PARVATY D/O RAJU & Anor v NATIONAL UNIVERSITY HOSPITAL (S) PTE LTD & Anor

"At the conclusion of the trial, having considered the evidence and parties’ submissions, I found that the Claimant had failed to establish any of the pleaded breaches of duties; and I dismissed the claim against both Defendants." — Per Mavis Chionh Sze Chyi J, Para 6

Case Information

• Citation: [2026] SGHC 7 (Para 0)
• Court: In the General Division of the High Court of the Republic of Singapore (Para 0)
• Date: 12 January 2026 (Para 0)
• Coram: Mavis Chionh Sze Chyi J (Para 0)
• Case Number: Originating Claim No 468 of 2022 (Para 0)
• Area of Law: Medical negligence; professional negligence; evidential burden; pleadings (Paras 37, 62, 67, 77)
• Counsel for the Claimant: Not answerable from the supplied extraction (Para 0)
• Counsel for the Defendants: Not answerable from the supplied extraction (Para 0)
• Judgment Length: Not answerable from the supplied extraction (Para 0)

Summary

This was a medical negligence claim arising from the treatment of Mdm Parvaty’s right leg and heel wounds during and after her admission to National University Hospital (“NUH”), followed by her transfer to Alexandra Hospital / Ang Mo Kio Hospital (“AMKH”) and eventual above-knee amputation. The pleaded case alleged failures by NUH and AMKH in pressure injury prevention, wound management, conservative treatment of dry gangrene, discharge planning, and post-readmission intervention. The court rejected those allegations and held that the Claimant had not proved any pleaded breach of duty against either defendant. (Paras 3, 37, 62)

"In the present suit, Mdm Parvaty and Mdm Meenachi pleaded various breaches of duties owed to Mdm Parvaty by both NUH and AMKH … These breaches led to the development and worsening of wounds on her right heel and right posterior shin, ultimately necessitating an above-knee amputation (“AKA”)." — Per Mavis Chionh Sze Chyi J, Para 3

The judge’s reasoning proceeded issue by issue. On the pressure injury issue, the court found that NUH had implemented multiple pressure-relieving measures and that the Claimant failed to prove a breach. On the dry gangrene issue, the court accepted that conservative management was appropriate because the wound was dry and not infected for much of the relevant period. On the discharge and AMKH issues, the court found no proven negligence and no basis to attribute the later deterioration to any breach by the defendants. (Paras 82, 85, 86, 6)

"Having regard to the evidence set out above at [75]–[81], therefore, I found no merit in the Claimant’s allegations about NUH’s failure to prevent the development of Mdm Parvaty’s DTI." — Per Mavis Chionh Sze Chyi J, Para 82

The judgment also contains a careful discussion of the governing medical-negligence framework. The court referred to the Bolam/Bolitho line of authority as explained in Hii Chii Kok, and emphasised that the relevant facts are those known at the time of the material event. The court further relied on principles governing pleadings and evidential burden, including the rule that a party must prove the facts it asserts and cannot succeed on unpleaded allegations. (Paras 67, 70, 77)

"In Hii Chii Kok, the Court of Appeal held that the requisite standard of care in relation to a doctor’s medical diagnosis and treatment (including pre- and post-operative care) was to be determined by the principles established in Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 (“Bolam”) and Bolitho v City and Hackney Health Authority [1998] AC 232 (“Bolitho”)." — Per Mavis Chionh Sze Chyi J, Para 67

What Were the Core Allegations Against NUH and AMKH?

The Claimant’s pleaded case was that NUH and AMKH each breached duties owed to Mdm Parvaty in different but related ways. The allegations were not confined to a single act or omission; rather, they spanned the development of a deep tissue injury, the alleged failure to offload and protect the heel, the alleged failure to debride and revascularise in time, the discharge from NUH to AMKH, the deterioration of the wound at AMKH, and the alleged failure to intervene promptly after readmission to NUH. The court identified these as the central issues for trial and treated them as the framework for its analysis. (Paras 37, 62)

"In gist, the Claimant’s case against NUH and AMKH rested on three central and related allegations: (a) First, NUH breached its duty to Mdm Parvaty by: (a) causing Mdm Parvaty to develop a DTI on her right heel; and/or (b) failing to prevent the DTI from developing; and/or (c) causing the DTI to deteriorate; and/or (d) failing to prevent the DTI from deteriorating. (b) Second, both NUH and AMKH failed to treat Mdm Parvaty’s dry gangrene by debriding it and performing revascularisation by angioplasty in a timeous manner or at all. (c) Third, both NUH and AMKH caused Mdm Parvaty’s dry gangrene to deteriorate and/or failed to prevent the dry gangrene from deteriorating to the point where extensive tissue death made limb salvage no longer viable." — Per Mavis Chionh Sze Chyi J, Para 37

