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23 June 2019

Your Ref: LPF/21827337

Messrs Skrine
Unit No 50-8-1, 8 Floor,
Wisma UOA Damansara,
50 Jalan Dungun,
Damansara Heights,
50490 Kuala Lumpur

Dear Sirs,

Re: Expert Report of Mr Gunaseekaran a/l Ealumalai (NRIC No : 600601-10-

7567) (“GE”)

Report prepared by: Dr Peter Jebaseelan Jesudason

Consultant Cardiologist

Professional Qualifications:

1. MBBChir (Cambridge)
2. BSc (Hons)
3. MRCP (UK)
4. Board Certified CBCCT (USA)

Registration

I, Dr Peter Jebaseelan Jesudason, [IC: 620621-07-5345], am a Consultant

Cardiologist & Physician at the Heart Centre1 st Floor , Block A, Pantai Hospital
Kuala Lumpur, 8 Jalan Bukit Pantai, 59100 Kuala Lumpur

1. I am registered with the Malaysian Medical Council with Registration Number

32596 and my National Specialist Registry Number is 128923.

2. I have been instructed by The Medical Protection Society (“MPS”) on behalf of

Dr Soo Lin Hoe (“Dr Soo”) and have been asked to answer several questions in
regard to Dr Soo’s medical management and treatment of GE.

Disclosure of Interests

3. I have no interest in Dr Soo, whose behalf I have been instructed. I have neither
provided advice to Dr Soo in regard to his care for GE, nor do I have a personal
interest in this dispute other than in connection with this report.
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4. In preparation of this expert opinion, the following documents were referred to:

(a) Chronology of Events

(b) The Core Bundle of Documents consisting of:

(i) 2017 European Society of Cardiology (ESC) Guidelines for the

Management of Acute Myocardial Infarction in Patients Presenting
With ST Segment Elevation

(ii) Clinical Practice Guidelines on the Management of Acute ST Segment

Elevation Myocardial Infarction (STEMI) 2014 – (3 rd Edition)

(iii) Timely PCI For STEMI – Still The Treatment of Choice. New England
Journal of Medicine, April 2013 ( Editorial )

Chronology of events of GE’s hospitalisation, surgical intervention and post-

operative care

6. GE was first admitted to Subang Jaya Medical Centre (“Hospital”) under the

care of Dr Puraviappan Periyanna, an ENT Specialist, on 5 December 2016

with complaints of vertigo, tinnitus, headache, chest pain and palpitations.

7. GE was then referred to Dr Soo on 6 December 2016, who saw GE for the first

time. Dr Soo’s assessment was of atypical chest pain and further tests were
arranged, including an Exercise Stress Test, a 24-hour Holter monitoring and
Echocardiography. All test results showed no abnormality, and this was
explained by Dr Soo to GE on 7 December 2016.

8. On 8 December 2016, GE complained of new chest tightness. Upon further

testing, the ECG showed acute anterior ST segment elevation myocardial

infarction. Medications were then administered to GE and he was sent to the
cardiac catheter lab whereby an occluded proximal LAD was re-opened and
stented, performed by way of Percutaneous Transluminal Coronary Angioplasty
(“PTCA”).

9. The Echocardiography and blood tests ran on 9 December 2016 showed

antero-apical MI with EF of 40% and trio T markedly elevated.

10. GE was transferred out of the CCU on 10 December 2016 and was fully mobile

when discharged from the Hospital on 12 December 2016 with a diagnosis of

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acute anterior MI, LVF and vestibular neuritis. The plan was for GE to present
himself in three weeks’ time for Dr Soo to review him.

11. In the evening of 12 December 2016 while at home, GE developed right-sided

weakness and aphasia at 8.00pm and was subsequently re-admitted to the

Hospital at about 8.30pm. He was then seen by Dr Yong Fee Mann (“Dr Yong”),
a Consultant Neurologist, who diagnosed GE with basal left middle cerebral
artery infarction.

12. On 13 December 2016, Dr Soo was notified of GE’s admission and upon

testing, found that GE had antero-apical hypokinesia with possible apical

thrombus. Aspirin, clopidogrel and heparin were administered to GE.

13. An echocardiography was performed again on 14 December 2016 which

showed recent antero-apical infarct with muscular bank in apex and no obvious
thrombus. GE’s cardiac status was stable during the daily review. GE received
rehabilitation care and was discharged on 22 December 2016.

