Dr Ang Yong Guan found guilty of misconduct in deviant prescriptions from guidelines

On Monday, the Court of Three Judges overturned the tribunal’s decision and found Dr Ang Yong Guan guilty of professional misconduct.

Dr Ang had appealed against his conviction on the alternate charges, while the SMC appealed against his acquittal and argued for a three-year suspension.

In its written judgment, the court, comprising Chief Justice Sundaresh Menon, Justice Belinda Ang, and Justice Tay Yong Kwang, ruled that Dr Ang’s deviations from the relevant guidelines in various prescriptions amounted to misconduct because he was unable to justify those decisions.

The patient had concurrent prescriptions of multiple benzodiazepines, concurrent prescriptions of benzodiazepines with opioid painkillers, and excessive dosages of mirtazapine and a controlled-release form of zolpidem.

Benzodiazepines are depressants, while zolpidem is used to treat insomnia.

Under the Medical Registration Act, doctors found guilty of professional misconduct can face penalties including being struck off the register, suspension, or fines, among other sanctions.

Dr Ang, who runs his own practice, Ang Yong Guan Psychiatry, began treating Mr Quek Kiat Siong on 8 February 2010, for conditions including insomnia, depression, post-traumatic stress disorder, obsessional ruminations, and anxiety.

Patient's 2012 demise: Multi-organ failure and mixed drug intoxication

His final prescription was issued on 31 July 2012, four days before Mr Quek died on 4 August that year.

The cause of death was certified as “multi-organ failure with pulmonary haemorrhage, due to mixed drug intoxication”, and his post-mortem blood concentrations of various drugs including Olanzapine, Duloxetine, Mirtazapine, and Bromazepam, all of which had been prescribed by Dr Ang, were found to be elevated beyond the therapeutic concentrations found in living subjects.

After Mr Quek’s death, his sister sued his insurers, who had denied liability under two personal accident policies.

She argued that he died as a result of accidental drug interactions, but the insurers denied that the death was accidental.

In 2017, the Court of Appeal ruled in favour of Ms Quek, ordering the insurers to pay out the sums under the policies, finding that Mr Quek had most likely taken his medication as prescribed.

Ms Quek then filed a complaint with the Singapore Medical Council (SMC) against Dr Ang in April 2017.

The first charge brought against Dr Ang pertained to prescriptions issued between 8 February 2010, and 31 December 2011, while the second charge concerned prescriptions issued between 1 January 2012, and July 31, 2012.

The third charge concerned the final prescription issued on 31 July 2012.

The final prescription included a daily dosage of 60mg of mirtazapine, which exceeded the permitted maximum daily dosage of 45mg, and a daily dosage of 25mg of controlled-release zolpidem, exceeding the permitted maximum daily dosage of 12.5mg.

It was undisputed that Dr Ang had made these prescriptions, which were inconsistent with both the guidelines issued by the Ministry of Health (MOH) and the package inserts for the medication.

The SMC’s Disciplinary Tribunal concluded that Dr Ang’s conduct did not amount to an intentional and deliberate departure from the standards of treatment, noting that he had shown “care and concern” for the patient and had “attempted to meet the standard” expected of him.

In its judgment, the court stated that while doctors may depart from codified standards adopted by the medical profession, they must demonstrate that the departure is objectively justified in terms of risks and benefits.

The court added that when significant risk is involved from the patient’s perspective, the doctor must show that the patient was informed of the risks, even if these were objectively outweighed by the benefits.

The court found that for the first two charges, Dr Ang had shown that some of his decisions to depart from the guidelines were objectively justifiable, while others were not.

The judgement noted Dr Ang justified his discontinuation of antidepressants before four weeks had passed, thus these charges were not made out in respect of these prescriptions.

However, Dr Ang failed to justify his prescriptions related to the concurrent use of multiple benzodiazepines and benzodiazepines with opioid analgesics. Therefore, he was found guilty of professional misconduct for these prescriptions.

On the second pair of charges, the court found Dr Ang's prescription of a six-month supply of benzodiazepines to the patient was deemed appropriate given the patient's circumstances. Therefore, these charges were not made out.

Similarly, the charges related to the prescription of benzodiazepines beyond the limits of short-term and intermittent use were not sustained.

Regarding the third charge, the court determined that Dr Ang was unable to justify his prescription of mirtazapine and zolpidem in excess of the stated maximum dosages.

The court will hear arguments at a later date on the appropriate sanctions to be imposed.

Before joining PSP, Dr Ang also served with the Singapore Armed Forces for 23 years from 1980 to 2003 as the Chief Psychiatrist.

Dr Ang isn’t a fresh face in the world of politics, having contested before in the 2011 and 2015 GEs with the Singapore Democratic Party (SDP) and then the Singapore First (SingFirst) party respectively.