission made by the Plaintiff was his criticism of “[t]he Defendant’s inaction for more than a week between 17 July 2011 and 26 July 2011” as “inexcusable.” ²⁶¹ At risk of belabouring the point, Mdm Lee was haemodynamically unstable and had to be resuscitated and stabilised from 17 to 19 July. Moreover, a further abdominal CT scan was in fact performed at 1430hrs on 24 July ²⁶² (the “24 July Abdominal CT Scan”), following which the Defendant ordered a percutaneous drainage procedure (see [156] below). It was thus incorrect for the Plaintiff to allege that the Defendant had been inactive between 17 and 26 July.

132 These sweeping submissions served only to distract from the real issues in question. The pertinent timeframe was 20 to 23 July, rather than the longer period of 17 to 26 July. I will explain this later (at [141]–[155] below), after describing the period from 17 to 19 July in order to contextualise the actions that were taken by the Defendant and to explain the state that Mdm Lee was in during that time.

133 When Mdm Lee arrived at the SICU at 1530hrs on 17 July (see [120] above), Dr Ng Shin Yi, the consultant-in-charge of the SICU, observed that she was “acutely ill”. ²⁶³ Besides a Dehiscence, she suffered from septic shock, a low and unstable blood pressure, and an acute kidney injury. ²⁶⁴ She was put on active non-surgical management to control the flow of fluids to the dehisced anastomosis in order to allow it to seal off naturally. ²⁶⁵

134 By 2100hrs on 17 July, Mdm Lee had become more stable. However, she remained on two inotropes. Her abdomen was slightly more distended than earlier in the day but was still soft. Her NGT drained bilious fluid, and both her abdominal drains drained turbid fluid. Her urine output was fair. ²⁷⁴ She had an elevated intra-abdominal pressure due to an accumulation of fluid in her abdomen. Across the day, she experienced severe coagulopathy and acidosis, and had low oxygen saturation that required intubation for ventilation. ²⁷⁵

135 On 18 July, Dr Ang assumed the role of consultant-in-charge of the SICU from Dr Ng Shin Yi, and with it, the care of Mdm Lee. ²⁷⁶ At 0830hrs, Mdm Lee remained “very unwell”. In her condition on 18 July, surgery carried a 70–80% risk of death. Accordingly, the objective was to continue resuscitation to improve her condition. ²⁷⁷ By 2020hrs however, Mdm Lee had gradually stabilised. She displayed good drainage from her right drain of 800ml. Her intra-abdominal pressure had fallen further, and her abdomen had become less tense and distended. ²⁷⁸ However, various issues persisted, including low blood pressure, severe coagulopathy, poor oxygen saturation, acidosis, acute kidney injury, raised intra-abdominal pressure, and septic shock. ²⁷⁹

136 By 0930hrs on 19 July, Mdm Lee had improved even further. Her oxygen saturation had increased, and a single inotrope sufficed to support her blood pressure. Her lungs were clear and she was able to obey commands. However, her coagulopathy, acute kidney injury, and raised intra-abdominal pressure remained unresolved. The Defendant consulted Dr Ang and concluded that Mdm Lee was in no condition for surgical intervention. ²⁸⁰

137 The Defendant testified that he had monitored Mdm Lee’s drainage and abdominal signs at all times, and would have intervened via percutaneous drainage or even surgery had she failed to progress as expected. ²⁸¹ However, Mdm Lee was from 17 to 19 July too ill for any intervention. ²⁸²

138 Dr Mak agreed that from 17 to 19 July, Mdm Lee was “not stable or in any fit condition to be transferred out of the [S]ICU for any length of time”. Any consideration of “the possibility of these various interventions, whether surgery or drainage … would have been academic because she was not fit at all for any of these procedures to be done.” ²⁸³

139 Dr Beckingham observed that up until 18 July, Mdm Lee was “as sick as a dog”. While a laparotomy was theoretically possible, his first choice would have been a percutaneous drainage procedure. ²⁸⁴ Nevertheless, Mdm Lee needed to be stabilised before any such percutaneous drainage could be performed. ²⁸⁵ Given her condition, he would have been cautious, and would have “th[ought] carefully about whether to do a radiological guided drainage” at all. ²⁸⁶ Since Dr Beckingham had observed that any intervention after 18 July would have been “too late” (see [52] above), he did not comment on her management thereafter.