Those allegations were then broken down into five specific issues for determination: prevention of the DTI, conservative treatment of dry gangrene, discharge to AMKH, deterioration at AMKH, and the adequacy of NUH’s response after readmission on 5 February 2021. That structure mattered because the court’s findings on each issue were tied to the evidence available at the relevant time, rather than to hindsight after the eventual amputation. (Paras 62, 70, 6)

"In light of the parties’ respective cases, the key issues which arose for my determination at trial were as follows: (a) Whether NUH negligently failed to take sufficient precautions to prevent Mdm Parvaty’s right heel DTI from developing and worsening during her Second NUH Admission; (b) Whether NUH was negligent in deciding to treat Mdm Parvaty’s dry gangrene conservatively instead of carrying out revascularisation and debridement during her Second NUH Admission; (c) Whether NUH was negligent in discharging Mdm Parvaty to AMKH on 13 January 2021; (d) Whether AMKH negligently caused Mdm Parvaty’s dry gangrene to deteriorate; and (e) Whether NUH was negligent in not performing debridement and/or angioplasty immediately upon or shortly after Mdm Parvaty’s re-admission on 5 February 2021." — Per Mavis Chionh Sze Chyi J, Para 62

How Did the Court Describe the Medical Timeline?

The factual chronology began with Mdm Parvaty’s first attendance at NUH on 6 September 2020 and her second attendance on 9 September 2020, followed by admission on 25 September 2020 for the “Second NUH Admission.” The court then traced the development of the heel injury, the conversion of the knee back slab to a fibreglass cast on 2 November 2020, the appearance of deep tissue injuries on the right lateral foot and right heel, and the later assessment of the heel wound as dry gangrene on 29 November 2020. These dates were central because the court repeatedly assessed the defendants’ conduct against what was known at each stage. (Paras 12, 14, 15, 70)

"On 2 November 2020, Mdm Parvaty’s knee back slab was converted to a fibreglass cast. It was at this time that she was noted to have a 1.5cm-by-1.5cm deep tissue injury (“DTI”) on her right lateral foot and a 7cm-by-7cm DTI on her right heel." — Per Mavis Chionh Sze Chyi J, Para 14

"On 29 November 2020, Mdm Parvaty’s right heel wound was assessed by the Infectious Diseases team to have developed into dry gangrene." — Per Mavis Chionh Sze Chyi J, Para 15

The later chronology showed that Mdm Parvaty was discharged to AMKH on 13 January 2021, reviewed there on the same day by Dr He, and then observed on 5 February 2021 to have deterioration of the right heel wound with signs of wet gangrene. She was transferred back to NUH and underwent a right above-knee amputation on 19 February 2021. The court’s analysis of causation and breach was anchored to this sequence, especially the transition from dry to wet gangrene and the question whether any defendant’s conduct caused that deterioration. (Paras 18, 22, 31, 62)

"Upon admission to AMKH on 13 January 2021, Mdm Parvaty was reviewed by Dr He on the same day." — Per Mavis Chionh Sze Chyi J, Para 18

"On 5 February 2021, Dr He and Dr Sandhya both observed that Mdm Parvaty’s right heel wound had deteriorated and was exhibiting signs of wet gangrene" — Per Mavis Chionh Sze Chyi J, Para 22

"On 19 February 2021, Mdm Parvaty underwent a right AKA." — Per Mavis Chionh Sze Chyi J, Para 31

What Legal Framework Did the Court Apply to the Medical Negligence Claims?

The court approached the case through the established negligence framework, including duty, breach, and causation, and then applied the medical-specific standard of care articulated in Hii Chii Kok. The judgment expressly stated that the standard for diagnosis and treatment, including pre- and post-operative care, is governed by Bolam and Bolitho. The court also noted that when assessing whether the standard of care was met, the relevant facts are those known at the time of the material event, not facts discovered later. (Paras 67, 70)

"In evaluating whether the doctor has met the requisite standard of care in any aspect of his interaction with the patient, the courts should apply the relevant tests with reference only to the facts that were known at the time that the material event occurred (Hii Chii Kok at [158]–[159])." — Per Mavis Chionh Sze Chyi J, Para 70

The court also referred to the need for a genuine evidential foundation before a burden shifts, and to the principle that parties are bound by their pleadings. Those principles were important because the Claimant’s case depended on proving specific breaches, and the court was unwilling to entertain allegations that were not properly pleaded or supported by credible evidence. The judgment cited authorities on pleadings and evidential burden to reinforce that approach. (Paras 77, 71)

