The Medical Council of Hong Kong

DISCIPLINARY INQUIRY
MEDICAL REGISTRATION ORDINANCE, CAP. 161

Defendant: Dr CHAN Raymond Tsz Tong (~*-T~U ~) (Reg. No.: M09073)

Dates of hearing: 5 November 2024 (Tuesday) (Day 1); 7 November 2024 (Thursday)
(Day 2); 4 February 2025 (Tuesday) (Day 3); and 23 February 2025
(Sunday) (Day 4)

Present at the hearing

Council Members/Assessors: Prof. TANG Wai-king, Grace, SBS, JP

(Chairperson of the Inquiry Panel)
Dr LING Siu-chi, Tony
Dr KWOK Siu-yin, Janette
Ms FUNG Dun-mi, Amy, MH, JP
Ms MA Man-chi

Legal Adviser; Mr Edward. SIDJM

Defence Counsel representing the Defendant: Mr Ashok K. Sakhrani as instructed by

Messrs. Kennedys

Legal Officer representing the Secretary: Ms Carol LEE as instructed by

Department of Justice

1. The charges against the Defendant, Dr CHAN Raymond Tsz Tong, are:

"That he, being a registered medical practitioner, disregarded his professional

responsibility to his patient ("the Patient ''), deceased,
in that:

(a) from about April to May 2012, he failed to arrange any imaging
investigation before starting chemotherapy on the Patient;

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 (b) he inappropriately or vvithout proper justification stated in the medical
records ofthe Patient on 17 July 2012: "Untreated 2-4112, Treated 18112 ",
when in fact the Patient 's condition was extremely poor; and

(c) from 26 June 2012 to 19 July 2012, he inappropriately or without proper

justification advised the Patient to undergo further (or second line)
chemotherapy.

In relation to the facts alleged, either singularly or cumulatively, he has been

guilty ofmisconduct in a professional respect. "

Facts of the case

2. The name of the Defendant has been included in the General Register from
12 July 1993 to the present. His name has been included in the Specialist
Register under the Specialty of Clinical Oncology since 7 July 2004.

3. Briefly stated, the Patient undenvent a body check in January 2010 and
discovered an ovarian mass. The Patient later accepted the medical advice of
one Dr SUM and underwent on 18 April 2012 laparotomy and left salpingo­
oophorectomy (the "1st Surgery") at the Hong Kong Baptist Hospital ("HKBH").

4. Prior to the l5 1 Surgery, Dr SUM had arranged for a pelvic ultrasound

examination which showed a 9+cm left ovarian cyst with solid areas but uterus
and right ovary were found to be normal.

5. Histopathology after the 1st Surgery then showed mucinous carcinosarcoma of

the left ovary.

6. The Patient was referred by Dr SUM to see one Dr CHAN, who later saw her at
her bedside at HKBH on 19 April 2012. According to the medical records
obtained from HKBH, Dr CHAN explained the histopathology findings to the
Patient and advised her of the need for further surgery and chemotherapy.
Dr CHAN also ordered chest x-ray ("CXR") for the Patient. The CXR done on
20 April 2012 however showed no obvious lung lesions.

7. With the consent from the Patient, "laparotomy, THRSO, omentectomy, pelvic
and para-arotic lymph node dissecrion, small bowel resection, end to end

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 reanastomoses, debulking operation" (the "2nd Surgery") were performed at
HKBH by Dr CHAN and another surgeon on 21 April 2012.

8. According to the Operation Record kept by HKBH for the 2nd Surgery, "8 x 4 cm
tumour deposit at the left peritoneum" was found. There were "[m}ultiple tumour
nodules in the remaining omentum". "Enlarged pelvic & small bowel
mesenteric & para-aortic lymph nodes (up to 3 cm in diameter)" and "4 tumour
masses along the small bowel, at the ileum and jejunum," were found. In
addition, there were "2 enlarged para-aortic lymph node at the supra-renal
levels near the subdiaphragm area, 2 cm and 3 cm in diameter".