14. When GE returned to the Emergency Department of the Hospital on 31

December 2016 with left-sided weakness, he was reviewed again by Dr Yong

and subsequently discharged.

15. Throughout the subsequent follow-ups from 5 January 2017 to 29 June 2017,

GE’s cardiac status was stable and his speech and heart function continued to
improve.

16. On 19 May 2018, GE was admitted to Hospital with complaint of burning chest

pain. Dr Soo diagnosed GE with gastroesophageal reflux disease. Results from

the cardiac tests performed showed no abnormality. The Echocardiography
showed small apical hypokinesia with improved heart function.

17. On 1 June 2018, GE presented himself before Dr Soo and upon examination,

Dr Soo found that GE had remained well and had a negative Exercise Stress
Test. This was the last follow-up GE had with Dr Soo.

Issues for determination by expert

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18. The following are the issues in the present case that my opinion has been
sought on:-

Pre-Procedures Evaluation

(i) During the period of 6 – 8 December 2016, whether Dr Soo’s medical

management and treatment of GE prior to the Percutaneous
Transluminal Coronary Angioplasty (“PTCA”) and Coronary
Angiogram (“CA”) procedures (hereinafter collectively referred as
“Procedures”) complied with the accepted professional practices and
guidelines;

Procedures

(ii) On 8 December 2016, whether the Procedures were the proper

medical treatment to treat GE when he was diagnosed with acute
anterior myocardial infarction;

(iii) Whether Dr Soo was negligent when conducting the Procedures on

GE;

(iv) Whether are there any alternative treatments available to GE if he

decides not to undergo the Procedures; if yes, whether the alternative
treatments take priority over the Procedures;

(v) Whether is it possible for the Procedures to cause GE to suffer from

stroke and/or brain haemorrhage;

GE’s readmission after Procedures

(vi) What are the possible and/or contributing factors that caused GE to
suffer from stroke?

(vii) During the GE’s readmission from 12 – 22 December 2016, when GE

was diagnosed with antero-apical hypokinesia with possible apical
thrombus by Dr Soo, whether Dr Soo’s medical management and
treatment of GE complied with the accepted professional practices
and guidelines;

GE’s follow up treatment

(viii) Whether Dr Soo follow up treatment with GE from 5th January 2017 to
1st June 2018 complied with the accepted professional practices and
guidelines;

Cause of GE’s alleged brain haemorrhage

(ix) Whether GE suffered from the alleged brain haemorrhage; if the

answer is in the positive, what are the possible factors which
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contributed or caused GE to suffer from the alleged brain

haemorrhage and whether it was caused by Dr Soo; and

(x) As to causation, whether there would have been a difference to GE’s

outcome if Dr Soo was found to be in breach of his management of
GE.

Opinion

19. With reference to the above, I now set out my opinion as below:-

Pre-Procedures Evaluation

(i) During the period of 6 – 8 December 2016, whether Dr Soo’s medical

management and treatment of GE prior to the Percutaneous
Transluminal Coronary Angioplasty (“PTCA”) and Coronary
Angiogram (“CA”) procedures (hereinafter collectively referred as
“Procedures”) complied with the accepted professional practices and
guidelines;

[ GE sustained an Acute Anterior STEMI which was managed by Dr Soo

appropriately and in a timely manner complying with current best practices
and guidelines. He was administered appropriate pre-procedural medication
as recommended by both the Health Ministry Clinical Practice Guidelines on
the Management of Acute ST Segment Elevation Myocardial Infarction (STEMI)
2014 – (3rd Edition) and the 2017 European Society of Cardiology (ESC)
Guidelines for the Management of Acute Myocardial Infarction in Patients
Presenting With ST-Segment Elevation.

Dr Soo obtained informed consent from GE for both the angiogram and the
PTCA after explaining the procedures to GE. The risks and benefits of the
procedures were clearly documented and this was consented to by GE ]

Procedures

(ii) On 8 December 2016, whether the Procedures were the proper

medical treatment to treat GE when he was diagnosed with acute
anterior myocardial infarction;

[ GE had a ‘Primary PTCA’ to treat his acute myocardial

infarction within the window period of less than 2 hours
whereby a PTCA procedure is proven to provide superior
clinical outcomes. Please refer to Editorial New England Journal
Medicine April 2013 – Timely PCI for STEMI – The Treatment of
Choice ]

(iii) Whether Dr Soo was negligent when conducting the Procedures on

GE;
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In the clinical context, Primary PTCA was the best option for GE
relative to Thrombolytic or medical therapy because it was
performed within 90 minutes from when the diagnosis was
made
with no complications documented. As such there was no
negligence.

