Mr Savarimuthu Arul Xavier, an Indian national working as a construction worker in Singapore, died in December 2014 after developing an invasive fungal infection after ingesting the medicine he was prescribed.
Dr Haridass Ramdass, the doctor operating from a clinic in Chander Road in Little India, was fined $1,500 after pleading guilty to one count of endangering the personal safety of his patient by a negligent act.
The doctor was initially charged with causing Mr Xavier’s death by rash act in 2014, but the charge was reduced by the prosecution later.
Mr Xavier’s Medical History
Back in 2014, the 28-year-old Mr Xavier had visited three different clinics between October and November 2014 after developing rashes all over his body.
All the clinics diagnosed him with psoriasis, an autoimmune skin disease that causes red, itchy, scaly patches usually near the joints, and is a long-term (chronic) disease without a cure. It tends to cycle, flaring up for a few weeks or months, before subsiding again.
Thus, they prescribed him medications such as antihistamines and steroid cream.
However, when Mr Xavier saw no improvement in his medical condition, he decided to visit a fourth doctor in Little India called Tekka Clinic on 24 November 2014.
Dr Haridass was the sole doctor operating at the clinic.
At that instance, he noticed that Mr Xavier had “extensive reddish and round lesions all over his body”, even going up to his scalp.
Mr Xavier proceeded to inform him that his skin condition had been persisting for over 20 days and he had seen three other doctors before him.
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Dr Haridass’ Prescription of Medication
Haridass came to the same conclusion that Mr Xavier was suffering from psoriasis and gave him an injection of dexamethasone, a steroid used to treat conditions like arthritis, hormone disorders, allergic reactions, and skin diseases.
Afterwards, he prescribed the patient 10 tablets of methotrexate (MTX), 10 tablets of prednisolone, and 10 tablets of chlorpheniramine.
Prednisolone is a type of steroid medication that is used to treat certain allergies, autoimmune disorders, and inflammatory conditions.
Chlorpheniramine is typically used to treat allergic conditions.
However, neither of the above were ultimately the cause of Mr Xavier’s death.
Rather, it was the methotrexate that dealt the most of the damage.
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MTX is a drug that is frequently used in cancer treatment and can also be used in the treatment of severe psoriasis.
One of its notable and possible side-effects include life-threatening toxic reactions.
According to Deputy Public Prosecutor (DPP) Koh, he said: “MTX may produce depression of the bone marrow and lead to a deficiency in red blood cells and platelets, as well as bleeding.
“Deaths have been reported to follow the use of MTX in the treatment of psoriasis… Potentially fatal opportunistic infections, for instance by fungi, may also occur with MTX therapy.”
Unbeknownst to Haridass because of his negligence when prescribing the medication, he was unaware that Mr Xavier had some kind of renal impairment.
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Back then, instead of arranging for Mr Xavier to undergo some tests first—which would have allowed him to discover the patient’s renal impairment—he skipped straight to the prescription without fully understanding the patient’s bodily condition.
For patients with impaired renal function, MTX therapy should be used with extreme caution, since the impairment increases the potential for MTX toxicity.
Worst still, the dosage that Haridass prescribed Mr Xavier did not follow the established guidelines, which originally caused the prosecution to slap him with the charge of causing death by a rash act under Section 304A(a) of the Penal Code.
Quick Deterioration of Mr Xavier’s Bodily Condition
The negligent act of prescribing MTX caused Mr Xavier to develop neutropenia, a condition that stems from the body not possessing enough neutrophiles, an important white blood cell to fight infections, as dictated by the American Academy of Allergy Asthma and Immunology.
Simultaneously, he also developed mucositis, a complication which arises in some cancer therapies where the lining of the digestive system becomes inflamed.
Adding on the inherent toxicity of the MTX, these developments resulted in Mr Xavier succumbing to “invasive fungal infection” that eventually led to his death.
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16 days after visiting Haridass’ clinic, Mr Savarimuthu Arul Xavier passed away on 10 December 2014.
Court Sentencing
Though Haridass was previously charged with causing a patient’s death via rash act, the charge he admitted to on Thursday (10 Feb) was endangering personal safety by a negligent act.
The DPPs argued for the maximum fine of $1,500, wanting the sentence to be of adequate deterrence to future medical professionals.
In response, Haridass’ lawyer, Senior Counsel Davinder Singh of Davinder Singh Chambers, appeased the prosecution by stating that there was no risk of Haridass re-committing the offence since he has retired and chosen not to renew his practising certificate.
Prior to Mr Xavier’s death, Haridass had been working as a general practitioner for 44 years, having received his medical degree from India’s Karnatak University in 1971.
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“He is genuinely remorseful and accepts that he is wrong,” Mr Singh affirmed.
Had Haridass been convicted of causing death by rash act not amounting to culpable homicide, he might have faced up to five years in jail, a fine, or both.
On the other hand, his lightened sentence of endangering the personal safety of the patient could have had a maximum penalty of three years in prison, concurrently with a fine of $1,500.
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