9. Specimen taken from "1. uterus +right ovary+ right tube +pelvic peritoneum
2. Left pelvic lymph nodes 3. Right pelvic lymph nodes 4. Peritoneal biopsy
5. Colic mesentery 6. Small bowel mesenteric lymph node 7. Omentum 8. Para­
aortic lymph node [and] 9. Small bowel" were sent for histopathology reporting.

10. In the Histopathology Report dated 25 April 2012, the following findings were
noted:­

"1 . Uterus + right ovary + right tube + pelvic peritoneum

The pelvic peritoneum shows carcinosarcoma, consistent with
metastasis.
A uterine leiomyoma.
The uterine cervix shows focal cervical intraepithelial neoplasia grade 11
· (CIN II).
The right fallopian tube and right ovary are negative for malignancy.

2. Left pelvic lymph nodes

No evidence ofmalignancy. (0 out of 10 lymph nodes)

3. Right pelvic lymph nodes

No evidence ofmalignancy. (0 out of17 lymph nodes)

4. Peritoneal biopsy
No evidence ofmalignancy.

5. Colic mesentery
No evidence ofmalignancy.

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 6. Small bowel mesenteric lymph nodes
5 out 7 oflymph nodes sho-w metastatic carcinosarcoma.

7. Omentum
No malignancy seen.

8. Para-aortic lymph nodes

No evidence ofmalignancy. (0 out of6 lymph nodes)

9. Small bowel
The small bowel segments show involvement by carcinosarcoma in
multiple nodules, compatible with metastases.
Extensive lymphovascular permeation is seen.
Resection margins are elem'."

11. Upon the referral of Dr CHAN, the Defendant first saw the Patient on 28 April
2012 at her bedside at HK.EH. According to his statement to the Preliminary
Investigation Committee ("PIC") of the Council dated 29 October 2019, the
Defendant "knew from Dr ... Chan about the Patient's condition through a phone
call on 271" April 2012 ... and Dr ... Chan ... informed [him} of the presence of
ovarian carcinosarcoma and that she was surgically staged,- and she has stage
IllC disease and it carried a poor prognosis,· and that she would need
postoperative adjuvant therapy. [Dr Chan} also told [him] that he had already
informed the Patient and her family the details of the operative findings and
histopathology report and that she needed adjuvant therapy... Based on the
documents reviewed by [him], including the operative report and pathology
reports, [he} noted that she was already adequately staged surgically for her
intra-abdominal disease, along with a CXR that showed absence of distant
visceral involvement and [he} had at no stage mentioned the necessity of a
PET/CT ... "

12. There is no dispute that in accordance with the Defendant's advice, first cycle of
chemotherapy using Taxol and Carbolplatin once every 3 weeks was given to the
Patient on 7 May 2012. This was followed by a second cycle of chemotherapy
using the same drugs on 29 May 2012.

13. Due to "worsening chronic back pain with low limb weakness", urgent MRI was
arranged for the Patient on 12 June 2012 which showed extensive para-spinal
metastases from T12 to L2. Some of these tumour tissues extended through the

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 intervertebral foramina into the intraspinal extrathecal space compressing on the
spinal cord and nerve roots from Tl2/Ll to Ll/L2. PET-CT on 13 June 2012
further showed tumour extension to left renal hilum, causing left hydronephrosis.
There were also metastatic lymphadenopathy, deposits in the pelvic cavity, right
buttock and left vulva and multiple bony sites.

14. Palliative radiotherapy to the spinal metastases was started on 13 June 2012.
However, after 4 fractions of radiotherapy treatment, there was no apparent
response noted. On 20 June 2012, spinal decompression was done by a
neurosurgeon. Thereafter, the Patient was further treated with 14 fractions of
conformal radiotherapy.

15. There is conflicting evidence as to whether the Defendant had advised the Patient
to undergo further (or second line) chemotherapy when the first two cycles of
chemotherapy failed·to yield the desired therapeutic results.