140 Dr Nikfarjam accepted that the plan from 17 July to stabilise Mdm Lee for surgery was reasonable. ²⁸⁷ He disputed only the delay in intervening, specifically via a percutaneous drainage procedure. He contended that “after 24 hours, if [she] did not improve rapidly enough for surgery … there shouldn’t have been any further time waiting for surgery.” ²⁸⁸ Nevertheless, he accepted that even after this 24-hour period, insofar as there was no risk of deterioration, “[i]f the SICU team and the surgeon are still saying that ‘Maybe this is not the best window for surgery; we can get her to a better window’, then it would be reasonable to wait till the best possible window.” ²⁸⁹ Since Dr Nikfarjam accepted that “from the septic point of view, there was improvement” with the non-surgical measures implemented from 17 July, I am of the view that the Defendant did not fall below the standard of care expected of him in holding off surgery or even percutaneous drainage, between 17 and 19 July.

141 On 20 July, Mdm Lee had been stable overnight, and her inotrope support had been decreased to a minimum. Her NGT and abdominal drains continued to drain well. She was, however, still coagulopathic with a low platelet count, and still needed dialysis for her kidneys. The Defendant decided to continue with non-surgical management, and to perform a laparotomy if there was no further improvement. ²⁹⁰

142 By 21 July, Mdm Lee had improved further even though she remained on the Dangerously Ill List. Her blood pressure had stabilised and she was taken off inotropes. Her bilateral basal atelectasis and oxygen saturation had improved further. Her acute kidney injury was healing, even though she remained on dialysis. However, she drained bilious fluid and had septic shock, a low albumin level, and coagulopathy. After consulting Dr Ang, the Defendant decided against a laparotomy. Mdm Lee’s NGT and abdominal drains were effectively draining the site of her Dehiscence. The risks of a laparotomy outweighed any potential benefits involved. ²⁹¹

143 At 0435hrs on 22 July, Mdm Lee was unable to focus her eyes, and her level of consciousness had deteriorated. ²⁹² However, she could move all her limbs, and continued to maintain her blood pressure without inotropic support. Her lungs were clear and her oxygen saturation was at 100%. However, her coagulopathy persisted. ²⁹³ At 1510hrs, Mdm Lee was sent for a brain CT scan because her lack of consciousness pointed to the existence of a life-threatening bleed of the brain. ²⁹⁴ However, the scan revealed the absence of any such bleed. ²⁹⁵

144 On 23 July, Mdm Lee maintained a similar clinical state to that which she was in on 22 July. Bilious fluid continued to be noted in her NGT, and her surgical drains drained clear brownish fluid. She continued to require blood products to support her coagulopathy, ²⁹⁶ which had worsened. ²⁹⁷

145 The Defendant testified that by 20 July, the focus had shifted away from optimising Mdm Lee for surgery to “using the conservative [non-surgical] management to get her well”. ²⁹⁸ Surgery was maintained as a consideration only “if [Mdm Lee was] not improving further.” ²⁹⁹ The effectiveness of these non-surgical measures was demonstrated by the “dramatic drop in the [WBC] count, from 28.14 x 109/L to 11.58 x 109/L, by 20 July”, as well as the general clinical improvements of a reduction in her need for inotropes and continued active drainage of fluid. ³⁰⁰ On 21 July, she was well enough to have her remaining inotrope removed, her WBC count had fallen further to 10.3 x 109/L, and she was afebrile. ³⁰¹

146 Dr Mak appeared to accept that there was an opportunity from the morning of 21 July, given that Mdm Lee was sufficiently stable without inotropic support to be brought out of the SICU, for percutaneous drainage to have been performed. ³⁰² The 17 July Abdominal CT Scan had revealed collections of fluid on the left side of her abdomen and in her pelvis that were not easily drained by her existing operatively-inserted drains. ³⁰³ Moreover, Mdm Lee had uncontrolled sepsis on 21 July (as evinced by her organ failure, renal failure, and on-going bleeding) even if she had improved from a septic point of view from 17 July. ³⁰⁴ The only collection of fluid that remained undrained was that in her pelvis, which needed to be “sorted out.” ³⁰⁵ Since, Mdm Lee was on 21 July in a very similar state of clinical stability as she was in at 24 July (when the Defendant eventually decided to perform a percutaneous drainage procedure), ³⁰⁶ Dr Mak would have considered performing percutaneous drainage on 21 July.

