The failure of medical practitioners to perform timely surgery for diagnosed ectopic pregnancy constituted negligence, leading to preventable complications and death.

[1] This is a medical negligence claim arising from the death of the late Suraya binti Rahmat ('the deceased') at Hospital Sultan Ismail Johor Bahru on 5 May 2009. She was 31 years old at the time of her death. The train of events that led to this tragic episode was set in motion when she was admitted to Hospital Sultanah Aminah Johor Bahru ("HSA") on 13 February 2009. She had on that day been referred to the hospital by a private Obstetrics and Gynaecology ("O & G") specialist Dr Chu Ah Onn (PW1) after she complained of bleeding for the previous six days and spotting on pad. Her urine pregnancy test had shown positive result, which means she was pregnant. After taking her medical history the HSA clerking doctor's impression was to rule out ectopic pregnancy with differential diagnosis of early pregnancy. Ectopic pregnancy is pregnancy outside the uterus and differential diagnosis is diagnosis that one could consider after having formed a provisional diagnosis. According to Professor Kulenthran Arumugam (PW2) who is the Senior Consultant in O & G at the Universiti Malaya Medical Centre, ectopic pregnancy is a life threatening condition to the mother as it has the potential to bleed and bleed severely. He said every doctor should know it is a potential killer and that when there is sufficient ground and evidence of ectopic pregnancy especially if the patient is symptomatic, ie, pain and bleeding, the benefit of doubt must be given to the patient and the doctor must intervene.

[2] After her admission, the deceased was referred to the O & G department of HSA and was seen and examined by the first defendant Dr Norlelawati binti Ab Latip (DW3). Her last menstrual period was recorded as in early January and this was confirmed by DW3 in cross examination. According to her it was the deceased herself who gave the information. A transvaginal scan (ultrasound) showed right hypoechoic mass, and an empty uterus. The impression again was to rule out ectopic pregnancy. At 4.15pm on the same day a repeat scan was done and it confirmed an empty uterus, an extra uterine adnexal mass measuring 2.1 x 1.9cm and a possible gestational sac within it measuring 0.9 x 0.8cm. Both ovaries were seen to be normal. The physical findings were tenderness over the right iliac region with vaginal bleeding and lower abdominal pain. The deceased was counselled on the clinical and scan findings and her decision was not to have diagnostic laparoscopy " for the current moment."Diagnostic laparoscopy is a procedure whereby a telescope is passed through the abdomen, gas insufflated and a clear view of the abdominal contents obtained to ascertain the diagnosis.A decision was then made by HSA to manage her pregnancy conservatively or sometimes referred to as expectant management. It means the doctors at HSA did not operate on the deceased and instead took a wait and see policy and watch how the ectopic pregnancy evolved. What they did was to monitor the deceased's serial pregnancy hormone or beta hCG ('bhCG') every 48 hours. BetahCG is like a hormone that is secreted by the growing foetus and that is why when a female wants to diagnose pregnancy she goes to the pharmacy to test her urine and it becomes positive (evidence of PW2). The deceased's bhCG was done at Gribbles, a private laboratory as HSA did not have such facility. The initial test showed that her serum bhCG was 296 1U/L.

[3] On 14 February 2009 when the deceased was reviewed at 8am and 8.45am she was noted to have the same abdominal pain with associated tenderness and vaginal bleeding. Whilst managing her conservatively the plan was also to carry out emergency laparotomy if symptoms of ectopic rupture occurred and the vital signs deteriorated. In other words an operation to remove the ectopic pregnancy would be done immediately if there were symptoms