16. There is however no dispute that the Patient was referred by the Defendant to
consult the Consultant of the Clinical Oncology Department of Queen Elizabeth
Hospital ("QEH"). There is conflicting evidence as to the purpose of the
referral. Be that as it may, the material parts of the Defendant's referral letter
dated 11 July 2012 read as follows:­

"Grateful ifyou can kindly review Ms. - a 40 yo female with a L ovarian

carcinosarcoma diagnosed on 2014112. She had TAHBSO/ Omentectomy/
Small bowel resection and multiple lymph nodes were noted along with
palpable paraaortic lymph nodes. Postop course was complicated by
severe wound infection and dehiscence that required second operation for
stitching and prolonged antibiotics.

Ultimately started on adjuvant chemotherapy with Q3 W Taxol" and

Carboplatin in late 512012 and after 2nd cycle, Ms. - developed bilateral
leg weakness and lower back pain. MRI showed cord compression at Tl 2,
LI, L2 levels. She was seen by Dr. Fung ... before and after the 4 fractions
of radiotherapy and ultimately had laminectomy on 2016112. Again no
improvement was noted, P ETCT showed multiple paraaortic lymph nodes,
pelvic lymph nodes, L vulva metastasis, pelvic bony metastases. Palliative
radiotherapy to residual paraaortic lymph nodes and all visible metastases
on PETCT was delivered: 45 Gy in 15 fractions. She is due to finish her
radiotherapy on 1617112 and I intend to try her on Jfx (infosfamide) and

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 CDDP (cisplatin) but I'll be grateful for your opinion. Given her
paralysis, she'd also require long-term inpatient care and it is not viable to
remain in private during the entire course. I'll be grateful if you can
kindly advise me on fiirther management"

17. Meanwhile, the Patient's condition continued to deteriorate. The Patient

received left percutaneous nephrostomy on 14 July 2012 for the obstructive
uropathy. CT scan on 17 July 2012 showed a new metastatic lesion over her
liver of about 2 cm in size and also a large para-aortic mass of about 4 cm in size
in the left lower hemithorax.

18. On 18 July 2012, the Patient visited QEH and was seen by one Dr WONG,
Resident Specialist of the Department of Clinical Oncology. In his reply letter
to the Defendant, Dr WONG specifically mentioned that:­

"A1s. was seen on 18 Jul 2012.

In view ofpoor [general condition], fi1rther chemo[therapy] is unlikely to

be helpful and we vvould like to suggest palliative care."

19. In order to relieve the Patient's abdominal ascites, abdominal paracentesis was
performed on 19 July 2012. However, her condition deteriorated rapidly and
eventually the Patient passed away on 21July2012.

20. The Patient's brother (the "Complainant") subsequently lodged this complaint
with the Secretary of the Council.

Burden and Standard of Proof

21. We bear in mind that the burden of proof is always on the Legal Officer and the
Defendant does not have to prove his innocence. We also bear in mind that the
standard of proof for disciplinary proceedings is the preponderance of
probability. However, the more serious the act or omission alleged, the more
inherently improbable must it be regarded. Therefore, the more inherently
improbable it is regarded, the more compelling the evidence is required to prove
it on the balance of probabilities.

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22. There is no doubt that the allegations against the Defendant here are serious ones.
Indeed, it is always a serious matter to accuse a registered medical practitioner
of misconduct in a professional respect. We must therefore take into account all
the evidence and to consider and determine each of the disciplinary charges
against him separately and carefully.

Findings of the Inquiry Panel

23. It is not disputed that the Defendant did not arrange for any imaging investigation
before starting chemotherapy on the Patient.

24. Dr YING, the Secretary's expert witness, and Dr FOO, the defence expert
witness, agreed and we accept that there was at all material times and still is no
guideline or consensus statement on the need for imaging investigations after
surgical removal of tumour and before chemotherapy.

25. Our attention was drawn by the Legal Officer to the recommendation in the
National Comprehensive Cancer Network Guidelines Version 2.2011 on
Epithelial Ovarian Cancer/Fallopian Tube Cancer/Primary Peritoneal Cancer
("2011 NCCN Guidelines") that one of the workups in the light of clinical
presentation of carcinosarcoma (which should be treated as per epithelial ovarian
cancer) from "Diagnosis by previous surgery or tissue biopsy" was "Ultrasound
and/or abdominal/pelvic CT'. From this, the Legal Officer sought to convince
us that the Defendant's failure to arrange any imaging investigation before
starting chemotherapy on the Patient was in breach of the 2011 NCCN
Guidelines.

