Khoo James v Gunapathy: Medical Negligence, Bolam Test & Brain Tumour Radiosurgery

In Dr Khoo James and Another v Gunapathy d/o Muniandy and another appeal, the Court of Appeal of Singapore heard an appeal from a High Court decision finding Dr. James Khoo, Dr. Khor Tong Hong, and Neurological Surgery Pte Ltd negligent in the diagnosis, treatment, and advice provided to Madam Gunapathy regarding a brain tumour. Gunapathy sued the doctors and the clinic, alleging negligence in advising her to undergo radiosurgery, which resulted in radionecrosis and serious disabilities. The High Court awarded Gunapathy damages of $2,555,158.96. The Court of Appeal allowed the appeals, finding that the doctors were not negligent in their diagnosis, treatment, and advice.

1. Case Overview

1.1 Court

Court of Appeal of the Republic of Singapore

1.2 Outcome

Appeals allowed; the doctors were not negligent in their diagnosis, treatment, and advice relating to Gunapathy's case.

1.3 Case Type

Civil

1.4 Judgment Type

Grounds of Decision

1.5 Jurisdiction

Singapore

1.6 Description

Court of Appeal judgment on medical negligence claim. Doctors not negligent in diagnosing brain tumour, recommending radiosurgery treatment.

1.7 Decision Date

12 May 2002

2. Parties and Outcomes

Party Name	Role	Type	Outcome	Outcome Type	Counsels
Dr Khoo James	Appellant, Defendant	Individual	Appeal Allowed	Won	Mak Wei Munn of Allen & Gledhill Josephine Low of Michael Khoo & Partners Andy Chiok of Michael Khoo & Partners Michael Khoo of Michael Khoo & Partners K Shanmugam of Allen & Gledhill
Gunapathy d/o Muniandy	Respondent, Plaintiff	Individual	Appeal Dismissed	Lost	Josephine Low of Michael Khoo & Partners Tan Beng Swee of Netto Tan & S Magin Andy Chiok of Michael Khoo & Partners Michael Khoo of Michael Khoo & Partners Anne Magdeline Netto of Netto Tan & S Magin
Dr Khor Tong Hong	Appellant, Defendant	Individual	Appeal Allowed	Won	Mak Wei Munn of Allen & Gledhill Josephine Low of Michael Khoo & Partners Andy Chiok of Michael Khoo & Partners Michael Khoo of Michael Khoo & Partners K Shanmugam of Allen & Gledhill
Neurological Surgery Pte Ltd	Defendant	Corporation	Appeal Allowed	Won	Mak Wei Munn of Allen & Gledhill Josephine Low of Michael Khoo & Partners Andy Chiok of Michael Khoo & Partners Michael Khoo of Michael Khoo & Partners K Shanmugam of Allen & Gledhill

3. Judges

Judge Name	Title	Delivered Judgment
Chao Hick Tin	Judge of Appeal	Yes
Tan Lee Meng	Judge	No
Yong Pung How	Chief Justice	No

4. Counsels

Counsel Name	Organization
Mak Wei Munn	Allen & Gledhill
Josephine Low	Michael Khoo & Partners
Andy Chiok	Michael Khoo & Partners
Michael Khoo	Michael Khoo & Partners
K Shanmugam	Allen & Gledhill
Tan Beng Swee	Netto Tan & S Magin
Anne Magdeline Netto	Netto Tan & S Magin

4. Facts

Gunapathy was diagnosed with a brain tumour in the left lateral ventricle in 1995.
Dr. James Khoo performed a craniotomy to remove the tumour.
The resected tissue was found to contain neurocytoma, a low-grade tumour.
Gunapathy underwent post-operative radiotherapy treatment.
An MRI scan in 1996 revealed a lesion near the site of the original tumour.
Dr. Khoo recommended radiosurgery for the lesion, believing it to be a remnant tumour.
Gunapathy underwent radiosurgery in 1997, which led to radionecrosis and serious disabilities.

5. Formal Citations

Dr Khoo James and Another v Gunapathy d/o Muniandy and another appeal, CA 600094/2001, 600097/2001, [2002] SGCA 25

6. Timeline

Date	Event
1995-03-01	Gunapathy married.
1995-10-01	Gunapathy started experiencing headaches and weakness in her right arm.
1995-11-15	Dr James Khoo performed a craniotomy on Gunapathy.
1995-12-06	Gunapathy was referred to Dr Khor Tong Hong for post-operative radiotherapy treatment.
1996-01-13	Gunapathy completed post-operative radiotherapy treatment.
1996-02-26	MRI scan revealed a lesion.
1996-12-27	Another MRI scan was done by Dr Esther Tan.
1997-01-14	Dr Khoo explained to Gunapathy that the result of the scan was likely to be a remnant tumour.
1997-01-21	Gunapathy saw Dr Ho Kee Pang for a second opinion.
1997-01-22	Dr Devathasan referred Gunapathy back to Dr Khoo.
1997-01-23	Gunapathy met with Dr Khor.
1997-01-27	Gunapathy consulted with Dr Khoo, followed by Dr Khor.
1997-01-31	Radiosurgery was performed.
1997-03-01	Gunapathy began to exhibit symptoms of radionecrosis.
1997-12-01	Gunapathy sought the opinion of Dr Prem Pillay.
1998-03-18	Dr Pillay performed a second craniotomy on Gunapathy.
2001-01-01	Case Number : CA 600094/2001, 600097/2001
2002-05-13	Decision Date

