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TORT: Negligence - Medical negligence - Prescription of beta blocker drug blocadren - Whether caused deceased's death - Whether blocadren caused resultant damage to deceased - Whether deceased would not have experienced severe restriction resulting in closing up of bronchioles `but for' effects of blocadren - Whether respondent aware blocadren ought not to have been prescribed to asthma patient - Whether there was duty of care on doctor's part - Whether breached - Chain of causation - Whether established

TORT: Negligence - Duty of care - Whether breached - Prescription of beta blocker drug blocadren - Whether caused deceased's death - Whether blocadren caused resultant damage to deceased - Whether deceased would not have experienced severe restriction resulting in closing up of bronchioles `but for' effects of blocadren - Whether doctor aware blocadren ought not to have been prescribed to asthma patient - Chain of causation - Whether established

[CIVIL APPEAL NO: W-02-351-2009]
24 DECEMBER 2013

The appellant was the administrator of the estate of his deceased daughter (`the deceased'). The respondent was at all material times a doctor in private general practice. On 28 July 1999, the deceased had complained of rapid heartbeat and hand tremors and was seen by the respondent at his clinic, accompanied by her mother (`PW1'). The respondent prescribed a drug "blocadren" in tablet form to help slow down the deceased's pulse rate. It was the appellant's case that upon arriving home that same evening, the deceased had swallowed the recommended dosage of a quarter of the said drug but almost immediately thereafter suffered breathing difficulties. In the car, on the way to Pantai Medical Centre, the deceased had collapsed. Upon arrival at Pantai Medical Centre, one Dr Damodaran (`PW5') a consultant anaesthetist, had resuscitated the deceased. Unfortunately, she suffered severe brain damage and remained in a coma from which she did not recover until her death on 15 March 2000. The appellant sued the respondent for negligence and damages pursuant thereto, in prescribing blocadren, a non-selective beta blocker to the deceased who was asthmatic, when this drug was contraindicated to her condition. The respondent disputed that blocadren had caused the violent reaction suffered by the deceased and that this event was not foreseeable. The High Court Judge held that the issue of causation had not been established and had dismissed the appellant's claim. The issue that arose herein was whether there was a failure by the appellant to establish causation. The appellant submitted that causation had indeed been proven but the trial judge had not had the benefit of referring to certain excerpts of the evidence adduced, since these particular excerpts were inadvertently omitted from the body of evidence before the court. The `missing evidence' was that of PW1, which was crucial since the issue at hand was whether upon consumption of the blocadren prescribed to the deceased by the respondent, the deceased had tried to use the ventolin inhaler after she experienced breathing difficulties. The trial judge had implied that should this be in evidence (that if the deceased had used her ventolin inhaler and if it had been proven to be ineffective, chances are that her receptor sites had been blocked by the effects of blocadren) it would have led him to conclude that the blocadren was the cause of the resultant `damage' suffered by the deceased. The burden rested on the appellant to prove causal connection on a balance of probabilities between the deceased's injury and the respondent's alleged negligence, thus the question that arose was whether the chain of causation had been established to the required degree of proof.

Held (allowing appeal with costs)

Per Zainun Ali JCA delivering the judgment of the court:

(1) On the strength of the evidence adduced by PW1, the deceased had in fact attempted to mitigate the sudden onset of what she believed to be an asthma attack, by using her ventolin inhaler, which in this case failed to ease her distress. A reference could have been drawn that her receptor sites had been blocked by the effects of blocadren, since the `rescue medication' was ineffectual. There was no evidence that the dosage of ativan, a muscle relaxant which was prescribed by PW3 the day before the said incident was high enough to reduce respiration to such an extent that the deceased's heart had actually stopped and her brain deprived of oxygen. The evidence given by PW1 was unchallenged. Thus, on a balance of probabilities, it would have been the blocadren which caused the deceased her resultant damage, in which case causation would have been proven. (paras 30, 78, 80, 91 & 92)

(2) Overwhelming evidence showed that both ativan and ventolin were not the precursors to the violent reaction experienced by the deceased. It was clear on a preponderance of probabilities that it was the blocadren tablet which brought on the severe reaction experienced by the deceased. The deceased had died from acute respiratory depression, hypoxic brain injury and respiratory arrest following a bronchial asthmatic attack. Even if it was argued that the deceased had ingested two ativan tablets the day before, they had no effect on her breathing and so could not be attributed to her injury thereafter. But her reaction to the blocadren was immediate and severe. The deceased would not have experienced a severe restriction resulting in the closing up of her bronchioles `but for' the effects of the blocadren. (paras 111, 112, 118, 119 & 120)