26. Whilst "Ultrasound and/or abdominal/pelvic CT' were listed under the heading
of"Work Up" along with other recommended workups at page OV-1 of the 2011
NCCN Guidelines, it is a quantum leap in our view for the Legal Officer to
submit that the Defendant had by his failure to arrange any imaging investigation
before starting chemotherapy on the Patient fallen below the standard expected
of registered medical practitioners in Hong Kong. We agree with Dr FOO that
the recommended workups were not meant to be mandatory.

27. It is important to read the 2011 NCCN Guidelines as a whole. According to

page OV-2 of the 2011 NCCN Guidelines, recommendation for "Primary
Treatment" of Stage III ovarian carcinosarcoma with "[s]uspect unresectable

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 residual disease" was said to be "[c} hemotherapy for a total of6-8 cycles"; and
"[c]onsider completion surgery after 3-6 cycles followed by postoperative
chemotherapy". Although "patient evaluation by a gynecologic oncologisf'
was said to be a "[s}tandard recommendation", there was no recommendation
on page OV-2 of the 2011 NCCN Guidelines for imaging before starting
chemotherapy.

28. We also agree with Dr FOO that when the Defendant first saw the Patient on
28 April 2012, he was presented with a diagnosis of Stage III ovarian
carcinosarcoma with "[i}ncomplete previous surgery and/or staging". In this
connection, we noted from reading page MS-15 of the 2011 NCCN Guidelines
that:­

"Carcinosarcoma (Malignant 1'vfixed lvfullerian Tumors)

MM1'v1T are rare tumors with a poor prognosis. lvfany pathologists now
consider MJ\1MT to be a variant ofpoor risk, poorly differentiated epithelial
ovarian cancer. The staging system for ovarian and primary peritoneal
cancer is also usedfor A1J\1J\1.T... After complete surgical staging, patients
with stage 11-IV carcinosarcoma (1"\1.1\1.A1.T) at the time of surgery should
have postoperative chemotherapy... The type ofchemotherapy is variable,
because there are no data to specifically define the optimal
chemotherapeutic regimen; ifosfamide-based regimens have been used
Patients with stage II-IV Afj\1.1\1.T or recurrence are treated using
recommendations for epithelial ovarian cancer (see OV-3) ... "

29. There was agam no recommendation on page OV-3 of the 2011 NCCN
Guidelines for imaging before starting chemotherapy.

30. We do not accept the Secretary's primary case that the Defendant had failed to
follow relevant guidelines. As a fallback argument, the Legal Officer
submitted that "by failing to give proper and/or siifjicient regard to the Patient 's
then characteristics, [the Defendant} had wrongly decided not to undergo any
imaging investigation before commencing chemotherapy and such decision
clearly fell outside the reasonable scope of disagreement and different
approaches as suggested' by Counsel for the Defendant to Dr YING in the
course of cross-examination.

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31. In this connection, Dr YING opined that "it would be prudent for [the Defendant}
to consider arranging imaging investigation before starting chemotherapy"
because "[w]ithout the proper imaging, an appropriate plan of disease cannot
be made and assessment ofresponse cannot be accurate".

32. Dr FOO opined on the other hand that detailed surgical findings in the 2nd
Surgery would make redundant the need for a baseline imaging before starting
chemotherapy because "[p}rogress imagingfindings can always be compared to
surgical findings".

33 . Dr YING further opined that ''proper staging ofmalignancy is important before

starting treatment" because of the "need to decide whether the aim oftreatment
is for cure or for palliation".

34. Dr FOO opined on the other hand that "[c]arcinosarcoma ofthe ovary ... is an
aggressive cancer with very poor prognosis"; and "[t}he combination of
carboplatin and paclitaxel is the recognized chemotherapy regimen for
carcinosarcoma of ovary". It is idle in our view to distinguish between
"whether the aim of [chemotherapy} treatment [in this case} is for cure or for
palliation".

