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Coroner's court: Man, 65, died after spinal surgery, no evidence COVID-19 vaccine implicated
SINGAPORE: A 65-year-old man with multiple chronic conditions died after his airway was blocked following an operation on his spine. He had received the COVID-19 vaccine 10 days before the operation, but there was no evidence the vaccine caused or contributed to his death, the coroner's court heard. The vaccine issue had been raised in court by the deceased man's daughter. In findings made available on Tuesday (Jul 29), State Coroner Adam Nakhoda ruled the death of Mr Lee Yong Chuan Edwin a medical misadventure. According to the findings, Mr Lee died on May 29, 2021 at Mount Elizabeth Hospital. He had several chronic medical conditions, including depression and panic attacks, ischaemic heart disease, hypertension, coronary artery disease and pancreatic cancer. He had undergone a Whipple resection - a procedure to treat tumours and other pancreatic conditions - at Mount Elizabeth Hospital in 2009 for the cancer, and received follow-up radiotherapy and chemotherapy. WHAT HAPPENED On Apr 7, 2021, Mr Lee saw Dr Tan Seang Beng at his clinic, complaining that he had experienced numbness and paraesthesia - a tingling or prickling sensation - in his hands for a number of years. A clinical examination along with a magnetic resonance imaging (MRI) scan of his spine revealed deterioration in his spine. He was diagnosed with a pinched nerve and an injury to his spinal cord from severe compression, along with a prolapsed intervertebral disc. In May 2021, Mr Lee consented to undergo a procedure called an anterior cervical discectomy and fusion (ACDF) of his vertebrae. It was scheduled for May 6, 2021 at Mount Elizabeth Hospital. The consent form highlighted, among other things, that the procedure would involve decompressing the nerves within the spine by removing the disc, removing bone spurs and repairing and reconstructing the spine by fusion. The form also highlighted possible complications such as voice and swallowing problems, wound infection, nerve or spinal cord injury and paralysis, complications related to anaesthesia, blood transfusion reactions, heart attack and death. The consent form stated that the listed risks and complications were not intended to be exhaustive. The anaesthetist explained to Mr Lee that there was a "slightly higher risk" of anaesthesia as an airway assessment revealed that Mr Lee's neck movements were limited, in particular neck extension. Mr Lee agreed to be monitored in hospital after the surgery. The procedure was carried out on May 6, 2021. Dr Tan said it was "uneventful" and was completed. Mr Lee was stable while under general anaesthesia and was able to speak and move his limbs after waking up. He was transferred to the intensive care unit (ICU) for routine monitoring at about 8.10pm, about half an hour after the surgery was completed. However, at about 10.10pm, Mr Lee told the nurses that he could not breathe. They propped him up, increased his oxygenation and encouraged him to breathe deeply. The nurses then inserted an oral airway in an attempt to suction his airway, as they suspected there was a mucous plug, since Mr Lee said he felt something in his throat. Mr Lee spat out the oral airway and repeated that he could not breathe. Other medical personnel were called in to help, but Mr Lee's oxygen saturation dropped and he became unresponsive. A "code blue" was activated and the nurses tried to perform Ambubag ventilation - artificial respiration using a hand-held device. The staff attempted to intubate him to no avail, and his condition improved only after doctors arrived and managed to intubate him. Mr Lee's blood pressure, heart rate and oxygen saturation were later maintained with full ventilation and IV adrenaline infusion, following interventions from doctors, and he was transferred to the ICU. However, MRI scans two days later showed severe brain damage consistent with hypoxia - insufficient oxygen - which was due to the long resuscitation time. There was also bleeding behind his throat. Mr Lee was supported in the ICU until May 28, 2021, when his condition deteriorated. He died a day later. An autopsy certified his cause of death as hypoxic ischaemic encephalopathy, a type of brain complication due to lack of oxygen, following cardiac arrest. This was in turn due to airway obstruction, due to retropharyngeal haemorrhage. This is a type of rare but life-threatening condition where blood accumulates behind the pharynx in the throat. This bleeding occurred after the spinal procedure. Senior Consultant Forensic Pathologist Teo Eng Swee said Mr Lee's death was related to a post-operative complication. Airway obstruction due to acute retropharyngeal haemorrhage is a known complication after the spinal procedure in this case, said Dr Teo. EVIDENCE FROM MR LEE'S FAMILY Mr Lee's daughter said her grandfather had been admitted to hospital due to impingement of nerves that required surgery and could cause paralysis. When Mr Lee realised