IN THE HIGH COURT OF THE REPUBLIC OF SINGAPORE

[2020] SGHC 260

Suit No 553 of 2016

Between

(1) Seto Wei Meng

(suing as the Administrator of the Estate and on behalf
of the dependants of Yeong Soek Mun, deceased)
(2) Seto Mun Chap
(suing as the Co-Administrator of the Estate and on
behalf of the dependants of Yeong Soek Mun,
deceased)
… Plaintiffs

And

(1) Foo Chee Boon Edward

(2) International Medical Group Holdings Pte Ltd
(3) TCS Medical Pte Ltd
… Defendants

And

Singapore General Hospital Pte Ltd

… Third Party

JUDGMENT

[Tort] — [Negligence]
 This judgment is subject to final editorial corrections approved by the
court and/or redaction pursuant to the publisher’s duty in compliance
with the law, for publication in LawNet and/or the Singapore Law
Reports.

Seto Wei Meng (suing as the administrator of the estate

and on behalf of the dependants of Yeong Soek Mun, deceased)
and another
v
Foo Chee Boon Edward and others
(Singapore General Hospital Pte Ltd, third party)

[2020] SGHC 260

High Court — Suit No 553 of 2016

Choo Han Teck J
14–17, 21–24, 28–30 July and 4–7 August 2020; 18 September 2020

26 November 2020 Judgment reserved.

Choo Han Teck J:

Introduction

1 Yeong Soek Mun (“Mandy Yeong”), a 44-year-old woman, underwent

a liposuction as well as a fat transfer surgical procedure on 28 June 2013 at TCS
at Central Clinic, also known as TCS Aesthetics Central Clinic (“the Clinic”).
The surgery was performed by the first defendant, Dr Foo Chee Boon Edward
(“Dr Foo”). The surgery began at 12pm and ended about 2pm. The Clinic was
located at The Central, Eu Tong Sen Street.

2 At 2.05pm, Mandy Yeong’s blood oxygen level had, according to the

Clinic’s anaesthetic record, dropped to 72%. The medical evidence that seems
undisputed is that should the blood oxygen level fall below 95%, action would
Seto Wei Meng v Foo Chee Boon Edward [2020] SGHC 260

be required to raise it back above the 95% level. Dr Foo attempted to do that
without success, and by 2.45pm, Mandy Yeong had suffered a cardiovascular
collapse and an ambulance was called at 2.53pm. An ambulance team reached
the Clinic within seven and a half minutes.

3 Mandy Yeong was taken to the nearest hospital, the Singapore General
Hospital (“SGH”). After she arrived at the SGH’s Accident and Emergency
(“A&E”) Ward at 3.23pm, the doctors and staff there continued with
resuscitation efforts but were unsuccessful and Mandy Yeong died at 5.46pm
on the same day. The parties accept that the cause of Mandy Yeong’s death was
pulmonary fat embolism, which refers to a condition whereby fat globules are
trapped in a patient’s blood vessels and obstruct his or her pulmonary
circulation.

4 The plaintiffs, who were the administrators of Mandy Yeong’s estate,

brought this action against Dr Foo and the second and third defendants for
negligently causing the death of Mandy Yeong. The second and third defendants
manage and own the Clinic. The previous shareholders of both companies were
one Dr Richard Teo (“Dr Teo”) and one Dr Chow Yuen Ho (“Dr Chow”).
Subsequently, Dr Teo died and his widow took over his shares. Both the second
and third defendants have since gone into liquidation and the plaintiffs have
discontinued the action against them. Dr Foo, who had initially brought in the
SGH as a third party, claiming that its doctors were responsible for or had
contributed to Mandy Yeong’s death, discontinued his case against it midway
through the trial.

5 In this action, the plaintiffs allege that Dr Foo was negligent in three
respects. First, that he was negligent in not obtaining informed consent from
Mandy Yeong because he did not personally advise her on the risks and

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complications associated with her procedure. Moreover, he did not explain to

Mandy Yeong that a liposuction involving a fat transfer would entail a higher
risk of fat embolism, particularly if it involved a repeat procedure. Second, that
Dr Foo was negligent in performing the liposuction and fat transfer procedure.
Third, that he was negligent in his attempt to manage Mandy Yeong’s
postoperative condition by, inter alia, failing to call for an ambulance in time.
Dr Foo denies all three allegations.

The fatal liposuction and fat transfer procedure

6 Mandy Yeong had two liposuction procedures prior to the third and fatal
one. The first was performed by one Dr Teo in 29 July 2010 and the second by
Dr Foo on 18 July 2011. The procedure in 2010, which was just for liposuction,
resulted in hollows and surface irregularities in Mandy Yeong’s thigh regions.
Unhappy with the outcome of the first procedure, Mandy Yeong underwent the
second procedure in 2011. This included both a liposuction as well as a fat
transfer, which involved taking the fat from Mandy Yeong’s ‘flanks’ to fill in
her thigh region.

