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Doctor suspended for 18 months over alleged care lapses during COVID-19 patient transport

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A Singapore doctor, Dr Kong Sim Guan has received an 18-month suspension for alleged care lapses during the transportation of a COVID-19 patient, resulting in the patient’s death.

Failures include neglecting to monitor and document vital signs and inadequate equipment preparation.

The suspension, issued by the Singapore Medical Council, restricts Dr Kong from medical evacuation or transport services. This action followed an incident in which the patient was critically transported from Batam to Singapore.



SINGAPORE: An incident involving a doctor, identified as Dr Kong Sim Guan, has resulted in an 18-month suspension from providing medical services for evacuations or medical transport.

This action comes following alleged failures in his care for a COVID-19 patient who required transportation from Batam to Singapore for treatment.

Dr Kong, also known as Sim Heng Guan, faced several allegations, including the failure to document the vital signs of a 67-year-old patient at Batam Ferry Terminal on 7 June 2021.

This crucial lapse continued as he did not assess the patient’s condition upon arrival at Tanah Merah Ferry Terminal.

Furthermore, he failed to check the patient’s well-being before the ambulance departed for Tan Tock Seng Hospital (TTSH).

Singapore’s health ministry deemed the patient to be in critical condition at that point and should have been handed over to the Singapore Civil Defence Force.

Regrettably, the patient passed away shortly after reaching Tan Tock Seng Hospital (TTSH) and the National Centre for Infectious Diseases (NCID) on the same day.

These lapses in care were outlined in a decision released on (Monday) 11 September by an interim orders committee appointed by the Singapore Medical Council (SMC).

At the time of the incident, Dr Kong served as the clinical director of a private ambulance operator, having previously worked as a psychiatrist and practising doctor at Clinique Suisse, an aesthetic clinic in Paragon Medical Centre.

Dr Kong explained that he returned to medical service “out of friendship.”

SMC investigates alleged lapses and imposes restrictions

SMC received information about Dr Kong’s alleged lapses from the Ministry of Health on 29 June 2021.

The ministry found that he had violated several guidelines under the SMC’s Ethical Code and Ethical Guidelines.

Subsequently, the case was referred to a Complaints Committee, which further referred it to an interim orders committee due to concerns about Dr Kong’s conduct as the sole registered doctor responsible for evacuating the patient.

The interim orders committee clarified that it does not determine whether Dr. Kong’s alleged behavior is accurate.

The Complaints Committee is yet to decide whether the complaint should proceed to a formal inquiry by a disciplinary tribunal.

In its decision, the interim orders committee imposed conditions and restrictions on Dr Kong’s medical registration for 18 months, effective from July 28 this year, or until the conclusion of disciplinary proceedings against him.

These restrictions prohibit him from offering or agreeing to act as a medical practitioner or providing medical services for any medical evacuation or medical transport assignments, including ambulance services, except for immediate life-saving procedures like cardiopulmonary resuscitation in cardiac arrest situations when he is the nearest available medical practitioner.

He must also inform SMC of his practice locations and notify any employing organization or person about his registration conditions.

Equipment shortfall and monitoring neglect during patient transfer

During the transfer of the patient from Batam to Singapore on 7 June 2021, Dr Kong admitted to bringing only basic medical equipment and putting on full personal protective gear.

However, he omitted crucial monitoring equipment like a pulse oximeter or blood pressure monitor, despite knowing the patient’s need for constant monitoring within a portable mobile isolation unit, stating that it “slipped his mind,” as reported by CNA.

Dr Kong stated that he relied on “Mr. F1,” a person from the private ambulance operator, to provide the necessary equipment.

He believed that Mr. F1 should be responsible for ensuring the equipment’s functionality.

“Dr Kong was of the view that Mr F1 had to equip him with the necessary equipment and ensure that the equipment issued was in good order, and he was not a trained medical technician who would know such things,” the interim orders committee stated.

During the journey, Mr F1 informed Dr Kong that the patient had cancer and heart disease.

The patient’s delay in reaching the ferry terminal was due to breathlessness, necessitating initial stabilization at Batam Hospital.

Upon assuming responsibility for the patient, Dr Kong did not systematically monitor or document vital aspects of the patient’s condition, such as consciousness level, pulse rate, and oxygen saturation.

This lapse persisted during the sea journey from Batam to Singapore.