(iv) Whether are there any alternative treatments available to GE if he

decides not to undergo the Procedures; if yes, whether the alternative
treatments take priority over the Procedures;

[ Yes, the alternative was Thrombolytic therapy. However, this would

have been an inferior alternative because revascularisation of the
infarct related artery would be relatively incomplete when compared
to Primary PTCA. Furthermore, the risk of brain haemorrhage is
Higher with Thrombolytic Therapy]

(v) Whether is it possible for the Procedures to cause GE to suffer from

stroke and/or brain haemorrhage;

[ The risk of stroke / brain haemorrhage albeit small, is well

recognised during PTCA either from embolic phenomena or due to
anticoagulants administered during the procedure. However, the risk
of brain haemorrhage would have been higher if Thrombolytic
Therapy was used as the alternative treatment option for the
myocardial infarction ]

GE’s readmission after Procedures

(vi) What are the possible and/or contributing factors that caused GE to
suffer from stroke?

[ GE suffered an infarct related stroke and not a haemorrhagic stroke.

The event occurred 4 days after the PTCA and therefore cannot be
attributed to a PTCA related embolic phenomenon causing the
infarct. It was most likely due to an embolic thrombus ( clot ) arising
from the apex of the heart as a result of antero-apical hypokinesis
following the heart attack. This is because the affected region of the
heart does not pump blood effectively, there is relative stasis of
blood which predisposes to thrombus formation. There were
documented features of an apical thrombus noted during an ECHO
examination on 13th December, a day after his stroke. ]

(vii) During the GE’s readmission from 12 – 22 December 2016, when GE

was diagnosed with antero-apical hypokinesia with possible apical
thrombus by Dr Soo, whether Dr Soo’s medical management and
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treatment of GE complied with the accepted professional practices

and guidelines;

[ As a result of the cerebral infarct ( stroke due to blockage of vessel

as opposed to haemorrhage) and documented apical thrombus, he
was appropriately treated with anticoagulants to minimise the risk of
a further cerebral infarct occurring. A repeat ECHO on the 14 th
December, showed no evidence of the apical thrombus seen earlier. ]

GE’s follow up treatment

(viii) Whether Dr Soo follow up treatment with GE from 5th January 2017 to
1st June 2018 complied with the accepted professional practices and
guidelines;
[ GE’s Stroke was managed by a Neurologist and there was a close
collaboration with Dr Soo Lin Hoe who managed the Cardiological
issues. He was given an anticoagulant ( Warfarin ) for an appropriate
period. He made a good recovery from his heart attack with
Echocardiography in May 2018 showing preserved LV function with
an Ejection Fraction of 58% ( normal ). There was a small area of
residual apical hypokinesia. An exercise ECG in June 2018 was
negative showing no evidence of lack of blood supply to the heart
muscle. ]

Cause of GE’s alleged brain haemorrhage

(ix) Whether GE suffered from the alleged brain haemorrhage; if the

answer is in the positive, what are the possible factors which
contributed or caused GE to suffer from the alleged brain
haemorrhage and whether it was caused by Dr Soo;

[ There is no evidence either from clinical assessment or brain

scans, to suggest that GE suffered a haemorrhagic stroke. All
evidence points to an infarct related stroke. As such, the claim
against Dr Soo Lin Hoe is not tenable because it is based on a false
premise. ]

(x) As to causation, whether there would have been a difference to GE’s

outcome if Dr Soo was found to be in breach of his management of
GE.

[ In my opinion, the cause of the stroke was due to an embolus

arising from the apical thrombus as a result of the heart attack. The
causation of the Stroke was unrelated to any possible breach in
management ]

Conclusion
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20. [ I am of the opinion that Dr Soo Lin Hoe treated GE in a most

professional and appropriate manner based on internationally recognised
current guidelines on treatment of an acute anterior STEMI. I could find
no evidence of negligence in his management of GE. ]

Statement of Truth

21. I hereby confirm that I have made clear which facts and matters referred to in
this report are within my own knowledge and which are not. I believe of the
correctness of my opinion and understand that in giving my report, my
overriding duty is to the Court and that I comply with that duty.

Yours sincerely,

Dr Peter Jebaseelan Jesudason

Consultant Cardiologist
Pantai Hospital Kuala Lumpur