High Court decides if psychiatrist was too reckless with prescriptions
The Court of 3 Judges of the General Division of Singapore's High Court recently dealt with a case involving a worker’s claims about professional judgment and responsibility.
The worker, a highly experienced professional, defended his approach to managing a particularly challenging situation.
He maintained that his decisions were made in good faith, based on his extensive background and a desire to achieve the best possible outcome. He argued that the unique complexities of the situation warranted flexibility in standard practices.
He also contended that his actions, while unconventional, did not result in direct harm. According to the worker, external factors beyond his control had contributed to the outcome in question.
The psychiatrist issued numerous prescriptions over two years that did not align with Ministry of Health guidelines. His final prescription on 31 July 2012 included 60mg of Mirtazapine per night, which exceeded the 45mg maximum recommended dose, and 25mg of Zolpidem CR, which was more than the 12.5mg daily limit.
He also prescribed multiple benzodiazepines alongside opioid analgesics, despite the known risks associated with such combinations.
A few days after the final prescription, the patient died. A post-mortem report found elevated levels of several prescribed drugs, including Olanzapine, Duloxetine, Mirtazapine, and Bromazepam. The cause of death was recorded as multi-organ failure due to mixed drug intoxication.
In subsequent civil proceedings against the patient’s insurers, the Court of Appeal noted that “the quantity and variety of drugs prescribed to [the patient] were such that even if these had been taken in their prescribed doses (which were at the high end to begin with), this could have resulted in the adverse reactions that led to his death.”
The psychiatrist argued that his prescriptions were intended to provide relief for the patient’s severe psychiatric condition. He maintained that his decisions were grounded in professional experience and an ongoing effort to monitor and manage the patient’s health.
He also contended that no clear causal link had been established between his prescriptions and the patient’s death, supporting his position that the penalties should be limited.
The Singapore Medical Council maintained that the psychiatrist’s prescriptions carried severe risks. The court highlighted the “significant risk of central nervous system depression, sedation, respiratory depression, and cardiovascular depression” associated with the prescribed medications.
It found that the psychiatrist “did not explain why he thought the risks to [the patient] were worth taking.” The court further noted that “the evidence did not even show that [the psychiatrist] had applied his mind to these risks at the material time.”
The psychiatrist had previously acknowledged that his prescription of 60mg of Mirtazapine was at the “edge of the killing range.” The court considered this acknowledgment in its evaluation, reinforcing concerns about the lack of justification for his decisions.
The court assessed the psychiatrist’s conduct under the Wong Meng Hang sentencing framework, which evaluates harm and culpability.
The first and second charges were found to have caused moderate harm with medium culpability. The third charge, which involved the final prescription, was determined to have caused severe harm with high culpability.
The court also determined that the psychiatrist had failed to properly inform the patient of the associated risks. “It is not for a doctor to dice with the life of [the patient] on their behalf, no matter how well-intentioned,” the court stated. The absence of informed consent was a key factor in assessing the level of misconduct.
The court imposed a 36-month suspension from practice, with consecutive sentences for the most serious charges. Additionally, the psychiatrist was censured and required to provide a written undertaking to refrain from similar conduct in the future.
The psychiatrist sought a reduced sentence, citing delays in prosecution, but the court rejected this argument. It found that the complexity of reviewing extensive documentation justified the time required.
The court also dismissed claims that the psychiatrist lacked insight into his actions, stating that “his inability to justify his prescriptions demonstrated a disregard for patient safety.”
The ruling underscores the expectation that professionals adhere to established standards and justify any significant deviations.
As the court found, “departures from established medical guidelines must be justified with clear, evidence-based reasoning to ensure patient safety.”