7 Mandy Yeong was still dissatisfied with the result of the second
procedure and so she consulted Dr Foo on 28 May 2013. During the
consultation, they discussed the liposuction and fat transfer procedure
performed by Dr Foo on Mandy Yeong in 2011, and Mandy Yeong’s
unhappiness with the uneven appearance of her thighs. Dr Foo recommended a
further liposuction and fat transfer procedure to correct that. As with the 2011
procedure, this would involve a liposuction (Mandy Yeong’s third since 2013)
and a fat transfer procedure (Mandy Yeong’s second since 2013) whereby the
fat from Mandy Yeong’s abdomen region would be transferred into her thighs

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to correct the unevenness. The procedure was initially scheduled for 14 June
2013 but was postponed, by mutual agreement, to 28 June 2013.

8 As recounted at [3] above, Mandy Yeong died on 28 June 2013 after the
fatal procedure. The cause of death, which is not disputed by the parties, was
found by the State Coroner to be “pulmonary fat embolism due to liposuction”.
When fat embolism manifests in clinical symptoms such as inflammation,
multi-organ dysfunction and neurological changes, it is known as fat embolism
syndrome. Here, the parties and experts are in agreement that Mandy Yeong
suffered from the fulminant form of fat embolism syndrome, which they say is
rarer and has an earlier onset and a poorer prognosis that ordinary fat embolism
syndrome. Fat embolism syndrome may not be fatal if appropriate medical
attention is given, but fulminant fat embolism is almost always fatal. The causes
and consequences of this will be addressed shortly.

9 I first address the question of Dr Foo’s liability for negligence. This

comprises several issues, which I shall now consider in turn.

Informed consent

10 Dr Foo claims that he discussed the 28 June 2013 procedure with Mandy
Yeong on 28 May 2013. He says that the risks of the procedure, including fat
embolism, had been told to her on that day. Despite his claim, his notes of that
consultation made no reference to any such advice. They barely covered half a
page and half of that concerned the surgical and medical fees. That, together
with a set of standard consent forms that Mandy Yeong signed on 28 June 2018,
formed the documentary evidence relating to Mandy Yeong’s consent to the
procedure. The plaintiffs allege that those forms were handed to Mandy Yeong
by the Clinic’s staff. Although Dr Foo maintains that he personally discussed

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the content of the forms with Mandy Yeong, there is no documentary evidence
supporting his claim. The forms were signed by Mandy Yeong, but no signature
appears where Dr Foo’s signature ought to be.

11 When a patient does not give her consent, the procedure for which
consent was lacking would result in the tort of trespass by the doctor, and that
is actionable even without proof of damage. Where consent is given but without
adequate advice, the wrong would be that of negligence, and the patient has to
prove the absent advice and convince the court that had she known of such
advice, she would not have consented to the procedure. The difference between
liability in trespass and liability in negligence lies mainly in the damages to be
awarded, but as we shall see, this is not an issue that I need to deal with.

12 In this case, there is a passage in the consent forms signed by Mandy

Yeong that refers to “serious complications”. The passage reads as follows:

… Although serious complications have been reported to be

associated with fat transfer procedures, these are very rare.
Such conditions include, but are not limited to: Fat embolism
(a piece of fat may find its way into the blood stream and result
in a serious life-threatening condition), stroke, meningitis
(inflammation of the brain), serious infection, blindness or loss
of vision, or death.

13 The form goes on with a passage on ‘pulmonary complications’ in which

the patient is told:

… Pulmonary (lung and breathing) complications may occur

from both blood clots (pulmonary emboli) and a partial collapse
of the lungs after general anaesthesia. Should either of these
complications occur, you may require hospitalization and
additional treatment. Pulmonary emboli can be life threatening
or fatal in some circumstances. Fat embolism syndrome occurs
when fat droplets are trapped in the lungs. This is a very rare
and possibly fatal complication of fat transfer procedure.

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14 I am of the view that the passages above would have sufficiently

discharged a surgeon’s duty to obtain informed consent for the procedure that
Mandy Yeong went through, had the patient’s attention been drawn to them.

15 In some cases, the patient may be able to understand the above passages
herself if they were given to her to read just before entering into consultation
with the doctor. In such cases, it may be enough for the doctor to ask if she had
read and understood the passages, and if she had questions to ask of them. But
this was not the situation in this case. Although Mandy Yeong would certainly
have understood those passages, given her education and profession, there is
some dispute as to whether she had been given sufficient time to read them.
Dr Foo’s position is that he had given Mandy Yeong the consent forms when
he met her on 28 May 2013 and that she had kept them for a month and returned
them, duly signed, on the date of the procedure. Conversely, the plaintiffs
contend that the consent forms were only provided to Mandy Yeong on the day
of the procedure. Aside from Dr Foo, no other witness was able to provide a
first-hand account of this matter. The signature of the person who signed as a
witness did not have a name to match.

16 The evidence is not all that clear, but I incline to accept that the forms
were not given in circumstances in which Mandy Yeong was likely to have read
and understood them in detail. It is unlikely that Mandy Yeong would only have
signed the consent forms on 28 June 2013 if she had managed to read them
beforehand. Dr Foo’s way of informing Mandy Yeong about the dangers of her
procedure was therefore not sufficient. The absence of any notes by Dr Foo
fortifies my belief that the danger of fat embolism was not adequately brought
to Mandy Yeong’s attention before the procedure on 28 June 2013. There is also
nothing to indicate that Mandy Yeong had been apprised of such risks at any

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time prior to 28 June 2013, eg during her consultation with Dr Foo on 28 May
2013, or before undergoing her 2010 and 2011 procedures.