35. Counsel for the Defendant referred us to the English High Court decision of
Jones v Conwy and Denbighshire NHS Trust [2008] EWHC 3172. In that case,
the claimant accused the defendant hospital staff of failure to conduct a CT scan
on the claimant's child on the day of her admission for sinus infection, which
developed into orbital cellulitis with a subperiosteal abscess that spread and
causing an intra-cranial collection of pus necessitating a craniotomy which
unfortunately caused her to develop epilepsy. The claimant' s experts were of
the view that a CT scan on admission to hospital was necessary either on the
basis that in a case of suspected orbital cellulitis, which would be a medical
emergency, such a scan was mandatory, or, if not always mandatory, was
required in respect of the child, having regard to the symptoms with which was
presented. A CT scan on admission would give valuable information as to the
site of the disease and its stage and would provide a baseline from which to
determine treatment and, if necessary, to plan surgery; and from which to observe
the progress of the disease. Defence experts took a different view. They
opined that in most cases of orbital cellulitis a CT scan would not be needed
because most such cases resolve themselves by the use of intravenous antibiotics.
The immediate treatment was going to be the same whatever the findings of the

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 CT scan. A reasonable course to treat the child, whose ophthalmologic
parameters were normal upon admission to hospital, was to treat her with such
antibiotics and see whether or not that would occur. Clarke J applied the Bolam
test as refined by the House of Lords in Bolitho v City and Hackney Health
Authority [1998] AC 232 and concluded that the body of opinion which would
not require an immediate CT scan was neither irresponsible nor unreasonable
given the child's presenting symptoms and that the result of the CT scan was
unlikely to alter the immediate treatment plan.

36. In our view, it all boils down whether the body of opinion which would not
require imaging before starting chemotherapy after surgical staging has been
done is irresponsible or unreasonable.

37. We agree with the Defendant that "[t} here was no clinical sign which suggested
any risk ofany distant, extra-abdominal metastasis" ; and we also agree with Dr
FOO that the treatment plan was going to be the same regardless of whether
imaging investigation had been arranged before starting chemotherapy on the
Patient. In our view, Dr FOO ' s expert opinion that chemotherapy for
carcinosarcoma could be started without arranging for prior imagmg
investigation is neither irresponsible nor unreasonable.

38. Applying the Bolam test (as refined) to the present case, we cannot find the
Defendant' s failure to arrange for imaging investigation before starting
chemotherapy on the Patient to have fallen below the standard expected of
registered medical practitioners, merely because there was a body of opinion
which would take a contrary view. Having said that, it might well be more
prudent in our view to arrange for imaging investigation before starting
chemotherapy given the rarity of carcinosarcoma.

39. For these reasons, we are not satisfied on the evidence before us that the
Secretary's case in respect of disciplinary charge (a) has been made out.
Accordingly, we find the Defendant not guilty of that charge.

40. The Defendant admitted that he put down in his medical record for the
consultation with the Patient on 17 July 2012, amongst others, the following:­

"Details of disease, prognosis and complications fully discussed [with

patient] + her family

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 Grave prognosis -+ untreated 2-4112,
treated~ 18112".

41. In his statement to the PIC dated 29 October 2019, the Defendant explained that:­

"70. However, due to long lapse oftime, I cannot recall the details about
the communication between the Patient and/or the Complainant and
me. Whilst it is my recollection that I had discussed with the Patient
and her family the "best and worst" case scenarios and against this
context, I made the entry "Untreated 2-3112, Treated 18112 ", and it
was probably made with reference to the data from studies involving
epithelial ovarian cancers due to the limited data regarding ovarian
carcinosarcoma at the material time. It may well be that I
mentioned those data as a backdrop for further discussion as these
were data generally true for advanced carcinosarcoma in the first­
line setting. And any discussion regarding her then condition and
decision regarding further treatment intent should take these into
account. It might also be that I was telling the family that should
she in a rare event improve and chemotherapy became an option,
those figures would be applicable in that setting. Such data were
only quoted as an indicator of her overall disease history and
prognosis and it helped to set the scene i.e. context ofher disease, for
discussion into conservative care alone. I greatly regret that the
family felt that they were misled in this regard and I would sincerely
apologize for such mishaps in communications that caused so much
distress to them ... "

42. We agree with Counsel for the Defendant that the meaning of the phrase
"untreated 2-4112 treated ~18112" must be construed in its proper c~ntext.

