Coroner's Practice in Medical Cases Digital

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The work of the coroner, even within the legal and medical professions, is not often well understood. Though the law on negligence relating to medical cases is well established, little or none has been written on the coroner’s practice in medical cases. Currently, there is little guidance available in Singapore for lawyers, doctors and other professionals who may become involved in the investigation of deaths where issues of medical mismanagement are raised. It is hoped that the publication of this book will fill the gap.

Author(s)/Editor(s)/Contributor(s): Lee Eng Hin, Gilbert Lau, George Paul, Lai Siang Hui, Yeo Khee Quan, Chin Jing Jih, Ong Yong Yau, Lee Kok Onn, District Judge Danielle Yeow, District Judge Tan Boon Heng & District Judge Amy Tung

Year of Publication: 2008

Page Extent: 312 pages

Member's Price: $50.00 (before GST)
Associate Student's Price: 
$40.00 (before GST)
Non-Member's Price: 
$75.00 (before GST)

Member's Price: SGD 50.00
Usual Price: SGD 81.75

Member's Price: SGD 50.00
Usual Price: SGD 81.75

CPD Points : N/A


Besides setting out the history, law and procedure of the Coroner’s Court, the book also contains a selection of actual medical cases, heard in the Coroner’s Court, categorised according to the causes of death.  In most of the cases, the observations of the forensic pathologist as well as the comments of the clinician are included.  In addition, where there was an opinion from an independent expert provided to assist the coroner in that inquiry, the material parts of the opinion are also set out.


This publication is the result of a collaboration between renowned experts of the local medical profession, forensic pathologists from the Forensic Medicine Division, Health Sciences Authority, and judicial officers from the Subordinate Courts of Singapore.