(3) The medical journals referred to by counsel supported the view that a non-specific beta blocker should never be given to an asthmatic, unless it was cardio-selective and that the asthma was well-controlled and monitored and/or where the benefits outweigh the risks. In addition, the comment made by the trial judge that `if there had been evidence that the deceased had tried to use ventolin after taking the blocadren tablet and that it had not worked, then perhaps one could safely say it was the blocadren that blocked the deceased's medication for asthma' becomes extremely significant in the light of the fact that the trial judge had been deprived of considering this very evidence in the missing notes of PW1's evidence. If the trial judge had been appraised of this evidence, he would have found differently on the issue of causation. (paras 121, 122 & 123)

(4) Every possible link in the chain of causation had been established to the degree of proof which was much higher than the requisite level. There were more than sufficient grounds for the trial judge on a balance of probabilities to have found that the beta-blocker blocadren was the direct cause of the status asthmatics in which the deceased found herself immediately after ingesting the same for the following reasons (i) no drug taken by the deceased would have elicited the violent response she experienced as the beta blocker she ingested and which was prescribed by the respondent; (ii) there were sufficient material and expert evidence adduced to confirm that a non-specific beta blocker was dangerous in asthmatics; and (iii) the respondent's own evidence suggested that he was aware that a beta blocker (blocadren) ought not have been prescribed in the circumstances. Hence, there was a duty of care on the respondent's part, that duty was breached and that the resultant damage was foreseeable. Causation was thus proved by the appellant. (paras 125, 126, 127 & 128)

Bahasa Malaysia Translation Of Headnotes

Perayu adalah pentadbir harta pusaka si mati anak perempuannya (`si mati'). Responden pada setiap masa adalah seorang doktor amalan umum swasta. Pada 28 Julai 1999, si mati telah mengadu mengalami denyutan jantung yang cepat dan getaran tangan dan, ditemani oleh ibunya (`PW1'), telah diperiksa oleh responden di kliniknya. Responden telah memberikan preskripsi ubat `blocadren' dalam bentuk tablet untuk membantu memperlahankan kadar nadi si mati. Adalah kes perayu bahawa apabila tiba di rumah pada waktu petang pada hari yang sama, si mati telah menelan dos yang disyorkan iaitu satu perempat daripada ubat tersebut tetapi dengan serta-merta selepas itu telah mengalami kesukaran pernafasan. Dalam perjalanan ke Pantai Medical Centre, si mati telah rebah. Apabila tiba di Pantai Medical Centre, Dr Damodaran (`PW5'), seorang pakar bius telah menyedarkan semula si mati. Malangnya, si mati telah mengalami kerosakan otak yang teruk dan kekal dalam koma dari mana dia tidak pulih sehingga kematiannya pada 15 Mac 2000. Perayu telah menyaman responden atas kecuaian dan kerugian dalam memberi preskripsi blocadren, satu penghalang beta tak spesifik kepada si mati yang mempunyai penyakit asma, apabila ubat ini tidak digalakkan dalam keadaannya. Responden mempertikaikan bahawa blocadren mengakibatkan tindak balas kuat yang dialami oleh si mati dan bahawa perkara ini tidak boleh dijangkakan. Hakim Mahkamah Tinggi memutuskan bahawa isu penyebaban gagal dibuktikan dan telah menolak tuntutan perayu. Isu yang timbul adalah sama ada terdapat kegagalan oleh perayu untuk membuktikan penyebaban. Perayu menghujahkan bahawa penyebaban telah dibuktikan tetapi hakim bicara tidak mempunyai manfaat untuk merujuk kepada petikan tertentu daripada keterangan yang telah dikemukakan, kerana petikan tersebut secara tidak sengaja diketepikan daripada keterangan di hadapan mahkamah. `Keterangan yang hilang' adalah dari PW1, dan adalah penting kerana isu yang timbul adalah sama ada apabila mengambil blocadren seperti yang telah dipreskripsi oleh responden kepada si mati, si mati telah cuba menggunakan alat sedut ventolin selepas mengalami kesukaran pernafasan. Hakim bicara dengan tersirat telah menyatakan bahawa jika ini terdapat dalam keterangan (jika si mati telah menggunakan alat sedut ventolin dan jika ia terbukti tidak berkesan, kemungkinan bahawa tapak reseptornya telah disekat oleh kesan blocadren) ia akan membawa hakim bicara kepada kesimpulan bahawa blocadren adalah punca `kerosakan' yang berlaku yang dialami oleh si mati. Beban terletak atas perayu untuk membuktikan hubungkait, atas imbangan kebarangkalian, antara kecederaan si mati dan kecuaian responden, oleh itu persoalan yang timbul adalah sama ada rantaian penyebaban telah dibuktikan pada tahap yang diperlukan bagi pembuktian.