147 However, Dr Mak pointed out that percutaneous drainage should only be performed after an abdominal CT scan had been carried out and then only if the scan revealed undrained fluid collections necessitating such intervention. ³⁰⁷ Also, Mdm Lee’s coagulopathy had to be corrected before percutaneous drainage could have been undertaken. ³⁰⁸ This was the case on 24 July. Moreover, even though Dr Mak would have considered percutaneous drainage, he would have taken Dr Ang’s guidance as to whether and when it would have been safe to bring Mdm Lee out of the SICU. ³⁰⁹ Although 21 July was the first available opportunity for percutaneous drainage, Dr Mak testified that he would have waited another day had Dr Ang told him to do so. In Dr Mak’s opinion, Mdm Lee did not appear to have been so unstable that he would have lost all opportunities to intervene simply by waiting an additional day. ³¹⁰

148 Dr Ang gave evidence that on 21 July, Mdm Lee had been “slowly improving” and remained on track for the definitive intervention of surgery. Hence, Dr Ang would not have recommended even an abdominal CT scan – much less the consequential measure of percutaneous drainage – because “there’s really no point to do a scan to see where the loculation is, if our intention is to open up the patient.” ³¹¹

149 It is not disputed that the Defendant, as the lead surgeon, made the decision whether to order percutaneous drainage or a laparotomy (or neither). However, Dr Ang candidly admitted that because Mdm Lee was in intensive care, any such decision involved a “collaborative discussion” ³¹² with her. Dr Ang would have been prepared to suggest percutaneous drainage had she thought it advisable. ³¹³ Yet, she did not suggest that percutaneous drainage be performed on 20 or 21 July. Notably, Mr Tan assured Dr Ang during cross-examination that he was “not suggesting any shortcoming on [her] part.” ³¹⁴

151 The Defendant’s position was that given Mdm Lee’s condition from 17 to 22 July, there were grave risks in moving her out of the SICU and into the radiology suite. She was so moved on 22 July only because of the graver concern about a life-threatening bleed of the brain. ³¹⁵ Given the grave risks of keeping Mdm Lee outside the SICU, the Defendant did not tag on a further abdominal CT scan while she was in the radiology suite. ³¹⁶ Dr Ang and Dr Mak agreed with this assessment. ³¹⁷ Notably, neither of the Plaintiff’s experts gave evidence on whether Mdm Lee should have had a further abdominal CT scan on 22 July when she was sent for a brain CT scan.

155 Hence, I am of the view that the Defendant did not fall below the standard of care expected of him in his management of Mdm Lee from 20 to 23 July.

156 On 24 July, in consultation with Dr Ang, the Defendant ordered a CT scan of Mdm Lee’s abdomen and pelvis to check her abdominal condition and healing potential. ³¹⁸ This was performed at 1430hrs, and it revealed a loculated fluid collection in the left suphrenic space and another along the stomach wall. Free intraperitoneal fluid was also seen in the pelvis. ³¹⁹ At 1730hrs, the Defendant ordered a percutaneous drainage procedure, and consent for this was obtained. ³²⁰

157 The Defendant testified that he had ordered the 24 July Abdominal CT Scan because the increase in Mdm Lee’s WBC count and the emergence of feculent matter in her abdominal drains indicated a new sinister development. ³²¹ Although, as the Plaintiff observed, these reasons were not mentioned in the AEICs of the Defendant and Dr Ang, ³²² they were recorded in Mdm Lee’s contemporaneous clinical notes: ³²³

Thereafter, the Defendant ordered that a percutaneous drainage procedure be performed to drain the loculated fluid collections that were revealed on the 24 July Abdominal CT Scan. ³²⁴ However, the procedure was not performed on 24 July because the radiologist asked that Mdm Lee’s coagulopathy be corrected first. ³²⁵

158 The Plaintiff’s position was that by 24 July, it was “too late” for a further abdominal CT scan. ³²⁶ Similarly, neither of his experts specifically challenged Mdm Lee’s management on 24 July, save for Dr Nikfarjam’s broader assertion that percutaneous drainage should have been performed on or after 17 July.