17 But the question remains as to whether Mandy Yeong would have gone
ahead with the procedure on 28 June 2013 even if she had read the two passages
above, or if Dr Foo had told her what the two passages above stated. Given the
rare nature of the risk of pulmonary embolism, Mandy Yeong’s personal
experience with liposuction, as well as her desire to correct the unevenness of
her thighs, it would seem that she would be more likely to accept the risk and
proceed. Thus, although Dr Foo had not in my view adequately drawn Mandy
Yeong’s attention to the risk of fat embolism, as well as the increased risk of fat
embolism in the case of a repeat liposuction with a fat transfer, he cannot be
said to have caused her death in this regard because there is no direct evidence
that she would not have consented otherwise; and the inference from what
evidence there is indicates that she would probably have gone ahead
nonetheless. As mentioned above, I accept that there is no evidence that Mandy
Yeong was properly advised before her 2010 and 2011 procedures, but the fact
remains that she went through those with no mishap other than her
dissatisfaction with the aesthetic results.

18 The Clinic was given a special licence on certain conditions to perform

liposuctions. The conditions that were in force at the material time are the
Specific Licensing Conditions for Special Care Service (Ambulatory Service –
Liposuction) (“Specific Licensing Conditions”) implemented under reg 37 read
with the Third Schedule of the Private Hospitals and Medical Clinics
Regulations (Cap 248, Rg 1, 2002 Rev Ed). One of these conditions was
specifically expressed to be the requirement to inform the patient of the
implications and increased difficulties of a repeat procedure, and to document
this advice in the doctor’s medical record. But for the reasons earlier stated, I

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think that Mandy Yeong would probably have gone ahead even if she had been
told of the increased risk. The risk was increased, but, according to the experts,
statistically, it would still be considered rare. I shall now turn to consider the
next major issue – Dr Foo’s alleged negligence in managing Mandy Yeong’s
postoperative condition.

Negligence in managing postoperative condition

19 The procedure in question on 28 June 2013 commenced at 12 noon and

ended about 2pm. There was some uncertainty as to whether it ended at 2pm
exactly or at 1.50pm, but I am of the view that this ten minutes’ difference is
not crucial to my judgment. What is important is that the parties are in
agreement that Mandy Yeong’s oxygen saturation level had fallen from 100%
at 2pm to 72% at 2.05pm. From that point, evidence from those present is
neither clear nor consistent, but the picture that emerges is that of total mayhem
and confusion. Nobody seemed to know what to do.

20 Apart from Dr Foo, three other doctors were present. One of them,
Dr Shenthilkumar s/o Sritharan Naidu (“Dr Shenthilkumar”), was only there
briefly at two moments — once at 2.10pm and once shortly before Mandy
Yeong collapsed — as he had been tending to his own patients. He did not have
much to say but what seems clear to me from his testimony is that when he
walked into Dr Foo’s surgery about 2.30pm, he had perceived that an
emergency was underway. It was obvious to him that an oxygen saturation of
92%, which was what he noted at that time, was not good. Dr Shenthilkumar
alleges that he had at that point advised Dr Foo to call an ambulance. This
sensible advice was unfortunately either not heard or disregarded by Dr Foo.

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21 In addition to Dr Shenthilkumar, there was a Dr Gerard Ee who

responded to the nurses’ call and other than helping to set up a drip, he did
nothing else. Finally, there was Dr Chow who was attending to his own patients
until slightly after 2pm when he was called to Dr Foo’s operating theatre to help
Dr Foo. By the accounts of both Dr Foo and Dr Chow, they were trying all sorts
of procedures to help raise Mandy Yeong’s oxygen saturation level. These
included using venti-mask and, subsequently, a bag-mask and valve to supply
air with higher oxygen content to Mandy Yeong. According to both of them,
Dr Foo was also simultaneously trying to diagnose the cause of the drop in
Mandy Yeong’s oxygen saturation level throughout the 40 to 45 minutes before
the ambulance was called.

22 Contrary to Dr Foo’s claim that the patient’s condition was improving,

the documentary evidence — in the form of a photograph of a monitor screen
depicting Mandy Yeong’s vital signs — shows that Mandy’s oxygen saturation
level was moving up and down because of Dr Foo’s and Dr Chow’s efforts, but
even then, with oxygen being given, the blood oxygen level did not go above
92%. That is an emergency. There is evidence that that was more than one
photograph of the vital signs monitor. One was by a phone camera belonging to
one of the nurses. The other was by Dr Chow’s small digital camera that was
not produced at trial although it seems that photographs might have been taken
with that camera.

23 Another point of contention is the question, when did Mandy Yeong

suffer a collapse? This is because in a hospital context, the moment a patient
collapse, “Code Blue” — the universal hospital signal for activating emergency
resuscitation — would be sounded. Furthermore, the time between the patient’s
collapse and the calling of the ambulance is especially significant in cases
involving fat embolism where time is of the essence. When exactly Mandy

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Yeong collapsed was disputed, not only because there were differing accounts
of what had transpired at the Clinic but also because the experts differed in their
definitions of a “collapse”. It is not necessary for me to comment on these
differences here. Suffice to say that the general consensus is that Mandy Yeong
had suffered a “collapse” in the sense of a cardiovascular collapse at around
2.45pm, and an ambulance was called at 2.53pm. The ambulance arrived at the
building in which the Clinic was situated in just four minutes and was tending
to Mandy Yeong by 3.01pm.