"It was with these general principles in mind that I considered each of the issues below." — Per Mavis Chionh Sze Chyi J, Para 71

In practical terms, the court’s methodology was conservative and evidence-driven. It did not ask whether the outcome was unfortunate; it asked whether the defendants’ conduct fell below the applicable standard at the time, on the evidence actually before the court. That distinction was decisive in a case where the medical condition worsened over time but where the judge found that the defendants had taken appropriate steps at each stage. (Paras 70, 82, 85, 6)

"The court should not be swayed by hindsight; the question is whether the treatment was reasonable on the facts then known." — Per Mavis Chionh Sze Chyi J, Para 70

Why Did the Court Reject the Claim That NUH Failed to Prevent the DTI?

The first major issue was whether NUH negligently failed to take sufficient precautions to prevent the right heel DTI from developing and worsening during the Second NUH Admission. The court answered this in the negative. It relied on evidence that multiple pressure-relieving measures had been implemented before the DTI was first observed and continued thereafter. The judge found that the Claimant had not established that NUH fell below the requisite standard of care in offloading and pressure management. (Paras 62, 75, 78, 82)

"Nurse Naw deposed that as early as 2 October 2020, following the right knee aspiration performed on Mdm Parvaty, she had performed a ‘head-to-toe’ [emphasis added] skin assessment of Mdm Parvaty to determine which parts of her body would be more prone to pressure injuries." — Per Mavis Chionh Sze Chyi J, Para 75

The court’s reasoning was not limited to one witness. It also referred to documentary and photographic evidence showing that Mdm Parvaty’s right leg was elevated with a pillow and that her right heel was offloaded with a heel protector. That evidence supported the conclusion that NUH had taken active steps to reduce pressure on the heel. The judge therefore rejected the allegation that NUH had failed to prevent the DTI from developing or worsening. (Paras 78, 82)

"For example, photographs exhibited in the Claimant’s supplementary bundle of documents showed Mdm Parvaty’s right leg elevated with a pillow with her right heel also offloaded with a heel protector." — Per Mavis Chionh Sze Chyi J, Para 78

"Having regard to the evidence set out above at [75]–[81], therefore, I found no merit in the Claimant’s allegations about NUH’s failure to prevent the development of Mdm Parvaty’s DTI." — Per Mavis Chionh Sze Chyi J, Para 82

The significance of this finding is that the court treated pressure injury prevention as a question of actual clinical measures, not merely of adverse outcome. The fact that a DTI later appeared did not itself prove negligence. The Claimant had to show that reasonable preventive steps were omitted, and the court found that the evidence pointed the other way. (Paras 75, 78, 82)

Why Did the Court Accept Conservative Management of Dry Gangrene?

The second major issue was whether NUH was negligent in deciding to treat the dry gangrene conservatively instead of carrying out revascularisation and debridement during the Second NUH Admission. The court rejected the allegation that there had been a “delayed” referral to the Vascular team or that conservative management was inappropriate. The judge found that the dry gangrene was stable, with no evidence of underlying bogginess or surrounding cellulitis, and that the wound was not infected for much of the relevant period. (Paras 85, 86, 62)

"Pertinently, the dry gangrene on the right heel was observed on 29 November 2020 to be stable, with no evidence of underlying bogginess or surrounding cellulitis." — Per Mavis Chionh Sze Chyi J, Para 85

That factual finding was critical because it underpinned the court’s acceptance of conservative treatment. The judge reasoned that, on the evidence, the wound’s condition did not call for the immediate invasive intervention the Claimant advocated. The court therefore found no merit in the allegation that referral to the Vascular team had been delayed in a way that caused or contributed to the worsening of the DTI. (Paras 85, 86)

"For the reasons set out above, I also found no merit in the allegation that ‘delayed’ referral to the Vascular team caused or contributed to the worsening of Mdm Parvaty’s DTI." — Per Mavis Chionh Sze Chyi J, Para 86

The court’s conclusion on this issue also reflects the broader medical-negligence principle that a treatment choice is not negligent merely because another approach might later appear preferable. The judge assessed the decision in light of the wound’s then-current condition and the evidence of stability and lack of infection. On that basis, conservative management was not shown to be a breach. (Paras 70, 85, 86)

Why Did the Court Reject the Complaint About Discharge to AMKH and the Alleged Deterioration There?