Chapter 1 The Coroner’s Court
A. Introduction
B. Statutory provisions governing the Coroner's Court
C. Jurisdiction of the coroner
Chapter 2 Preparations for Coroner's Inquiry in Medical Cases 
A. Special characteristics of medical cases
B. Mentions and Pre-inquiry Conferences
C. Materials to be reviewed
D. Independent expert reports
Chapter 3  The Coroner’s Inquiry
A. Procedure
B. Role of coroner
C. Role of the assisting officer
D. Role and rights of the next of kin
E. Role and rights of the potential defendant
F. Role and rights of other interested persons
G. Rules of evidence
Annex A    List of Exhibits
Annex B    Caution and Rights under Sections 288 to 290, Criminal Procedure Code
Chapter 4 Findings of Coroner
A. Types and nature of findings
B. Standard of proof
C. Test of negligence in medical cases
D. Implications and impact
E. Review of coroner’s findings
Chapter 5 Case Studies of Selected Medical Cases
A. Cases directly and indirectly related to the use of anti-coagulants
B. Iatrogenic deaths resulting from surgical repairs, perforations and punctures
C. Deaths relating directly or indirectly to septicaemia
D. Deaths resulting from adverse drug reactions
E. Deaths relating directly or indirectly to peritonitis
F. Deaths resulting from other causes 
Chapter 6 Coronial Systems in Other Jurisdictions
A. Common law systems
B. Civil law systems
Chapter 7 Conclusion and Potential Reform
  • Coroner's Practice in Medical Cases Digital
  • 978-981-17-0844-2
  • Digital
This book helps to make us feel less threatened with regards to medical-related deaths in particular. This book grapples with life that ended during the course of medical practice, something that rightly concerns both individuals and the State. It is a review of how the Singapore coronial system deals with medical-related deaths, from a legal and forensic medical perspective.
The contributors to this book include 3 district judges from the Subordinate Courts, 3 pathologists, and 5 medical practitioners. The Singapore State Coroner is a district judge who investigates the causes and circumstances of certain types of deaths as defined in the Criminal Procedure Code.  This includes deaths where issues of medical mismanagement might be raised. In the book preface, it is mentioned that the book is aimed at lawyers, doctors and other professionals who might be involved in the investigation. Thus, in the 7 chapters, the book takes the reader through (1) the Coroner’s court; (2) preparations for the Coroner’s inquiry in medical cases; (3) the Coroner’s inquiry; (4) findings of Coroner; (5) case studies of selected medical cases; (6) coronial systems in other jurisdictions; and (7) conclusion and potential reform.
In Chapter 1 (The Coroner’s court), the 3 sections give an interesting historical account of the development of coroner’s practice in Singapore, state the statutory provisions that govern coroner’s practice, and discuss the coroner’s jurisdiction. In the last section, issues regarding what deaths need to be reported to the coroner, and what constitutes an unnatural death is discussed, among other issues. These are important issues for the medical practitioner to know as there are currently no statutory definitions, and in medical-related deaths, the dividing line between what is a natural or unnatural death can be blur and might not be very obvious. In this chapter, I would have liked to see a larger mention made of the role of the forensic pathologist in the death investigative process.
Chapter 2 (Preparation for Coroner’s Inquiry in Medical cases) the first section explains the special characteristics of medical cases (for example, where the patient is likely to die if there is no medical intervention), the scope of the coroner’s inquiry, and areas that should concern medical experts. The 2nd section explains the processes of the coroner’s mention and pre-inquiry conference. The 3rd section runs through the types of documents that the coroner might need for the inquiry. The 4th section deals briefly with the role of independent expert clinical opinion, sought from the Academy of Medicine of Singapore. It would have been good if there were some tips on what makes an effective medical expert. Going even further, future editions of this book might consider practice directions for expert witnesses in coroner’s inquiries, for example, in terms of disclosure of information, and the use of evidence-based medicine where appropriate.
Chapter 3 (The Coroner’s Inquiry) deals with the coroner’s procedures; the coroner’s statutory duties and powers; the role of the assisting officer (a senior police officer or a State Counsel who presents the evidence and makes recommendation on possible action); the roles and rights of the next-of-kin and potential defendants; and the rules of evidence.
Chapter 4 (Findings of Coroner) explains the verdicts used by the coroner; the standard of proof for a verdict; the test of negligence in medical cases; the implications of a verdict of negligence; and how a coroner’s verdict can be reviewed. I recommend the very extensive section on negligence and its implication (pages 68 to 123) to all doctors who are concerned about medical negligence issues. There is an obligatory discourse on Bolam test, modified by Bolitho (and the chapter also mentions departures from the Bolam test in Australia and Malaysia). But what is more interesting is the local case law (pages 85 to 103), examining cases like Francisco v Dr Thng, Vasuhi v Tan Tock Seng Hospital, Harte v Dr Tan Hun Hoe and Gleneagles Hospital, Pai Lily v Dr Henry Yeo Peng Hock, Supuletchmi v Dr Tay Boon Keng, Gunapathy v Dr James Khoo, JU v Dr See Tho Kai Yin.
Chapter 5 (Case Studies of Selected Medical Cases) is an extensive chapter (pages 125 to 265) presenting 41 diverse medical-related cases, in the following format – medical history, forensic evaluation, coroner’s verdict, and comment. This is an invaluable resource of information, as the only other source of information about local coroner’s practice and verdicts for doctors is through reports in the media from time to time. Coroner’s verdicts are not found in law reports. This book therefore serves as an immensely important outreach to medical practitioners whose practice might possibly be affected by the coroner’s decisions.
Chapter 6 (Coronial Systems in Other Jurisdictions) gives an overview of the systems in England and Wales, Ireland, New Zealand, Australia, Canada, Hong Kong, France, Spain and Switzerland.
Chapter 7 (Conclusions and Potential Reform) skims in 2 pages the potential reform, mainly in the potential enactment of a separate Coroner’s Act, which would remove the Coroner’s rules from the Criminal Procedure Code. This would emphasize the inquisitorial nature (as opposed to an adversarial nature) of the coroner’s proceedings. This would be an enlightened look at reform, for although the coroner’s system is one if antiquity, it should not become antiquated, and if necessary, the system should be modified to meet additional contemporary needs, other than fact finding - like health service quality, safety monitoring, epidemiological understanding of death. Also as Chapter 6 demonstrates, the coronial system is not the only system of judicial investigation of unnatural death. The forces of globalization and information access may prompt the need for even more radical reform by combining the best of different forms of judicial death investigation.
I would recommend this book for medical professionals who wish to obtain a clearer understanding of the coroner’s practice in medical cases in Singapore. For potential expert witnesses in the coroner’s process, this book will assist you to understand your complementary contribution to the coroner’s investigation of medical cases.
Dr Cuthbert Teo
Chairman, Chapter of Pathologists
Disclaimer: The views expressed in this review are my personal views, and do not represent the views of any institution.
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