24 Dr Foo explained in his testimony in court that it was medical procedure

to gradually exclude one condition after another until the correct diagnosis was
made. However, there is no reason why Dr Foo could not have called an
ambulance while simultaneously diagnosing the problem. Furthermore, there is
no evidence that fat embolism was eventually diagnosed by Dr Foo. And the
fact that it took him 45 to 50 minutes to realise that he could not figure out what
was going on compels me to infer that Dr Foo was not adequately trained for
such surgeries. Liposuction and related procedures are generally considered the
specialty of plastic and reconstructive surgeons, and Dr Foo is a general surgeon
who only attended several overseas liposuction courses and internships before
practising liposuction. This is not to say, however, that general surgeons should
never be allowed to carry out liposuction surgeries. It is ultimately for the health
authorities and the medical profession to sort out these boundaries.

25 One of the experts that Dr Foo called to give evidence on his behalf was
Dr Sung Ki-Su (“Dr Sung”) from South Korea, a country well known for its
cosmetic surgery expertise, but it was remarkable that Dr Sung himself had no
formal qualifications as a plastic and reconstructive surgeon. He was, on his
own admission, a psychiatrist who had taken up some training in liposuction,
and then began to practise liposuction on his own. I find little comfort or

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confidence in accepting Dr Sung’s testimony. On the other hand, where medical

safety and protocol are concerned, as well as where the incident and
consequences of fat embolism are concerned, the plaintiffs’ witnesses, Dr Boey
Wah Keong (“Dr Boey”) and A/Prof Lim Thiam Chye (“A/Prof Lim”) gave
evidence supported not just by their professional degrees and experience, but
also the soundness of their testimony to the lay ear.

26 Not only do I think that the written literature about serious complications
such as fat embolism was not explained to Mandy Yeong, it seems to me that
Dr Foo himself was not au fait with that potential problem and was unable to
recognise its possibility when Mandy Yeong collapsed on his table. That
accounted for the 45 to 50 minutes of frantic exploration in the vain hope that
something might help to improve her oxygen saturation levels. Dr Boey’s view
was that Dr Foo did not consider fat embolism syndrome as a possible cause of
Mandy Yeong’s collapse. I accept that opinion because had Dr Foo considered
the possibility of fat embolism syndrome, he would have called the ambulance
straightaway. Dr Foo testified that he did not do so because he was trying to
diagnose what the cause was. The only problem with this evidence is that he
could not explain why he took so long. He testified that fat embolism syndrome
was only diagnosed after the autopsy, but he forgets that at the material point,
he was not undertaking an autopsy but merely considering the possible causes
of the collapse. With the information that he had then, which we now know at
trial, fat embolism syndrome should occupy top ranking once the other possible
causes such as a heart attack, a cerebrovascular accident, or a massive
haemorrhage to the abdomen had been ruled out; and these can be ruled out very
quickly.

27 The plaintiffs’ experts’ testimonies on this point were simple and direct
— when a doctor finds himself unable to handle the situation, he must call for

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help. In this case, calling for help is an understatement — Dr Foo should have
pounded the alarm; and should have done so much earlier.

28 Initially, Dr Foo deflected liability by blaming the doctors at the SGH’s

A&E department for not adequately tending to Mandy Yeong, and in particular,
for not recommending the use of extracorporeal membrane oxygenation
(“ECMO”), a device that supplements normal resuscitation known as
cardiopulmonary resuscitation (“CPR”). The doctors from the SGH explained
that the patient was already in such bad condition when she arrived that they did
not think ECMO would have helped. In the event, Dr Foo discontinued his third-
party claim against the SGH and its doctors midway through the trial.

29 What we are left with from all the doctors who testified on behalf of the
plaintiffs and the SGH, is that Mandy Yeong had arrived at the A&E department
of the SGH too late to be saved. The general consensus among the doctors was
that had the ambulance been summoned when Mandy Yeong’s blood oxygen
fell with no ostensible cause, she would have had a chance of surviving the fat
embolism.

30 Mr Sreenivasan, counsel for Dr Foo, submitted that Mandy Yeong had

fulminant fat embolism, a condition that was almost invariably fatal. Dr Boey
is of the opinion that the fulminant form of fat embolism syndrome “has an
earlier onset (within 1–2 hours) and a more pronounced respiratory and a
haemodynamic deterioration”, when compared with the non-fulminant variety
of fat embolism syndrome. This fits exactly into Mandy Yeong’s situation. The
operation had ended about 2pm. Within five minutes Mandy Yeong was heard
coughing and making a gurgling sound. Her oxygen saturation fell to 72% when
her blood pressure and heart rate were stable. In spite of assisted ventilation, her
oxygen saturation fluctuated and never rose above 92%.

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31 To say that fulminant embolism is almost always deadly is not wrong,

but misses three important points. First, fulminant fat embolism is a diagnosis
made after the event. One of Dr Foo’s witnesses, Dr Sriram Shankar, explained
that the word “fulminant” merely denotes that the patient was in a high-risk
situation. The medical literature also defines “fulminant” as a descriptor for an
event or process that occurs suddenly and is severe to the point of lethality. Most
patients who die from fat embolism are diagnosed as having the fulminant form.
It is possible that had they survived, their condition would merely have been
classified as fat embolism.

