Case Details
- Citation: [2025] SGHC 53
- Title: Cheng Shi Ying Cherissa v Khoo Chong Kiat and another
- Court: High Court of the Republic of Singapore (General Division)
- Originating Claim No: 235 of 2023
- Date of Judgment: 3 April 2025
- Judges: Choo Han Teck J
- Hearing Dates: 4–7 and 11–14 February 2025; 17 March 2025
- Judgment Reserved: Yes
- Plaintiff/Applicant: Cheng Shi Ying Cherissa (“Ms Cheng”)
- Defendants/Respondents: (1) Khoo Chong Kiat (“Dr Khoo”); (2) Royal Clinics of O&G Pte Ltd
- Legal Areas: Professions — Medical profession and practice; Tort — Negligence
- Core Claims (as pleaded in the extract): Negligence, including alleged failure to obtain informed consent before cervical sweeps, episiotomy, manual fundal pressure, and repair of a rectovaginal tear
- Key Medical Context (as described): Induction of labour; cervical sweep(s); artificial rupture of membranes; vaginal delivery with mediolateral episiotomy; manual fundal pressure; subsequent rectovaginal buttonhole tear and later development of rectovaginal fistula
- Expert Witnesses (as described): For Ms Cheng: Prof Andrew Robert Korda; Dr Michael John Mar Fan. For Dr Khoo: Dr Han How Chuan; Dr Kam Ming Hian
- Length of Judgment: 24 pages, 7,814 words
- Statutes Referenced: Not specified in the provided extract
- Cases Cited: [2025] SGHC 53 (as provided in metadata; additional authorities not included in the truncated extract)
Summary
This High Court decision concerns a claim in negligence arising from obstetric care during Ms Cheng’s first pregnancy and delivery in May 2020. Ms Cheng alleged that Dr Khoo failed to obtain informed consent for several procedures performed during labour and delivery, and that these failures (and related clinical acts) caused or contributed to a rectovaginal fistula (“RVF”) and subsequent physical and psychological sequelae. The pleaded negligence also included allegations relating to the performance of a cervical sweep and the repair of a rectovaginal tear.
The court accepted key parts of Dr Khoo’s evidence, including that he had explained the purpose and process of at least the cervical sweep before proceeding. It also found that Ms Cheng’s account of a second cervical sweep was not supported by evidence, and that the evidence did not establish that the alleged procedures caused the eventual tear and RVF. On the consent issue, the court treated the standard of disclosure and consent in obstetric practice as fact-sensitive, and it was not persuaded that the absence of formal written consent for routine labour procedures amounted to actionable negligence on the facts.
Ultimately, the claim against Dr Khoo and Royal Clinics of O&G Pte Ltd failed. The decision is a useful reference point on how Singapore courts approach (i) proof of causation in medical negligence, (ii) evidential weight where contemporaneous records are limited, and (iii) the scope of “informed consent” in the context of labour and delivery procedures.
What Were the Facts of This Case?
Ms Cheng, a 32-year-old marketing and communications executive, consulted Dr Khoo in September 2019 when she was pregnant. She had ten consultations with him between September 2019 and April 2020. Dr Khoo is a senior consultant obstetrician and gynaecologist practising under the name “CK Khoo Clinic for Women & Laparoscopy”. Royal Clinics of O&G Pte Ltd was the company that formally employed Dr Khoo.
On 2 May 2020 at around 12.05am, Ms Cheng was admitted to Mount Elizabeth Novena Hospital to begin induction of labour. A nurse inserted Cervidil to soften the cervix. A vaginal examination at 4pm showed the cervix was still closed. At 9pm, Dr Khoo examined Ms Cheng and performed what is described as a “cervical sweep” (stretching the cervix with the doctor’s fingers to induce labour). Ms Cheng claimed she was unaware of this procedure, but the court later accepted Dr Khoo’s evidence that he had explained its purpose and process beforehand. After the cervical sweep, the cervix dilated to 3cm, and at 10.40pm Dr Khoo performed an artificial rupture of the membrane of the amniotic sac.
On 3 May 2020 at 9.20am, Dr Khoo performed another vaginal examination and observed cervical dilation of only 4cm. Ms Cheng’s account was that at 9.25am Dr Khoo informed her an emergency caesarean section was required, and she consented. She further alleged that Dr Khoo then said he wanted to “try something” to attempt natural delivery, and that he performed a second cervical sweep by manually widening her cervix to 10cm. Dr Khoo denied performing a second cervical sweep at that time, stating that he only performed a vaginal examination and that the only cervical sweep was on 2 May 2020 at 9pm. He explained that at 9.25am he discussed the possibility of a lower segment caesarean section (“LSCS”) if labour remained slow, and he arranged an operating theatre and an anaesthetist on standby. By 9.40am, however, he found the cervix had fully dilated to 10cm, so there was no clinical indication for LSCS and he proceeded with natural delivery.