Dr Kong, while tasked with monitoring the patient’s vital signs, refrained from doing so due to the unavailability of essential equipment for tracking the patient’s pulse, blood pressure, or oxygen levels.

During the ferry ride, Dr Kong noticed signs of distress in the patient, including a visible “look of despair,” gestures toward his chest, head shaking as if signaling surrender, and attempts at communication.

Despite these clear indicators of distress, Dr Kong allegedly did not thoroughly assess the patient’s condition.

Additionally, he failed to document the patient’s vital signs upon arrival at Tanah Merah Ferry Terminal.

When Dr Kong encountered the ambulance crew responsible for transporting the patient from the terminal to TTSH and NCID, he did not identify himself as the attending physician, nor did he reveal his medical qualifications or his role as the clinical director of a private ambulance service.

This oversight prevented the onboard emergency medical technician (EMT), who sat with the patient in the ambulance cabin, from escalating the deteriorating situation to Dr Kong.

According to Dr Kong, the EMT extended an invitation for him to sit at the front of the ambulance.

Although aware that he was the sole qualified individual to lead the crew during the ambulance journey, Dr Kong did not actively monitor the patient’s condition nor provide necessary care.

As the patient’s condition worsened during transit, Dr Kong, positioned at the front of the ambulance, was unable to intervene.

Upon arriving at the hospital at 507 pm, the patient was devoid of a pulse, not breathing, and unresponsive.

Cardiopulmonary resuscitation efforts were terminated after 30 minutes due to the absence of any medical prospects, and the patient passed away at 5.48 pm.

SMC’s request for restrictions and Dr Kong’s defense

The Singapore Medical Council (SMC) requested the imposition of an 18-month period of conditions and restrictions on Dr Kong’s medical registration due to the perceived “substantial risk of harm” to both his patients and the general public.

In response, Dr Kong presented several arguments.

He asserted that there was “no indication” of EMT detecting any urgency concerning the patient during the ambulance journey.

Dr Kong claimed that he frequently glanced back at the ambulance cabin but did not witness the EMT continuously monitoring the patient’s breathing.

Dr Kong also mentioned that he had made a few observations regarding the patient’s movements, breathing, and pulse, but the turbulent sea conditions made documentation challenging, ultimately leading him to abandon the effort.

Additionally, he explained that upon returning home, he and his wife disposed of everything from Batam and the ferry due to concerns about contamination, including the notes he had taken during the journey.

Regarding his personal reflections, Dr Kong acknowledged “mistakes made and shortcomings.”

He admitted to lacking prior experience in such a high-responsibility situation and expressed a willingness to perform better if given another opportunity.

The interim orders committee stated that Dr Kong had stepped out of retirement to assist Mr F1 and his ambulance service as a gesture of friendship.

However, this episode had taken a toll on Dr Kong’s physical well-being.

As a heart patient, he was reluctant to jeopardize his health and life for such services, leading him to contemplate downgrading and restricting his medical license with the intention of returning to full retirement permanently.

The committee based its decision on the gravity of the undisputed facts, recognizing the paramount importance of protecting the public from doctors who undertake critical medical assignments but fail to fulfill their duty of providing proper care to patients, potentially jeopardizing their health and lives.

Despite the apparently isolated nature of the complaint against Dr Kong, the committee noted that the SMC did not advocate for the suspension of Dr Kong’s medical practice.

The conditions proposed by the SMC were deemed reasonable, as Dr Kong’s lapses posed a potential risk to all future patients undergoing medical evacuations.

The committee stressed the significance of upholding public confidence in the integrity of medical evacuations, particularly in light of the patient’s unfortunate demise in this specific case.

The committee members included Professor Alan Ng, Adjunct Associate Professor Tan Tze Lee, and Professor John Lim Chien Wei, with lawyer Kenny Chooi serving as a legal assessor.

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From this report, there seems to be a case to charge Dr Kong for criminal neglect. His is not merely a case of lapses. At the minimum, it is professional neglect. I find it difficult to believe a doctor would destroy all notes taken during the journey along with clothing for fear of contamination. Thus, his medical licence to practise should be suspended for a significant length of time; not just an18-month suspension from providing medical services for evacuations or medical transport. The family of the late patient should also sue Dr Kong for failure to accord due care and… Read more »