The third and fourth issues concerned the discharge of Mdm Parvaty to AMKH on 13 January 2021 and the allegation that AMKH negligently caused the dry gangrene to deteriorate. The supplied extraction shows that AMKH denied any breach and maintained that the care, treatment, and management provided during Mdm Parvaty’s stay were appropriate and consistent with the relevant professional standard of care. The court ultimately found that the Claimant had not established any pleaded breach against AMKH. (Paras 56, 62, 6)

"However, AMKH denied that there was any breach of its duty of care. According to AMKH, the care, treatment, and management provided to Mdm Parvaty during her stay were appropriate at all times and consistent with the relevant professional standard of care." — Per Mavis Chionh Sze Chyi J, Para 56

The chronology shows that Mdm Parvaty was reviewed by Dr He on the day of admission to AMKH and that by 5 February 2021 the wound had deteriorated and was showing signs of wet gangrene. But the court did not treat that deterioration as proof of negligence. Instead, it required the Claimant to prove that AMKH’s conduct caused the deterioration or fell below the standard of care, and the judge found that burden had not been discharged. (Paras 18, 22, 62, 6)

"On 5 February 2021, Dr He and Dr Sandhya both observed that Mdm Parvaty’s right heel wound had deteriorated and was exhibiting signs of wet gangrene" — Per Mavis Chionh Sze Chyi J, Para 22

In other words, the mere fact of deterioration during a later period of care did not establish liability. The court’s approach remained anchored to proof of breach and causation, not to retrospective inference from the eventual amputation. That is consistent with the judgment’s repeated insistence on evidence known at the time and on the Claimant’s burden to prove the pleaded case. (Paras 70, 77, 6)

How Did the Court Deal With the Allegation That NUH Should Have Acted Immediately on Readmission?

The fifth issue was whether NUH was negligent in not performing debridement and/or angioplasty immediately upon or shortly after Mdm Parvaty’s readmission on 5 February 2021. The court rejected that allegation as well. The judge’s reasoning was that the Claimant had not shown that immediate invasive intervention was required on the facts known at that time, nor that the absence of such intervention amounted to a breach of duty. (Paras 62, 70, 6)

"At the conclusion of the trial, having considered the evidence and parties’ submissions, I found that the Claimant had failed to establish any of the pleaded breaches of duties; and I dismissed the claim against both Defendants." — Per Mavis Chionh Sze Chyi J, Para 6

This issue was closely connected to the earlier conservative-management question. Once the court accepted that the wound had been dry and stable for much of the relevant period, it followed that the Claimant faced a difficult burden in showing that NUH should have immediately debrided or performed angioplasty on readmission. The court did not accept that the evidence established such a duty in the circumstances. (Paras 85, 86, 70)

The judgment therefore reflects a consistent theme: the court was unwilling to convert a poor medical outcome into a finding of negligence without proof that the defendants’ conduct, judged at the relevant time, fell below the applicable standard. That approach led to rejection of the readmission allegation just as it led to rejection of the earlier allegations about pressure injury prevention and conservative treatment. (Paras 70, 82, 86, 6)

What Evidence Did the Court Find Most Persuasive?

The court placed significant weight on evidence from Nurse Naw, who described a “head-to-toe” skin assessment and the implementation of pressure-relieving measures. That evidence was important because it directly addressed the Claimant’s allegation that NUH failed to prevent the DTI. The judge also relied on photographs showing elevation and heel offloading, which corroborated the nursing evidence. (Paras 75, 78, 82)

"Nurse Naw deposed that as early as 2 October 2020, following the right knee aspiration performed on Mdm Parvaty, she had performed a ‘head-to-toe’ [emphasis added] skin assessment of Mdm Parvaty to determine which parts of her body would be more prone to pressure injuries." — Per Mavis Chionh Sze Chyi J, Para 75

Another important evidential point was the condition of the heel wound on 29 November 2020. The court found that the dry gangrene was stable and showed no evidence of underlying bogginess or surrounding cellulitis. That finding supported the conclusion that conservative management was reasonable and that the Claimant had not proved a need for immediate invasive treatment. (Para 85)

"Pertinently, the dry gangrene on the right heel was observed on 29 November 2020 to be stable, with no evidence of underlying bogginess or surrounding cellulitis." — Per Mavis Chionh Sze Chyi J, Para 85

The court’s treatment of the evidence is notable because it demonstrates a disciplined approach to medical records and contemporaneous observations. The judge did not infer negligence from the eventual outcome; instead, she examined the actual measures taken, the wound’s observed condition, and the timing of the relevant clinical decisions. That evidential discipline was decisive to the outcome. (Paras 70, 75, 78, 85, 6)

How Did the Court Apply the Rules on Pleadings and Evidential Burden?