32 Second, the non-fulminant form of fat embolism occurs most commonly

in patients with traumatic injuries involving lower limb fractures (eg fractures
of the thigh or shin bones), and in this form, it takes a longer time for the
symptoms to appear. Fulminant fat embolism is much rarer and for this to occur,
it would mean that a large volume of fat had suddenly been introduced into the
patient’s bloodstream. One plausible cause of this is the direct injection of fat
into the bloodstream. I agree with Ms Kuah, counsel for the plaintiffs, that the
fact that Mandy Yeong’s symptoms appeared so swiftly after the procedure
indicates that the cause arose during the procedure. This is relevant to the
plaintiffs’ claims that the procedure was carried out negligently, which will be
discussed later.

33 Third, patients with fat embolism have reasonably good chances of

survival when they are given prompt expert resuscitation in a hospital with such
facilities. Even patients with fulminant fat embolism can recover with such
treatment. The SGH has the necessary resuscitation equipment, but not Dr Foo’s
clinic. Dr Foo and his clinic were unprepared to save Mandy Yeong. Hence,
speedy conveyance to the SGH was vital, and I am of the opinion that Dr Foo’s
delay in sending for the ambulance was an act of negligence.

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34 Mr Sreenivasan submits that even if Dr Foo had been negligent, his

negligence did not result in loss because the chances of surviving a fulminant
fat embolism are slim. As I mentioned above, I accept the evidence of the
plaintiffs’ experts that fulminant fat embolism is a retrospective diagnosis. More
importantly, I do not think that a tortfeasor may be excused on the ground that
the chances of a person’s survival are slim when the very chance of survival
was snatched from her by the tortfeasor’s act of negligence.

Negligence in performing procedure

35 Furthermore, I think that the evidence supports a finding that the fat
embolism occurred as a result of the surgical procedure in which Dr Foo inserted
a blunt tip cannula into Mandy Yeong’s thigh and directly injected fat molecules
into her bloodstream. That is not an accepted risk if the surgery is properly
carried out, and thus, the inference must be that the surgeon was negligent in
the course of the procedure itself.

36 A/Prof Lim testified that fat embolism syndrome can occur in the
procedure that Dr Foo performed, and that the incidence of this complication
ranges from 2% to 22% depending on the different aetiological causes. That is
a statistic of all such cases. What I have to find is whether, on the balance of
probabilities, Dr Foo’s negligence in carrying out the procedure was likely to
have caused Mandy Yeong to fall into the 2% to 22% category. What the
statistic tells us is that even when there is a fat transplant done using the method
that Dr Foo employed, 78% would not have developed fat embolism syndrome.
It does not tell us whether in this instance whether Dr Foo had negligently
performed Mandy Yeong’s surgery and caused her onset of fat embolism
syndrome.

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37 In this case, Mandy Yeong had previous fat transplants done on the same
areas that, the experts say, would have left scar tissues, and injecting fat into
these areas would have been more difficult because of the resistance due to the
scarred tissues. Furthermore, as mentioned at [32] above, the extremely rapid
onset of symptoms in this case meant that a large volume of fat had suddenly
entered into Mandy Yeong’s bloodstream. Finally, one of the SGH’s doctors,
Dr Lim Jia Hao, testified that when he was treating Mandy Yeong, he had noted
bruising on her abdominal wall and upper thighs, which indicated that her
femoral vessels might have been inadvertently punctured. All things considered,
it was more likely than not that Dr Foo had inadvertently punctured a blood
vessel as he was injecting the fat into Mandy Yeong’s thigh.

38 It seems to me that the clearest evidence of this is the temporal proximity

between the completion of the procedure and the subsequent onset of Mandy
Yeong’s symptoms, but that is a strong connection in the evidence of contrary
evidence or evidence that might suggest otherwise. There is no other
explanation as to how such a large volume of fat could have gotten into Mandy
Yeong’s bloodstream. I am accordingly of the view that Dr Foo’s negligent
performance of Mandy Yeong’s procedure caused her eventual demise.

Other aspects of note

39 Dr Foo also breached the Specific Licensing Conditions when he

collected a deposit of $2,311.20 from Mandy Yeong after her consultation on
28 May 2013 even though Condition 17(3) stipulates that no financial
transaction relating to a liposuction procedure could be made for seven days
from the day of first consultation on that procedure. Dr Foo explained that it
was Mandy Yeong who had wanted to make payment on that day because she
did not want the trouble of going back seven days later just to make payment.

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That may be so, but it is still a breach of the conditions. It is a condition imposed
on the Clinic and for Dr Foo and the Clinic staff to comply. The blame for a
breach cannot be shifted to the patient. In itself, however, the breach is not a
cause of Mandy Yeong’s death.