Dr Khoo left Ms Cheng with a nurse at about 10am. Following the nurse’s instructions, Ms Cheng began pushing and after about 15 minutes was told the baby was “crowning”. She was then told to stop pushing and wait for Dr Khoo. Two other nurses entered shortly after. Dr Khoo returned at about 10.30am, was told the baby was “crowning”, and instructed Ms Cheng to push again. After Ms Cheng’s initial push, Dr Khoo moved to her left-hand side and applied “manual fundal pressure” (pressure at the top of the fundus using his right palm) to expedite vaginal birth. Before applying manual fundal pressure, Dr Khoo performed a mediolateral episiotomy, described as a controlled cut at the perineum to relieve tension and prevent extensive tears. The baby was delivered in good health at 10.35am.
After delivery, Ms Cheng claimed Dr Khoo told her he noticed faecal matter in her vagina and would stitch her up. She assumed stitching was standard for all vaginal deliveries. Dr Khoo denied noticing faecal matter. He testified that he noticed a rectovaginal buttonhole tear of 0.5cm when repairing the episiotomy and that he informed Ms Cheng and her husband before repairing two layers: the rectal wall and the vaginal wall. His clinical notes at 11am on 3 May 2020 corroborated that a rectovaginal tear was identified, although he incorrectly referred to it as a “fistula”. He prescribed Duphalac (a stool softener) and Enhancin (antibiotics). Ms Cheng was discharged at 11.30am on 4 May 2020.
On 5 May 2020, Ms Cheng noticed she was excreting faecal matter through her vagina and informed Dr Khoo via WhatsApp at 8.38pm, stating there was “still some small poo discharge from [her] vagina”. Dr Khoo responded that he needed to examine her and “may need to stitch some more”. On 6 May 2020, Dr Khoo examined her and told her an RVF had developed, likely due to breakdown of the repair and extension of the tear into an abnormal communication between vagina and rectum. He recommended colorectal specialists, including Dr Ng Kheng Hong. Dr Khoo called Dr Ng in Ms Cheng’s presence to explain the condition. Dr Ng did not find a fistula on examination and advised conservative management. Ms Cheng later reported increased faecal discharge.
At about 6pm on 6 May 2020, Ms Cheng attended SGH A&E on Dr Khoo’s advice and was admitted for observation. Dr Mok and Dr Ravichandran observed a 0.5cm defect from the anal verge and referred her to colorectal surgeon Dr Ng Jia Lin. On 8 May 2020, Dr Ng Jia Lin treated her conservatively and advised repair after inflammation settled. On 28 October 2020, almost six months after delivery, Associate Professor Tang Choong Leong performed a repair of the RVF. The wound healed by 5 January 2021.
Ms Cheng claimed that as a result of the incident she suffered major depressive disorder (postpartum onset), post-traumatic stress disorder including mother-infant bonding difficulties, first degree uterine prolapse, and grade two bladder prolapse (cystocele). These injuries and losses formed the basis of her damages claim.
What Were the Key Legal Issues?
The central issue was whether Dr Khoo (and by extension Royal Clinics of O&G Pte Ltd) was negligent in the course of obstetric care. In particular, Ms Cheng alleged that Dr Khoo failed to obtain her informed consent before performing: (i) cervical sweeps; (ii) an episiotomy; (iii) manual fundal pressure; and (iv) the repair of the rectovaginal tear. These allegations raised both a duty-and-breach question (what disclosure and consent were required) and a causation question (whether any breach caused the RVF and its sequelae).
A second key issue concerned factual proof of what procedures were actually performed and when. Ms Cheng alleged a second cervical sweep between 9.25am and 9.40am on 3 May 2020. The court noted that there was no evidence supporting this claim, and that there were no contemporaneous medical records or witnesses verifying her account. Dr Khoo’s position was that he performed only a vaginal examination at that time, and that the only cervical sweep occurred on 2 May 2020 at 9pm. The court therefore had to decide whether Ms Cheng’s narrative was credible and whether the alleged second sweep mattered to causation.
Third, the court had to consider medical causation and expert evidence. Even if consent was not obtained in the manner Ms Cheng contended, the court still needed to determine whether the alleged failures caused the eventual tear and RVF. The extract indicates that expert evidence did not support the proposition that manual cervical dilation could have caused the tear, and the court had to weigh competing expert opinions from clinicians who practised in different jurisdictions.
How Did the Court Analyse the Issues?
The court’s analysis began with the evidential foundation for the alleged events. On the alleged second cervical sweep, the court emphasised the absence of corroboration. Ms Cheng’s account lacked contemporaneous medical records or witnesses, and Dr Khoo denied performing a second sweep. The court therefore treated the factual allegation as unproven. This mattered because, without proof that the second sweep occurred, the consent complaint tied to that alleged procedure could not advance Ms Cheng’s case.