7. Legal Issues

Negligence in Diagnosis
- Outcome: The Court of Appeal found that the doctors were not negligent in their diagnosis.
- Category: Substantive
- Sub-Issues:
  - Failure to properly interpret MRI scans
  - Failure to consider alternative diagnoses
Negligence in Treatment
- Outcome: The Court of Appeal found that the doctors were not negligent in their treatment.
- Category: Substantive
- Sub-Issues:
  - Inappropriate use of radiosurgery
  - Incorrect collimator size
  - Excessive radiation dosage
Negligence in Advice
- Outcome: The Court of Appeal found that the doctors were not negligent in their advice.
- Category: Substantive
- Sub-Issues:
  - Failure to adequately inform patient of risks
  - Misrepresentation of the simplicity of the procedure
Application of Bolam Test
- Outcome: The Court of Appeal clarified the application of the Bolam test, emphasizing the need for expert testimony to have a logical basis.
- Category: Procedural
- Sub-Issues:
  - Standard of care for medical professionals
  - Role of expert medical opinion
  - Threshold test of logic
Admissibility of Unpleaded Defence
- Outcome: The Court of Appeal agreed with the trial judge that the unpleaded defence should be disallowed.
- Category: Procedural
- Sub-Issues:
  - Introduction of 'residual tumour' theory at trial
  - Impact on credibility of defendants and experts

8. Remedies Sought

Monetary Damages

9. Cause of Actions

Medical Negligence
Breach of Duty of Care

10. Practice Areas

Medical Malpractice
Commercial Litigation

11. Industries

Healthcare

12. Cited Cases

Case Name	Court	Affirmed	Citation	Jurisdiction	Significance
Bolam v Friern Hospital Management Committee	N/A	Yes	[1957] 1 WLR 582	N/A	Established the Bolam test for the standard of care required of a medical practitioner.
Hunter v Hanley	Court of Session	Yes	Hunter v Hanley 1955 S.L.T. 213	Scotland	Case concerning the standard of care required of a medical practitioner.
Whitehouse v Jordan	House of Lords	Yes	[1981] 1 WLR 246	England	Approved the Bolam test on the issue of treatment.
Maynard v West Midlands Regional Health Authority	House of Lords	Yes	[1984] 1 WLR 634	England	Approved the Bolam test on the issue of diagnosis.
Sidaway v Bethlem Royal Hospital Governors	House of Lords	Yes	[1985] 1 All ER 643	England	Addressed the neurosurgeon’s duty to disclose information about the risks of an operation.
Chin Keow v Government of Malaysia	Privy Council	Yes	[1967] WLR 813	Malaysia	Case where a doctor was found liable for failing to make proper inquiry about a patient's allergy.
Bolitho v City & Hackney Health Authority	House of Lords	Yes	[1998] AC 232	England	Supplemented the Bolam test, clarifying that expert testimony must have a logical basis.
Yeo Peng Hock Henry v Pai Lily	N/A	Yes	[2001] 4 SLR 571	Singapore	Affirmed the application of the Bolam test as supplemented by Bolitho in Singapore.
Vasuhi d/o Ramasamypillai v Tan Tock Seng Hospital Pte Ltd	High Court	Yes	[2001] 2 SLR 165	Singapore	Considered the application of Bolam and Bolitho in the context of medical negligence.
Hucks v Cole	Court of Appeal	Yes	[1993] 4 Med.L.R. 393	N/A	Example of a defendant held to be negligent despite the existence of a body of professional opinion sanctioning his conduct.
Edward Wong Finance Co. Ltd. v Johnson Stokes & Master	Privy Council	Yes	[1984] AC 296	Hong Kong	Case where the Privy Council found lawyers negligent despite industry-wide acceptance of their practice.
Yeo Yoke Mui v Ng Liang Poh	N/A	Yes	[1999] 3 SLR 529	Singapore	Case where the court found a lawyer negligent despite compliance with standard conveyancing practice.
Penney & ors v East Kent Health Authority	Court of Appeal	Yes	[2000] PNCR 323	N/A	Case illustrating the principle that a question of fact does not fall within the province of the Bolam test.
Canterbury v Spence	U.S. Court of Appeals, District of Columbia Circuit	Yes	Canterbury v Spence (1972) 464 F. 2d 772	United States	Recognized the doctrine of informed consent.
Reibl v Hughes	Supreme Court	Yes	Reibl v Hughes (1980) 114 DLR (3d) 1	Canada	Recognized the doctrine of informed consent.

13. Applicable Rules

Rule Name
No applicable rules

14. Applicable Statutes

Statute Name	Jurisdiction
No applicable statutes

15. Key Terms and Keywords

15.1 Key Terms

Radiosurgery
Radionecrosis
Neurocytoma
Bolam Test
Craniotomy
MRI Scan
Tumour
Lesion
Radiotherapy
Collimator
Isocentre
Histopathology
Glioma
Expert Testimony

15.2 Keywords

Medical Negligence
Bolam Test
Brain Tumour
Radiosurgery
Singapore
Court of Appeal
Medical Malpractice
Diagnosis
Treatment
Advice

17. Areas of Law

Area Name	Relevance Score
Medical Negligence	95
Negligence	70
Personal Injury	60
Breach of Duty of Care	50
Standard of Care	40
Professional conduct	40
Civil Procedure	30
Civil Practice	30

16. Subjects

Medical Profession and Practice
Liability
Negligence
Brain Tumour
Radiosurgery
Medical Opinion
Duty of Care
Pleadings
Defence