What the phrase "untreated 2-4112 treated ~18112" connoted in the medical
records of the Patient on 17 July 2012 is a matter for the Defendant to explain.

43. In his supplemental statement dated 21 June 2023, the Defendant further
explained that:­

"15. As explained in the JS1 statement, due to the long lapse of tirne, I
cannot recall the details about the communication between the
Patient and/or the Complainant and me. However, I would like to
stress that, I was fully aware that the Patient 's condition at the

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 material time was po01; in a deteriorating trend despite completion
of two cycles of chemotherapy. Therefore, upon completion of
radiotherapy on 16 July 2012 as planned, I reviewed the management
plan.for the Patient and considered that the appropriate management
was to provide conservative treatments, without having any plan for
further (or second line) chemotherapy. I therefore arranged an
interview with the Patient and the Complainant, which took place on
17 July 2012, to advise on my plan for the Patient, i.e. to provide
conservative treatments. Even before the interview on 17 July 2012,
there had been earlier discussions with them regarding the Patient's
poor condition and unsuitability for the Patient further (or second
line) chemotherapy .. .

16. ... I would like to stress that based on my recollection, the phrase of
"untreated 2-4112 treated - 18112" was only reference to some study
data, including data ofthe original disease of the Patient before any
complications set in. I can only think that the reason why I made
such reference was to facilitate my discussion with the Patient about
further management for her, including that she was not suitable for
further chemotherapy, ·when the Patient and the Complainant still
hoped to explore possibility offur ther treatment. The data set out a
backdrop that the average survival ofstage Ill carcinosarcoma with
paraaortic lymph nodes involvement and without metastases would
be around 18 months if treated in the first line setting; whereas the
average survival of the disease with paraaortic lymph nodes which
had rapidly developed metastases, if not treated, would be around 2
to 4 months, consistent with international clinical study that I had
came across throughout my practice ... Therefore, the prognosis ofthe
Patient would even be poorer, even if she was fit for further
chemotherapy, which she in fact was not, especially when she had
developed metastases with rapid progression despite completion of
two cycles ofchemotherapy.

17. As reflected in the above entry, no further (or second line)

chemotherapy was plannedfor the Patient on 17 July 2012. Jn view
of the Patient 's "Grave prognosis", which was an even poorer
condition than "untreated 2-4112 treated - 18112" at the time of the
interview on 17 July 2012."

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44. The Complainant was however adamant that the Defendant had made it clear to
the Patient and her family that without further (or second line) chemotherapy,
the Patient might only survive for 2 to 4 months; whereas with further (or second
line) chemotherapy, the Patient might survive for 18 months.

45. When being cross-examined, the Complainant produced 3 sets of handwritten

notes, which he claimed to be contemporaneous or made soon thereafter.

46. It is pertinent to note however that there was no mention in the first set of
handwritten notes that the Defendant had ever told the Patient and the
Complainant on 17 July 2012 that without further (or second line) chemotherapy,
the Patient might only survive for 2 to 4 months; whereas with further (or second
line) chemotherapy, the Patient might survive for 18 months. We find it
implausible that the Complainant would omit this had the Defendant told him
and the Patient of the same. This is particularly true because the whole point
in making these notes was to keep a contemporaneous record of what had
happened to the Patient in case he wished to complain against her treating
doctors.

47. We cannot dismiss on the evidence before us the Defendant's explanation that
"the phrase of "untreated 2-4112 treated 18112" was only reference to some
study data, including data of the original disease of the Patient before any
complications set in".