159 On 25 July, Dr Lim assumed the role of consultant-in-charge of the SICU from Dr Ang. At 0720hrs on 25 July, the Defendant reviewed Mdm Lee together with Dr Ang and Dr Lim. ³²⁷ Dr Lim was of the opinion that any improvement in Mdm Lee’s condition had plateaued. ³²⁸ The clinical view of both the surgical team and the intensivist team was that she was in the best possible state for any intervention. The Defendant therefore decided to perform a laparotomy instead of a percutaneous drainage procedure. ³²⁹ This laparotomy was eventually performed on 26 July. ³³⁰

160 On 27 July, Mdm Lee appeared to improve. ³³¹

161 At 0445hrs on 28 July, Mdm Lee took a sudden turn for the worse. ³³² At 0730hrs, a second laparotomy was performed. ³³³ Yet, Mdm Lee continued to deteriorate, and passed away that evening.

162 The Plaintiff also did not appear to take issue with the Defendant’s management of Mdm Lee from 25 to 28 July. Although the Plaintiff challenged the performance of the two laparotomies (on 26 and 28 July) in his SOC, he did not pursue this allegation at trial or in submissions (see [12] above). I am thus of the view that the Defendant did not fall below the standard of care expected of him in his management of Mdm Lee from 25 to 28 July.

165 The Plaintiff submitted that where the loss stemming from a negligent omission could have been avoided if all of several hypothetical intermediate events had occurred, causation is established if the occurrence of each intermediate event – assessed individually – is proved on a balance of probabilities. It was immaterial that the entire series of intermediate events, on a cumulative probability, was less likely than not to have occurred. ³³⁴

170 Dr Beckingham asserted only that an abdominal CT scan performed between 11 July and 2300hrs on 16 July “may well have identified further collections in the abdomen”, and that there “may well have been a collection in the pelvis on the 11th which has not yet been drained”. ³³⁵ This was vague, and did not prove on a balance of probabilities that an abdominal CT scan before 2300hrs on 16 July would have revealed such collections.

171 Dr Mak opined that the images of Mdm Lee’s abdomen produced by the 11 July chest CT scan did not show the presence of fluid beyond the right suphrenic space. Accordingly, an abdominal CT scan done on 11 July would have shown only the same fluid in the right suphrenic space revealed on the chest CT scan and no other abnormal features beyond that. ³³⁶ Since there were no signs of tenderness, guarding, or rebound tenderness, there would likely have been no evidence of a Dehiscence.

172 Dr Nikfarjam initially gave evidence that an abdominal CT scan performed on 14 July would have revealed the same features shown on the abdominal CT scan that was performed on 17 July (see [118] below). The improvements that Mdm Lee displayed on 15 and 16 July were due to her good organs compensating for the deficiencies in the organs that had failed. By 2300hrs on 16 July, however, she had become so unwell that she was unable to support her vital signs. ³³⁷ However, Dr Nikfarjam subsequently conceded that the extent of the fluid collections revealed would differ between an abdominal CT scan performed on 14 July and the 17 July Abdominal CT Scan. The fluid was building up within Mdm Lee’s abdomen between 14 and 17 July. ³³⁸

174 The Plaintiff made no submissions on the question of causation in relation to the events after 2300hrs on 16 July. ³³⁹ I reiterate that Mdm Lee was in no condition for percutaneous drainage from 17 to 19 July (see [137]–[140] above), while percutaneous drainage was in fact ordered on 24 July (see [156] above). This leaves only the period from 20 to 23 July.

175 In my view, even if the Defendant had ordered a percutaneous drainage procedure between 20 and 23 July, it was unlikely that the procedure would have been performed immediately. Mdm Lee was in no better a coagulopathic state from 20 to 23 July than she was in on 24 July. ³⁴⁰ At 1730hrs on 24 July, the radiologist tasked with performing the percutaneous drainage ordered by the Defendant had directed that the coagulopathy be corrected first (see [157] above), and the correction had not been completed by 0720hrs the following morning. ³⁴¹

176 Accordingly, the Plaintiff has not established that the Defendant’s omission to order a further abdominal CT scan (and a percutaneous drainage procedure) between 2300hrs on 16 July and the 24 July Abdominal CT Scan caused Mdm Lee’s demise.