More broadly, the court approached the consent allegations by examining what Dr Khoo actually did and what he communicated to Ms Cheng. The extract shows that the court accepted Dr Khoo’s evidence that he explained the purpose and process of a cervical sweep before proceeding. This acceptance was significant because it undermined the premise that Ms Cheng was “kept in the dark” about the procedure. The court also noted that Ms Cheng’s own admissions at trial (as far as the extract indicates) were consistent with Dr Khoo’s account, further weakening her claim of non-disclosure.
On the standard of consent, the court considered the difference between formal written consent and informed consent in practical obstetric settings. Dr Khoo’s evidence was that it is not standard practice for consent to be formally obtained for certain routine labour procedures, and that verbal information would ordinarily suffice. Dr Han corroborated this view, stating that written consent is not typically obtained for a cervical sweep and that an obstetrician would usually verbally inform the patient if a cervical sweep is useful. Similarly, Dr Han explained that written consent is not typically obtained for an episiotomy; rather, the obstetrician would tell the patient that a small controlled cut is being performed and that it will be repaired once the baby is delivered.
In contrast, Ms Cheng’s expert, Professor Korda, took a more expansive view of informed consent. He opined that it is appropriate practice to obtain informed consent prior to any procedure, including cervical sweep and episiotomy, and that verbal consent could satisfy the requirement. However, the court’s reasoning indicates that the legal question was not whether consent could theoretically have been obtained in a more detailed manner, but whether the defendant’s conduct fell below the applicable standard of care in the circumstances. The court accepted that Dr Khoo had explained the purpose and process of the cervical sweep, and it did not find that the absence of formal written consent for routine obstetric steps amounted to negligence.
Turning to causation, the court addressed whether the alleged breaches could have caused the eventual rectovaginal tear and RVF. The extract indicates that nothing turned on the alleged second cervical sweep because there was no evidence that either cervical sweep caused the eventual tear and RVF. It also notes that Professor Korda testified he did not think manual cervical dilation could have caused the tear. This expert position was important because it linked the consent and procedure allegations to the medical mechanism of injury. Without a credible causal pathway, the claim could not succeed even if there were shortcomings in consent.
Finally, the court’s approach reflects a common structure in medical negligence cases: it first resolves disputed facts, then assesses whether the defendant’s conduct breached the standard of care, and then evaluates whether the breach caused the harm. The extract suggests that the court’s findings on factual proof and causation were decisive. Where the court was not satisfied that the alleged second sweep occurred, and where expert evidence did not support causation, the negligence claim could not be sustained.
What Was the Outcome?
For the reasons summarised above, the High Court dismissed Ms Cheng’s negligence claim against Dr Khoo and Royal Clinics of O&G Pte Ltd. The court accepted Dr Khoo’s evidence on explanation and disclosure for the cervical sweep, found that Ms Cheng’s allegation of a second cervical sweep was not supported by evidence, and concluded that the evidence did not establish that the alleged procedures (or any consent failures) caused the rectovaginal tear and subsequent RVF.
Practically, the decision means that Ms Cheng did not obtain damages for the physical and psychological sequelae she attributed to the obstetric incident. For clinicians and healthcare providers, the judgment also provides guidance on how courts may evaluate informed consent in labour and delivery contexts, particularly where routine procedures are involved and where causation is not established.
Why Does This Case Matter?
This case matters because it sits at the intersection of two recurring themes in Singapore medical negligence litigation: (i) the evidential and substantive requirements for proving breach of duty in relation to informed consent, and (ii) the need for robust causation evidence linking the alleged breach to the injury. The court’s insistence on proof of disputed procedural events (such as the alleged second cervical sweep) underscores that plaintiffs must do more than assert what happened; they must support their narrative with credible evidence, especially where contemporaneous records are limited.
From a consent perspective, the judgment is instructive for practitioners because it reflects a realistic approach to obstetric practice. The court did not treat the absence of formal written consent for routine labour procedures as automatically negligent. Instead, it focused on whether the patient was adequately informed about the purpose and process of the procedure, and whether any alleged deficiency could be causally linked to the harm. This is particularly relevant for consent disputes involving urgent or time-sensitive clinical decisions during labour.
For law students and litigators, the case also highlights the importance of expert evidence not only on standard of care but on causation. Even where there is a disagreement between experts about what informed consent should entail, the claim may still fail if the medical evidence does not support a causal mechanism. The decision therefore reinforces that medical negligence claims require a coherent evidential chain: facts → breach → causation → loss.
Legislation Referenced
- Not specified in the provided extract.
Cases Cited
- [2025] SGHC 53 (the case itself, as provided in metadata)
Source Documents
This article analyses [2025] SGHC 53 for legal research and educational purposes. It does not constitute legal advice. Readers should consult the full judgment for the Court's complete reasoning.