48. In the course of cross-examination, the Defendant was also asked to look at
section 1.1.3 of the Code of Professional Conduct (2009 edition) ("the Code")
which stipulated inter alia that "All doctors have the responsibility to maintain ...
clear, and contemporaneous medical records" of their patients. From this, the
Legal Officer now submits to us that "even ifthe phrase in question did not refer
to the Patient's specific conditions on 17 July 2012, it is unclear as a medical
record'.

49. It is pertinent to note in this regard that the term "medical records" in section
1.1.3 of the Code should be read in conjunction with section 1.1. l of the Code
which stipulated that "[t}he medical record is the formal documentation
maintained by a doctor on his patients' history, physical findings, investigations,
treatment, and clinical progress." It does not mean that every single phrase that
the Defendant put down in the medical records had to be "clear" in its meaning
"even if the phrase in question did not refer to the Patient's specific conditions

13
 on 17 July 2012."

50. Bearing in mind that the burden of proof is always on the Secretary, we are not
satisfied on the evidence the Secretary's case against the Defendant in respect of
disciplinary charge (b) has been made out. Accordingly, we find the Defendant
not guilty of that charge.

51. According to the Complainant, the Defendant had advised further (or second line)
chemotherapy for the Patient; and he also learned from the Patient's short
message of 10 July 2012 the names ofthe chemotherapy drugs were "ifosfamide"
and "cisplatin''. When being cross-examined, the Defendant denied having
told the Patient the names of these chemotherapy drugs. There is however no
dispute that the names of these chemotherapy drugs were specifically mentioned
in the referral letter for the Patient to consult the Consultant of the Department
of Clinical Oncology of QEH.

52. In the Consultation Summary written by the Resident Specialist of the

Department of Clinical Oncology of QEH who saw the Patient on 18 July 2012,
it was also mentioned that:­

"2nd line palliative chemo[therapy} !ft (ifosfamide) and CDDP (cisplatin)

was suggested by Dr Chan" .

53. In his Supplemental Statement dated 21 June 2023, the Defendant explained
that:­

"Upon reviewing of the referral letter issued by me to QEH .. as disclosed

under the Complainant 's Statement, it is noted that I referred the Patient to
the Department of Clinical Oncology ofQEH on 11 July 2012 ... I recalled
that on the same day. I made an urgent phone call to Dr Wong ... consultant
of the Department of Clinical Oncology of QEH, detailing the Patient's
intention to attempt second line chemotherapy despite her poor condition.
I requested for arrangement of an urgent consultation for the Patient, so
QEH doctor could revert with their opinion as soon as possible. 1 did not
expressly state my view that the Patient was not suitable for further
chemotherapy as I did not wish to inte1fere with the independent opinion of
the QEH doctor. In view of the strong wish of the Patient and the
Complainant for second line chemotherapy, which the Patient was not fit
for, I also stated the names of the drugs that would usually be used in

14
 chemotherapy for carcinosarcoma according to my professional knowledge:
I intend[ed} to try her on !Fx and CDDP but I'll be grateful for [their
opinion}". In such case, in the unlikely event that QEH doctor considers
the Patient was suitable for further chemotherapy, she could also be
advised on whether the two drugs, which were available at QEH, were
deemed appropriate for her disease and whether she could receive further
management at QEH, if and only if QEH doctor sees fit. In any event,
regardless of whether the Patient would decide to pursue further
chemotherapy treatment. In view of the Patient's paralysis which
necessitated long-term in-patient care, I also sought for advice on the
appropriateness of the Patient 's further management at QEH, so the
Patient could consider this option. "

54. When being cross-examined, the Defendant initially told us that "I've been
trying my best to help the patient and if I couldn't do it, I refer her on". But
when being further cross-examined why he did not make this clear in his referral
letter, the Defendant told us that "[t}he letter was written in the situation when I
was asked by the family to provide improvement, to provide the likely agents I
use in that scenario. So !just put down two drugs by deliberately [choosing .. .}
not the wrong ones but the very strong ones so that they will say no. Again that
is consistent with my diplomatic approach. I was silently inviting the Queen
Elizabeth people to say no."