40 The absence of medical, consultation, and surgical notes has made it

difficult to understand what happened to Mandy Yeong. It is because of this that
I am limited to drawing fewer inferences than I could otherwise do. I have set
out the specific instances that are important, but I should now conclude that
reviewing the case as a whole, it also seems to me, and I so find, that Dr Foo,
who may well be a competent general surgeon, was not adequately trained to
perform the liposuction and fat transfer procedures. Unfortunately, Dr Foo
believed himself capable and thus did not manage this case as a competent
surgeon in this field should have done. I therefore find that the cause of Mandy
Yeong’s death was due to the negligence of Dr Foo.

41 For completeness, I briefly address the plaintiffs’ pleaded argument —

which was abandoned at the close of the trial — that Dr Foo had failed to
administer fluids intraoperatively and during the postoperative period.
Dr Boey’s evidence in this regard was that the amount of fluids that Dr Foo had
administered to Mandy Yeong during the surgery and during the resuscitation
process was “grossly inadequate” and that this had placed Mandy Yeong at a
disadvantage when pulmonary embolism occurred. Dr Foo argues that he had
adopted the tumescent technique in carrying out his liposuction procedure, and
that the use of tumescent anaesthesia negates the necessity of administering
additional intravenous fluids during the procedure. I make no finding on this
issue save to observe that the medical evidence on this point appears to be
divided. Indeed, some medical literature warns against the administration of
additional fluids intraoperatively when the tumescent technique was used.

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42 I now turn to consider the plaintiffs’ claims for damages, which fall
under the following heads:

(a) An estate claim, comprising funeral expenses, medical expenses

incurred at the Clinic, legal costs and disbursements incurred for
obtaining the Letters of Administration, general damages for pain and
suffering, and legal costs and disbursements incurred in relation to the
coroner’s inquiry (“the Estate Claim”); and

(b) a dependency claim, comprising the amounts claimed for

bereavement and loss of support for Mandy Yeong’s dependants (“the
Dependency Claim”); and

(c) a loss of inheritance claim for the loss of inheritance suffered by

Mandy Yeong’s dependants (“the Loss of Inheritance Claim”).

The Estate Claim

43 Where the Estate Claim is concerned, Dr Foo does not dispute the
amounts being claimed by the plaintiffs for funeral expenses, medical expenses
and legal costs and disbursements incurred for obtaining the Letters of
Administration.

44 The plaintiffs claim $7,000 as general damages for pain and suffering.
This is disputed by Dr Foo, who claims that a sum of $5,000 is sufficient given
that Mandy Yeong had become unconscious soon after her blood oxygen levels
plummeted. In my view, $7,000 is the appropriate figure. The evidence is that
Mandy Yeong was conscious from 2.05pm, when the oxygen desaturation first
began, till about 2.45pm. During this period, she would have felt severe
breathlessness and distress from the lack of oxygen. The nurses and doctors who

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were present also testified that Mandy Yeong had been restless and
uncomfortable while she was still conscious.

45 As for the coroner’s inquiry fees, the plaintiffs’ position is that these
should be taxed if not agreed, while Dr Foo argues that they should not be
claimable at all. In Zhu Xiu Chun (alias Myint Myint Kyi) v Rockwills Trustee
Ltd (administrators of the estate of and on behalf of the dependants of Heng
Ang Tee Franklin, deceased) and other appeals [2016] 5 SLR 412, the Court of
Appeal held (at [76]) that coroner’s inquiry fees are claimable as long as the
amount claimed is reasonable and proportionate. I therefore see no reason to
disallow the plaintiffs’ claim in this regard.

The Dependency Claim

46 The plaintiffs claim bereavement at the statutory sum of $15,000 set out
under s 21(4) of the Civil Law Act (Cap 43, 1999 Rev Ed). This is undisputed
by Dr Foo and thus I need say no more on this matter.

47 The plaintiffs seek to utilise the “traditional method” to calculate the loss
of support suffered by Mandy Yeong’s dependants as a consequence of
Dr Foo’s negligence. By this method, the court must determine the deceased’s
dependents’ reasonable expectation of pecuniary benefit by adding together the
value of the benefits received by the dependants from the deceased (Armstrong,
Carol Ann (executrix of the estate of Peter Traynor, deceased, and on behalf of
the dependents of Peter Traynor, deceased) v Quest Laboratories Pte Ltd and
another and other appeals [2020] 1 SLR 133 (“Armstrong”) at [212]).

48 At the time of her death, Mandy Yeong had been the Head of Regional
Market Development for Roche Diagnostics Asia Pacific Pte Ltd (“Roche”),
where she had worked for nearly 20 years. She was survived by her two elderly

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Seto Wei Meng v Foo Chee Boon Edward [2020] SGHC 260

parents (Mr Yeong and Mdm Lee), her husband (Mr Seto), as well as her sons
(aged 17 and 13 respectively at the time of their mother’s death).

49 Mr Seto and Mdm Lee gave evidence that prior to her demise, Mandy
Yeong had provided her parents with a total monthly allowance of $1,000. On
top of this allowance, Mandy Yeong frequently bought her parents gifts and had
given them a few hundred dollars each month to pay their foreign domestic
helper’s salary and foreign worker levy (“FWL”). Mr Yeong passed away on
8 October 2016. As such, the plaintiffs submit that the total multiplicand should
be $1,500 per month for the period preceding Mr Yeong’s death, and $1,000
per month thereafter. Since Mdm Lee was 71 years old at the time of Mandy
Yeong’s death, and the average life expectancy of a female in Singapore is about
86 years old, the discounted multiplier for Mdm Lee’s loss of support ought to
be 11.25 years (ie, 15 years’ dependency period with a discount of 25% for
accelerated receipt and vicissitudes of life).