177 It was not part of the Plaintiff’s pleaded case that Mdm Lee’s post-operative feeding between 11 July and 2300hrs on 16 July was inappropriate. ³⁴² However, the question of feeding was raised by the Plaintiff at trial and in submission. For completeness, I will consider the feeds provided to Mdm Lee that have been raised by the Plaintiff.

178 The Plaintiff submitted that “the major disruption late on 16 July 2011 was likely the result of the Defendant’s failure to cease oral feeding and on the contrary increasing Mdm Lee’s feeding to full liquid feeds and soft feeds thereafter.” ³⁴³

180 The Plaintiff submitted that “it was imperative to be certain that a patient did not have a Leak prior to commencing them on feeding.” ³⁴⁴ Hence, the only prudent course from 11 July was to keep Mdm Lee Nil-by-Mouth (ie, no oral feeding). ³⁴⁵ He relied on Dr Mak’s opinion that oral feeds may aggravate a Dehiscence, ³⁴⁶ on Dr Beckingham’s assertion that “pouring fluid into her mouth [without eliminating the possibility of a Dehiscence] may cause infection or irritation and cause a SIRS response” ³⁴⁷ [see [190] below], and on Dr Nikfarjam’s evidence that “[i]n patients with a PG [anastomosis], once a major anastomotic leak occurs food and fluid that is taken orally is likely to leak out the stomach, exacerbating the problem.” ³⁴⁸

181 However, Dr Beckingham testified that the small liquid feeds were “insignificant”, ³⁴⁹ did not do any harm, ³⁵⁰ and were “reasonable” whether or not Mdm Lee had a Dehiscence. ³⁵¹ Dr Nikfarjam agreed that there was “no established restriction against giving oral intake after a POPF, by definition, is present”, ³⁵² and that it was appropriate that she was “put progressively on liquids” from 8 to 13 July. ³⁵³

183 From 1900hrs on 13 July until the morning of 14 July, Mdm Lee had a soft food ³⁵⁴ diet. ³⁵⁵ However, after her bout of abdominal pain at 1000hrs on 14 July (at [85] above), she was kept Nil-by-Mouth. ³⁵⁶

184 The Plaintiff submitted that the signs and symptoms exhibited by Mdm Lee on and after 14 July (at [85]–[87] above]) “started surfacing almost immediately after Mdm Lee was commenced on soft foods in the evening of 13 July”. ³⁵⁷ He concluded that “[a]s evident from the final outcome, the result of commencing soft foods was truly disastrous and could have been avoided.” ³⁵⁸

185 However, neither of the Plaintiff’s experts took issue with this soft food diet and the placing of Mdm Lee Nil-by-Mouth thereafter. Dr Nikfarjam found the soft food diet reasonable and “the correct order to make”, even if there was a POPF by definition. ³⁵⁹ Dr Beckingham testified that the soft food diet was reasonable only if there was no Dehiscence, ³⁶⁰ but conceded that there was no evidence that it produced sufficient gastric fluid to cause pain, and that any such increase in gastric fluid could in any event have been controlled by the abdominal drains. ³⁶¹

187 Around 1900hrs on 14 July, when the pain had subsided, Mdm Lee was given 250ml of small liquid ³⁶² feeds. ³⁶³

188 At 0810hrs on 15 July, the surgical team increased Mdm Lee’s liquid feeds to 500ml/day after reviewing her and finding no complaints of pain. At 1320hrs, she had taken her liquid feeds well, continued to have no complaints, and was cheerful, mobilising, and hungry. Her abdominal signs were normal, soft and non-distended, and she was passing flatus. The Defendant thus increased her liquid feeds to 1L/day. ³⁶⁴ At 2130hrs, she had tolerated these full or unrestricted ³⁶⁵ liquid feeds well. ³⁶⁶

189 On 16 July, Mdm Lee was continued on full liquid feeds. At 0903hrs, she had 200ml of coffee. ³⁶⁷ At 0930hrs, the Defendant ordered that a soft food diet be kept in view if there was no more pain (although Mdm Lee never did progress to the soft food diet). ³⁶⁸ At 1300hrs, Mdm Lee had 100ml of Milo. ³⁶⁹ Thereafter, she continued to be clinically well despite her abdominal pain, which was localised to faecal loading and which resolved once she passed motion. The full liquid feeds were thus maintained. ³⁷⁰