55. It is however evident to us from reading the referral letter for the Patient to
consult the Consultant of the Department of Clinical Oncology of QEH that the
Defendant used the words "I intend to try her on Jfx (infos/amide) and CJ)DP
(cisplatin)". If the Defendant genuinely wished to tell the Patient through the
mouth of the clinical oncology specialist that further (or second) line
chemotherapy was not suitable for her case, there was no reason in our view why
he needed to mention any names of chemotherapy drugs. We do not accept the
Defendant's explanations.

56. We agree with Dr YING that for a patient who "had spinal cord compression
and irreversibly paralyzed, second line chemotherapy would be dangerous as
paralyzed patient tolerate[s} chemotherapy poorly with higher rate of
complications like sepsis".

57. Dr YING and Dr FOO also agreed and we accept that given her grave situation
and multiple metastases, the Patient was not suitable for further (or second line)

15
 chemotherapy after she had failed to respond to two cycles of chemotherapy
treatment and radiotherapy treatment as planned. In our view, the Defendant's
advice for the Patient to undergo further (or second line) chemotherapy was
without proper justification.

58. We wish to supplement that even if the Defendant genuinely wished to tell the
Patient through the mouth of the clinical oncology specialist that further (or
second) line chemotherapy was not suitable for her case, his advice to the Patient
in this case was nevertheless inappropriate. The Defendant ought in our view
to be open and honest with the Patient and told her directly that further (second
line) chemotherapy was not suitable for her case and would be dangerous for her.
This could save the Patient from the ordeal of having to travel from HKBH to
QEH on 18 July 2012 when her condition was so frail that she succumbed three
days later.

59. For these reasons, we are satisfied on the evidence that the Secretary's case
against the Defendant in respect of disciplinary charge (c) has been made out.
By advising inappropriately or without proper justification the Patient to undergo
further (or second line) chemotherapy, the Defendant had by his conduct fallen
below the standard expected of registered medical practitioners in Hong Kong.
Accordingly, we find the Defendant guilty of misconduct in a professional
respect.

Sentencing

60. The Defendant has one previous disciplinary record for unnecessary I
inappropriate treatment for a patient back in or about April to August 2009. On
8 March 2023, his name was ordered to be removed from the General Register
for a period of 6 months and the operation of the removal order was suspended
for a period of 18 months.

61. We bear in mind that the primary purpose of a disciplinary order is not to punish
the Defendant but to protect the public from persons who are unfit to practise
medicine and to maintain public confidence in the medical profession by
upholding its high standards and good reputation.

62. We accept that both the present case and the incident relating to the previous
disciplinary case of the Defendant happened long time ago .

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63. We acknowledge that the Defendant has tremendous support from his
professional colleagues and patients.

64. We are however particularly concerned that the Defendant had changed his
stories as he went along when they suited his case, which we do not accept.

65. We are told in mitigation that in addition to taking CME courses, which exceeded
the minimum of 90 CME points per 3-year cycle, the Defendant had taken a
certificate course co-organized by the Federation of Medical Societies of Hong
Kong and the Hong Kong Society for Healthcare Mediation through which he
learned the importance of open and honest communications with professional
colleagues and patients, particularly in difficult cases.

66. Whilst we believe the Defendant had learned his lesson and we hope the
Defendant would put in practice what he had learned to rectify the shortcomings
which underlay his misconduct in this case, we need to make sure that the
Defendant will not commit the same or similar misconduct in the future.

67. Taking into consideration the nature and gravity of the disciplinary charge for
which we find the Defendant guilty and what we have read and heard in
mitigation, we order in respect of disciplinary charge (c) that the name of the
Defendant be removed from the General Register for a period of 9 months. We
further order that the operation of the removal order be suspended for a period
of 36 months.

Remark

68. The name of Defendant is included in the Specialist Register under the Specialty
of Clinical Oncology. It is for the Education and Accreditation Committee to
consider whether any action should be taken in respect of his specialist
registration.

Prof. TANG Wai-king, Grace, SBS, JP

Chairperson of the Inquiry Panel
The Medical Council of Hong Kong

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