50 Dr Foo’s position is that the plaintiffs lack the standing to make a

dependency claim on Mr Yeong’s behalf as he has since passed away.
Moreover, there is a serious evidentiary issue as to whether Mandy Yeong had
even provided Mdm Lee with an allowance.

51 In my view, the plaintiffs are entitled to make a claim on Mr Yeong’s

behalf as he only passed away after the suit had commenced. I am also prepared
to accept, based on Mr Seto’s and Mdm Lee’s testimony, that Mandy Yeong
was a filial daughter who willingly provided for her parents. However, there is
nothing to show that Mandy Yeong had given her parents a monthly sum of
$1,500 prior to her death. The only documentary evidence available is a bank
statement showing that Mandy Yeong had paid for her parents’ foreign domestic
worker’s FWL in June 2013. Considering the circumstances in their totality, I

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Seto Wei Meng v Foo Chee Boon Edward [2020] SGHC 260

am of the view that a multiplicand of $1000 per month for the period preceding
Mr Yeong’s death (approximately 40 months) would be fairer. For the period
subsequent to Mr Yeong’s death, a multiplicand of $500 per month and a
discounted multiplier of 9 years (12 years with discount of 25%) ought to be
applied.

52 On behalf of Mandy Yeong’s husband, Mr Seto, the plaintiffs claim

$322,920 for loss of support for household expenses, $816,962.97 for loss of
support for expenses relating to an investment property (“the Hilloft”) which
Mandy Yeong and Mr Seto jointly owned, and $296,700 for loss of support of
car expenses. Mr Seto continues to own the Hilloft property to-date but there is
no evidence that he is earning rental income from the property.

53 Where the household expenses are concerned, Dr Foo argues that there
are two “gaping holes” in the plaintiffs’ claim: first, that the plaintiffs have not
shown the apportionment of household expenditure between Mandy Yeong and
her husband, and second, that they have not shown any proof of expenses
incurred or to be incurred after Mandy Yeong’s passing.

54 Although the plaintiffs have not adduced documentary evidence of

actual expenditure on household expenses, I am of the view that Mr Seto’s
estimate of $2,600 per month is reasonable. The key question is how that sum
ought to be apportioned between the parties. It is clear that Mandy Yeong earned
considerably more than her husband. Her income for 2012 (ie, her last drawn
income before her death) exceeded $420,000, while Mr Seto’s income in 2013
was around $120,000. This being said, I agree with counsel for Dr Foo that there
is no evidence that Mandy Yeong would have continued to earn three times her
husband’s income for the remainder of her career. More importantly, even if
Mandy Yeong’s income was thrice the amount of Mr Seto’s income, this is not

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Seto Wei Meng v Foo Chee Boon Edward [2020] SGHC 260

proof that she contributed three times the amount that Mr Seto contributed to
the family’s household expenses. For this reason, I am of the view that a fairer
approach would be to apportion the household expenses in the ratio of 66.6% to
Mandy Yeong, and 33.3% to Mr Seto. This would result in a multiplicand of
$20,779.20.

55 There is some dispute as to whether Mandy Yeong would have worked

till age 62 or age 67, as the Human Resources Policy of Roche states that the
retirement age of Roche is “as the law prescribes currently”. Under the
Retirement and Re-employment Act (Cap 274A, 2012 Rev Ed), the minimum
retirement age of an employee is 62, but employers must offer re-employment
to employees up to the age of 67 if they are medically fit and assessed as having
satisfactory work performance. Given Mandy Yeong’s good health and her
stellar track record at work, I accept that it is more likely than not that she would
have been offered employment till the age of 67. The appropriate multiplier
should therefore be 13.8 years (23 years with a discount of 40%).

56 As to the Hilloft and car expenses, I am of the view that the plaintiffs’
claims are reasonable and that they have adduced sufficient evidence to
substantiate their claims. I do not think that the Hilloft mortgage should be
excluded simply because it could, in theory, be covered by the rental income
that is earned from the property. As stated at [52] above, there is no evidence
that Mr Seto is renting or intends to rent out the Hilloft. I also accept that Roche
provided Mandy Yeong with the free use of a company car and that they would
likely have continued doing so if not for Mandy’s demise. The plaintiffs’ claim
for the cost of two cars is not unreasonable given that that Roche gave Mandy
Yeong the option to change her car for a newer model every 5 years or so.

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57 On behalf of Mandy Yeong’s two sons, the plaintiffs claim $113,601 for
the older son and $249,433.20 for the younger son, encompassing monthly
expenses, additional expenses (eg, holidays, gifts and healthcare benefits), as
well as one-off expenses for driving lessons and university fees.