Diputuskan (membenarkan rayuan dengan kos)

Oleh Zainun Ali HMR menyampaikan penghakiman mahkamah:

(1) Atas kekukuhan keterangan yang telah dikemukakan oleh PW1, didapati bahawa si mati telah cuba mengurangkan serangan asma dengan menggunakan alat sedut ventolin, yang dalam kes in telah gagal untuk melegakan kecemasan yang dialaminya. Rujukan boleh diambil bahawa tapak reseptornya telah disekat oleh kesan blocadren, kerana `ubat penyelamat' tidak berkesan. Tiada keterangan menunjukkan dos ativan, ubat relaksan otot yang telah dipreskripsikan oleh PW3 sehari sebelum kejadian tersebut berlaku adalah cukup tinggi untuk mengurangkan pernafasan sehingga tahap jantung si mati berhenti dan menyebabkan kekurangan oksigen dalam otaknya. Keterangan yang telah diberikan oleh PW1 tidak dibantah. Oleh itu, atas imbangan kebarangkalian, ia adalah blocadren yang telah menyebabkan kerosakan yang berlaku pada si mati, di mana penyebaban telah dibuktikan.

(2) Keterangan yang memadai telah menunjukkan bahawa kedua-dua ativan dan ventolin bukanlah petanda kepada reaksi kronik yang telah dialami oleh si mati. Adalah jelas atas beberapa kebarangkalian bahawa tablet blocadren yang telah menyebabkan tindak balas teruk yang dialami si mati. Si mati telah meninggal dunia akibat kekurangan pernafasan akut, kecederaan otak hipoksia dan pernafasan terhenti disebabkan serangan asma bronkus. Walaupun dihujahkan bahawa si mati telah menelan dua tablet ativan sehari sebelum kejadian tersebut, ia tidak mempunyai kesan ke atas pernafasannya dan tidak boleh dikaitkan dengan kecederaannya selepas itu. Tetapi reaksinya kepada blocadren adalah serta merta dan teruk. Si mati tidak akan mengalami sekatan yang begitu teruk sekali mengakibatkan penutupan bronkiol si mati `but for' kesan blocadren.

(3) Jurnal perubatan yang dirujuk oleh peguam menyokong pendapat bahawa penghalang beta tak spesifik tidak sepatutnya diberikan kepada seorang yang mempunyai penyakit asma, melainkan jika ia adalah kardio terpilih dan asma itu adalah dikawal dan dipantau dan/atau di mana manfaat melebihi risiko. Tambahan lagi, ulasan yang diberikan oleh hakim bicara bahawa `jika terdapat keterangan yang si mati telah mencuba menggunakan ventolin selepas menelan tablet blocadren dan ia gagal memberi kesan yang diingini, maka mungkin ia adalah selamat untuk menyatakan bahawa blocadren telah menghalang ubat si mati untuk asma' menjadi amat penting memandangkan bahawa hakim bicara telah dilucutkan daripada mempertimbangkan keterangan ini dalam nota keterangan PW1 yang telah hilang. Jika hakim bicara telah dapat menilai keterangan-keterangan ini, beliau akan membuat kesimpulan yang berbeza berkenaan isu penyebaban.

(4) Setiap penghubung dalam rantaian penyebab telah dibuktikan dengan tahap bukti yang lebih tinggi daripada tahap yang diperlukan. Terdapat alasan yang mencukupi untuk hakim bicara, atas imbangan kebarangkalian, mendapati bahawa penghalang beta blocadren adalah sebab langsung status asma yang melanda si mati selepas dia menelan ubat tersebut atas alasan (i) ubat yang diambil oleh si mati tidak akan merangsang tindak balas teruk yang dialami si mati sepertimana penghalang beta yang diambilnya dan yang telah diberi preskripsi oleh responden; (ii) terdapat material yang memadai dan keterangan daripada pakar yang dikemukakan untuk mengesahkan bahawa penghalang beta tak spesifik adalah berbahaya kepada pesakit asma; dan (iii) keterangan responden sendiri menunjukkan bahawa dia sedar penghalang beta (blocadren) tidak sepatutnya dipreskripsikan dalam keadaan sedemikian. Mahkamah ini berpuas hati bahawa terdapat kewajipan berhati-hati dari pihak responden, bahawa kewajipan telah dilanggar dan kerosakan yang terhasil adalah boleh dijangkakan. Penyebaban oleh itu telah dibuktikan oleh perayu.

Case(s) referred to:

Bolitho v. City and Hackney Health Authority [1997] 4 All ER 771 (refd)

Jaafar Shaari & Siti Jama Hashim v. Tan Lip Eng & Anor [1997] 4 CLJ 509 SC (refd)

Mohd Nazari Ab Majit v. Tan Keo Hock & Anor [1999] 1 CLJ 601 HC (refd)


For the appellant - Americk Sidhu; M/s Isharidah, Ho Chong & Menon

For the respondent - MS Dhillon (KB Karthi with him); M/s PS Ranjan & Co

[Appeal from High Court, Kuala Lumpur; Civil Suit No: S6-22-1036-2002]

Reported by Suhainah Wahiduddin

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