he might have the same condition as his father, he sought medical attention and consulted Dr Tan. Mr Lee's daughter said Dr Tan had recommended the spinal procedure, which was the same one Mr Lee's father had undergone in February 2021. Mr Lee's daughter advised him to wait before having the surgery, but Mr Lee decided to go ahead after a discussion with Dr Tan. Mr Lee's daughter said "the only risk (Mr Lee) talked about then was paralysis, a common one of spinal surgery". She added that her father had received a COVID-19 vaccination 10 days before the surgery. She raised several concerns during the inquiry. These included whether the surgical team fully considered her father's complex medical history and whether he was sufficiently advised about the risks, given his "complex medical and health status" including the COVID-19 vaccine he had received less than two weeks before the operation. At the time of the operation, there was an imminent tightening of safe management measures for COVID-19, and hospitals were deferring elective surgeries, said Mr Lee's daughter. She asked why her father's surgery proceeded during the ongoing pandemic at the time. She also asked if the respiratory arrest was preventable. THE DOCTOR'S RESPONSE On the timing of the procedure, Dr Tan said Mr Lee was concerned that his condition might deteriorate as his father's had and did not want to delay it. Dr Tan said he had "thoroughly explained" the risks and benefits of the spinal surgery, and had taken the general precautions during the operation. He said the medical staff were not sure what caused Mr Lee's respiratory arrest at the time, and that the priority was to intubate him, but the first attempts were unsuccessful. About 10 to 15 minutes passed between his respiratory arrest and his intubation, and it was this prolonged downtime that resulted in Mr Lee's brain injury, said Dr Tan. He said the existence of a blood clot at the surgical site was discovered only after the MRI done two days after the surgery. ON THE COVID-19 JAB Dr Tan testified that he was aware that Mr Lee had the COVID-19 jab 10 days prior to the surgery. He said Mr Lee had fully recovered from the vaccination and had "no abnormal symptoms" which could be attributed to the vaccine. In addition, he had been determined to be fit for the surgery by the cardiologist and anaesthetist. He said Mr Lee's collapse was "very sudden", his blood pressure had spiked, and his oxygen saturation came down "all within a couple of minutes". Dr Teo, who had conducted the autopsy, said "there was no reason to delay surgery after a patient receives COVID-19 vaccination". "In fact, an unvaccinated patient entering a hospital environment would be at a higher risk of contracting a COVID-19 infection," he said. He added that patients who developed COVID-19 infections after surgery were at risk of slower recovery or an adverse outcome, especially if they had other chronic medical conditions. He said there was in fact an increased risk of post-surgical mortality related to the COVID-19 infection. Dr Teo said there was no autopsy evidence that the vaccine had caused or contributed to Mr Lee's death. He also noted that there was no indication in any of the medical reports that the medical staff was concerned that the vaccine was related to the cause of death. ON WHY THE ELECTIVE SURGERY WAS DONE The director of operations for Mount Elizabeth Hospital, Dr Ng Shang Qun Shawn, noted that there were two policies issued by the Ministry of Health at the time Mr Lee's surgery was performed. One circular stated that healthcare resources were tight and should be prioritised according to medical needs and urgency. Another stated that public healthcare institutions had been informed to start triaging and deferring non-urgent surgery and admission as well as non-urgent specialist outpatient clinic appointments from May 3, 2021. However, Dr Ng explained that private hospitals like Mount Elizabeth Hospital were not mandated to defer non-urgent surgeries. The circular recommended that private hospitals defer non-urgent surgeries only "where possible so as to avail capacity, resources and manpower should they be needed to support the private sector". Therefore, based on the circulars, doctors at private hospitals would "make a call" and proceed on some elective surgeries based on available capacity and resources. In Mr Lee's case, the elective surgery had been allowed to proceed as the doctors involved made the decision that it could. Mr Tan said Mr Lee had been counselled on the risks and benefits of the surgery, the alternative surgical options and the option for conservative treatment. The coroner found the consent form for the procedure was "a very comprehensive" one, and there was no evidence to suggest that the risks were not highlighted to Mr Lee. Mr Lee had accepted them of his own accord and opted for the procedure, said the coroner. He added that there was no evidence to suggest that having a COVID-19 jab made him unsuitable for the procedure.
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