58 The parties agree that the discounted multipliers for the older son and
the younger son ought to be 6 and 9 years respectively. Dr Foo is also prepared
to accept the figures proposed by the plaintiffs in relation to the driving lessons
and the university fees. However, Dr Foo asserts that the amounts claimed for
monthly and additional expenses are excessive and unsubstantiated. Although I
agree with Dr Foo that the plaintiffs have not tendered evidence of the sons’
actual monthly expenditure, it would not be appropriate to substitute the figures
proposed by the plaintiffs with a nominal sum. In the circumstances, I am of the
view that a sum of $1,200 per month for the older son’s monthly expenses and
a sum of $900 per month for the younger son’s monthly expenses would suffice.
As for the additional expenses, a sum of $3,000 per child per year is reasonable
and appropriate. Again, these expenses would be apportioned in the ratio of
66.6% to Mandy Yeong, and 33.3% to Mr Seto.

The Loss of Inheritance Claim

59 The plaintiffs claim $4,956,551.11 for loss of inheritance based on

Mandy Yeong’s projected income and $767,970 for loss of inheritance based
on the stock options which Roche would have awarded to Mandy Yeong during
the course of her employment.

60 Parties are agreed that the applicable test for the computation of a loss
of inheritance claim is that set out in Armstrong (at [113]). Dr Foo’s main
objection to the plaintiffs’ claim is that they did not call a representative from

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Roche to give evidence on Mandy’s projected remuneration. I am unable to

accept this contention. The compensation statements and pay slips tendered by
the plaintiffs are sufficient to satisfy me of the fact that Mandy Yeong had
enjoyed annual salary increments of between 6.5% and 20.2% from 2009 till
2014. It is also evident from Mandy Yeong’s performance appraisals that she
was a competent and highly valued employee. Taking all these factors into
account, I am led to the conclusion that Mandy Yeong would most likely have
enjoyed an average annual salary increment of about 5% until the age of 60.
This would translate into an average annual income of $754,468.13.

61 The plaintiffs claim that Mandy Yeong’s annual expenses on her

dependants would amount to about $111,427.79 a year. This sum ought to be
reduced in light of my findings above that Mandy Yeong’s expenditure on
household expenses, property-related expenses, and her parents’ and sons’
expenses would not have been extensive as the plaintiffs claim. In my view, an
approximate figure of about $90,000 per year would be appropriate. I also
accept the presumption endorsed in Armstrong (at [212]) that a person in a
household of four with two children would typically spend 25% of her income
on personal expenses. This means that Mandy Yeong’s average annual personal
expenditure would have been $188,617.03. As such, the appropriate
multiplicand for loss of inheritance based on Mandy Yeong’s projected income
should be $475,851.10. The applicable multiplier would be 6.9 years (23 years
with a discount of 70%).

62 As to the stock options, I am hesitant to find — based on the limited

evidence available — that Mandy Yeong would have continued to accumulate
1,200 stock options annually till the end of her working life. In my view, a more
conservative and realistic estimate would be 1,000 stock options (valued at

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Seto Wei Meng v Foo Chee Boon Edward [2020] SGHC 260

$92.75 each) per year for a total of about 20 years. The appropriate multiplier is
therefore 6 years (20 years with a discount of 70%).

Apportionment

63 I turn finally to consider Dr Foo’s argument, raised belatedly in the

Defendants’ Reply Submissions, that if Dr Foo were found to be negligent, he
only ought to be liable for a third of the damages claimable by the plaintiffs.
This submission is clearly a non-starter. As the analysis in this judgment makes
clear, Dr Foo’s negligent acts alone were sufficient to cause Mandy Yeong’s
death. He should thus be liable in full for the losses suffered by the plaintiffs.

64 In conclusion, I award the plaintiffs the following damages:

(a) for the Estate Claim, the sum of $31,390.99 (comprising

$12,714.78 in funeral expenses, $4,983 in medical expenses incurred at
the Clinic, $6,596.80 for the legal costs and disbursements incurred for
obtaining the Letters of Administration, $96.41 for the cost of obtaining
a medical report from SGH and $7,000 as general damages for pain and
suffering), as well as the coroner’s inquiry fees which are to be taxed if
not agreed;

(b) for the Dependency Claim, the sum of $1,728,293.90

(comprising $15,000 for bereavement, $94,000 for Mdm Lee’s and
Mr Yeong’s loss of support, $1,400,415.93 for Mr Seto’s loss of
support, $96,881.69 for the older son’s loss of support and $121,996.28
for the younger son’s loss of support);

(c) for the Loss of Inheritance Claim, the sum of $3,839,872.59

(comprising $3,283,372.59 for loss of inheritance based on projected

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Seto Wei Meng v Foo Chee Boon Edward [2020] SGHC 260

income and $556,500 for loss of inheritance in relation to the stock

options).

65 Pre-judgment interest is to be awarded at the default interest rate of

5.33% per annum for all of the plaintiffs’ claims except for the claim for the
medical expenses incurred at the Clinic, for which an interest rate of 3% per
annum shall apply.

66 I will hear submissions on costs at a later date.

- Sgd -
Choo Han Teck
Judge

Kuah Boon Theng SC, Yong Shuk Lin Vanessa and Chain Xiao Jing
Felicia (Legal Clinic LLC) for the plaintiffs;
Narayanan Sreenivasan SC, Sundararaj Palaniaapan, Lim Min (K&L
Gates Straits Law LLC) (instructed) and Gan Guo Wei (Charles
Lin LLC) for the first defendant;
Mak Wei Munn, Teh Shi Ying and Ong Hui Fen Rachel (Allen &
Gledhill LLP) for the third party.

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