190 The Plaintiff submitted that the major disruption late on 16 July 2011 stemmed from the Defendant’s failure to cease oral feeding. Instead, the Defendant put Mdm Lee on full liquid feeds. ³⁷¹ The Plaintiff cited the oral evidence-in-chief of Dr Beckingham: ³⁷²

192 First, Dr Beckingham’s opinion above had to be viewed with circumspection. It was unclear whether his reference to “food” on 14 July was to the soft food diet that morning or the small liquid feeds that evening: the Plaintiff could not prove that the soft food diet that morning was unreasonable (see [184] above), while Dr Beckingham accepted that the small liquid feeds that evening were appropriate. ³⁷³ It was also unclear whether Dr Beckingham had mistakenly believed that Mdm Lee had consumed solid foods rather than liquid feeds from 1900hrs on 14 July. I thus hesitate to conclude that the liquid feeds on 15 July exacerbated the POPF. Dr Beckingham’s subsequent comment in cross-examination that “the thing that I would not want to do is start pouring fluid into her mouth … which may cause infection or irritation and cause a SIRS response [emphasis added]” ³⁷⁴ was, with respect, unconsidered, given his earlier acceptance that small fluid feeds would be insignificant and not cause any harm (see [181] above). Indeed, the Plaintiff relied on the comment not to show that the liquid feeds had in themselves caused or materially contributed to Mdm Lee’s condition at 2300hrs on 16 July, but only to establish that there was already a Dehiscence. ³⁷⁵

193 Secondly, although Dr Mak said that he would not have given small liquid feeds of up to 1L/day from 15 July, he added that there was no evidence that the Dehiscence was aggravated by the liquid feeds that Mdm Lee had from the evening of 15 July. ³⁷⁶

194 Thirdly, Dr Nikfarjam, who took the position that Mdm Lee had a Dehiscence by 7 July, nevertheless agreed that the “continuation of liquids from 14th night to 16th [was] reasonable.” ³⁷⁷

195 In the interests of completeness, I note also that Dr Mak accepted in cross-examination that he would not have ordered liquid feeds of 1L/day on 15 July if he had suspected that Mdm Lee had a Dehiscence. ³⁷⁸ However, the questions put to him in cross-examination were limited to what he himself would have done on 15 July, and not whether what the Defendant in fact did on 15 July was negligent. Neither party addressed this aspect of Dr Mak’s evidence in its submissions.

196 Accordingly, I find on a balance of probabilities that the Plaintiff has failed to establish that Mdm Lee’s feeds caused or materially contributed to the injuries suffered by her.

197 The Plaintiff has taken a machine-gun approach with his allegations in the hope that one of the bullets fired would find its target. In his SOC, he alleged that the Defendant (a) failed to obtain the informed consent of Mdm Lee to the Whipple operation; (b) failed to perform the Whipple operation and two subsequent surgeries in the manner required of an HPB specialist; and (c) failed to deliver timely and appropriate post-operative care (see [11] above). It was only before the trial commenced that he narrowed his allegation to the post-operative management of Mdm Lee, which was limited to the period between the Whipple operation on 4 July and 17 July (although he subsequently attempted to extend it up to 24 or 26 July) (see [12] and [47] above). Even then, many of his allegations of negligence were not borne out by the evidence of his experts.

198 Unfortunately, the Defendant also muddied the waters by his attempts to downplay the possibility that Mdm Lee had suffered a Dehiscence, which included the tenuous distinctions between a POPF and a Dehiscence, and between suspecting and diagnosing each condition. These assertions were contrived, particularly in view of the Defendant’s belated submission that he had suspected a Dehiscence from 7 July (see [40] above). Even so, the burden remains on the Plaintiff to prove his case on a balance of probabilities.

199 The Plaintiff has not shown that the Defendant was negligent in omitting to order an abdominal CT scan before 2300hrs on 16 July. Even if it was open to him to argue that a further abdominal CT scan should have been performed before 1430hrs on 24 July, he has also been unable to establish that the Defendant was negligent in failing to do so. Further, he has not established that such an abdominal CT scan or further abdominal CT scan would have led the Defendant to have managed Mdm Lee differently. Finally, he has not proven that such a different management of Mdm Lee would have saved her life.

200 Accordingly, I find that the Plaintiff has failed to discharge his burden of proof. I dismiss his claim against the Defendant.

201 I will hear the parties on costs.