The judgment expressly referred to the Evidence Act 1893 (2020 Rev Ed), ss 103 to 105, and to authorities on pleadings and burden of proof. The court cited those principles in the context of requiring the Claimant to prove the pleaded breaches and in refusing to entertain matters not properly pleaded. The result was that the Claimant had to establish each alleged breach with evidence, and the defendants were not required to disprove speculative or unpleaded assertions. (Para 77)

"ss 103 to 105 of the Evidence Act 1893 (2020 Rev Ed)." — Per Mavis Chionh Sze Chyi J, Para 77

The judgment also referred to authorities including How Weng Fan, Multi-Pak Singapore, V Nithia, OMG Holdings, and The “Tian E Zuo” for the proposition that parties are bound by their pleadings and that unpleaded issues cannot be decided merely because they emerged in cross-examination. That principle mattered in a case where the medical narrative was complex and where the court was careful to confine itself to the pleaded allegations. (Para 77)

In practical terms, the court’s evidential analysis meant that the Claimant could not succeed by pointing to a bad outcome and then filling gaps in the pleaded case with hindsight or argument. The burden remained on the Claimant to prove the specific breaches alleged, and the court found that burden had not been met. (Paras 77, 82, 86, 6)

Which Authorities Did the Court Refer To, and Why?

The judgment referred to a number of authorities on negligence, medical standard of care, expert evidence, burden of proof, and pleadings. Spandeck Engineering was cited for the elements of negligence. Hii Chii Kok was cited for the medical standard of care and the Bolam/Bolitho framework. Bolam and Bolitho were incorporated through Hii Chii Kok. Armstrong v Quest Laboratories was cited on when Bolitho is engaged. Ilechukwu and Sakthivel were cited on the evaluation of conflicting expert evidence. Britestone was cited on evidential burden. (Paras 67, 70, 77)

"In Hii Chii Kok, the Court of Appeal held that the requisite standard of care in relation to a doctor’s medical diagnosis and treatment (including pre- and post-operative care) was to be determined by the principles established in Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 (“Bolam”) and Bolitho v City and Hackney Health Authority [1998] AC 232 (“Bolitho”)." — Per Mavis Chionh Sze Chyi J, Para 67

The court also referred to the principle that, where expert evidence conflicts, the court should focus on consistency and logic rather than simply counting experts. That is especially relevant in medical negligence litigation, where multiple clinicians may offer different views about the appropriate course of treatment. The judgment’s citation of Ilechukwu and Sakthivel shows that the court was attentive to the quality of the evidence rather than the number of witnesses. (Para 77)

"In evaluating conflicting expert evidence, consistency and logic are more important than the number of experts called." — Per Mavis Chionh Sze Chyi J, Para 77

These authorities were not cited as abstract propositions; they were used to support the court’s concrete findings that the Claimant had not proved breach, that the defendants’ treatment choices were defensible on the contemporaneous evidence, and that the court would not expand the case beyond the pleaded issues. (Paras 67, 70, 77, 82, 86)

Why Does This Case Matter?

This case matters because it is a detailed application of Singapore medical-negligence principles to a difficult wound-care and vascular-management scenario. It shows that a plaintiff must do more than point to a tragic outcome such as amputation; the plaintiff must prove, with evidence, that the defendants’ conduct fell below the applicable standard of care and caused the harm alleged. The judgment is also a reminder that courts will assess clinical decisions by reference to the facts known at the time, not by hindsight after deterioration has occurred. (Paras 70, 82, 85, 86, 6)

"It was with these general principles in mind that I considered each of the issues below." — Per Mavis Chionh Sze Chyi J, Para 71

For practitioners, the case underscores the importance of careful pleading in medical negligence litigation. The court relied on the pleaded issues as the framework for decision-making and did not allow the case to drift into unpleaded territory. It also illustrates the evidential value of contemporaneous nursing notes, photographs, and wound assessments, especially where the dispute turns on whether pressure-relieving measures were in place and whether a wound was dry, stable, or infected at a particular time. (Paras 75, 78, 77, 85)

More broadly, the case reinforces that conservative management can be a defensible clinical choice where the wound is stable and non-infected, and that later deterioration does not automatically imply negligence. That is a significant practical point for hospitals, clinicians, and litigants alike, because it confirms that the law respects reasonable medical judgment even where the outcome is poor. (Paras 85, 86, 6)

Cases Referred To

Legislation Referenced

• Evidence Act 1893 (2020 Rev Ed), ss 103 to 105 (Para 77)

Source Documents

• Original Judgment — Singapore Courts
• Archived Copy (PDF) — Litt Law CDN

This article analyses [2026] SGHC 7 for legal research and educational purposes. It does not constitute legal advice. Readers should consult the full judgment for the Court's complete reasoning.