Coroner rules COVID-19 patient’s death a medical misadventure, cannot confirm TCM pills’ link

Coroner rules COVID-19 patient's death a medical misadventure, cannot confirm TCM pills' link

SINGAPORE: The death of a 61-year-old man who was suffering from COVID-19 and an allergic reaction to an unknown substance was ruled a medical misadventure by a coroner’s court on Wednesday (Jan 24).

Mr Koh Choon Lim died at Tan Tock Seng Hospital on Jul 29, 2022, two days after taking four capsules of Lianhua Qingwen Jiaonang to deal with the COVID-19 symptoms he was experiencing.

While the traditional Chinese medicine (TCM) pills were flagged as a possible trigger for the allergic reaction in medical notes, State Coroner Adam Nakhoda said in his findings on Wednesday that this could not be conclusively confirmed in a post-mortem setting.

Mr Koh, a Singaporean who leaves behind his wife and children, died as a result of a mix of factors.


His final cause of death was anaphylaxis – a severe, life-threatening allergic reaction – and a COVID-19 respiratory tract infection, which his emphysema and coronary artery disease contributed to.

Emphysema is a lung condition that causes shortness of breath.

The coroner stated that smoking was considered the primary cause of Mr Koh’s emphysema – he was a regular smoker who smoked about 16 cigarettes a day.

He also had high cholesterol and hypertension, both of which may have contributed to his coronary artery disease.


The coroner’s court heard that Mr Koh began to show symptoms of a COVID-19 infection on Jul 26, 2022.

He tested positive with a faint line that day and a starker line the next day, and had symptoms including a headache and a sore throat.

At about 11.30pm on Jul 27, 2022, Mr Koh took four of the TCM pills, which he had taken before.

The next morning, Mr Koh went to a clinic and saw a doctor, who assessed that Mr Koh was displaying symptoms of an anaphylactic reaction.

He administered injections to manage the symptoms and advised Mr Koh to go to an emergency department. The doctor told Mr Koh that anaphylaxis was a life-threatening condition which could rebound, and that it could be the difference between life and death if his condition deteriorated further.

Mr Koh declined and accepted the risks. He was monitored at the clinic for an hour, during which his symptoms improved. Despite this, the doctor again advised him to go to an emergency department, but Mr Koh did not want to be referred to one.

Later that afternoon, Mr Koh’s family members realised that he was exhibiting strange behaviour, appearing disoriented and unaware of his actions.


He was taken to Tan Tock Seng Hospital’s accident and emergency department at 7.30pm with a three-day-old COVID-19 infection, suspected anaphylaxis and an altered mental state.

He had mild swelling over his upper lip and eyelids, but he was not in respiratory distress, a CT scan of his brain was “unremarkable” and his airway was not obstructed, the coroner said.

Medical notes stated that the anaphylaxis was from an “unclear precipitant” but possibly was from the TCM pills and less likely due to a stroke.

Extensive test investigations were carried out and Mr Koh was admitted to the National Centre for Infectious Diseases (NCID) in the early morning of Jul 29, 2022.

In the ward, he was stable and placed on four-hourly monitoring. However, Mr Koh was noted to be hyperactive, confused and restless.

He repeatedly removed his diapers and pants that nurses put on him, as well as the intravenous cannula in his arm, staining his clothes.

As Mr Koh was assessed to have a “high fall risk”, he was placed in restraints and a body vest.

The coroner found that it was clear that the nursing staff regularly checked on Mr Koh and observed him from the time he was admitted to the NCID ward up to about 7am.

Until this time, there was no acute deterioration in his clinical state, said the coroner.

However, evidence suggested that Mr Koh was not attended to between 7am and 7.45am.

At 7.45am, Mr Koh was found to be unresponsive and cardiopulmonary resuscitation was performed on him while a code blue team was activated. Code blue refers to a situation where a patient is in cardiac or respiratory arrest.

He was pronounced dead at about 8.30am.


The coroner noted that while next-of-kin would wish for constant communication on the conditions of their loved ones, “this might not be practical in a hospital setting when staff have a number of patients they need to care for”.

He said the incidents that morning, including Mr Koh’s removal of his IV cannula and diapers and his placement in restraints and a geriatric chair, might be significant events to the family, but did not warrant a call to them from the hospital staff.

The coroner said the hospital’s decision to place Mr Koh in restraints and a body vest was not unreasonable.

As to why his condition had suddenly deteriorated, the coroner said he accepted an expert’s testimony that Mr Koh’s “anaphylaxis presentation was atypical”.

The coroner conveyed his condolences to Mr Koh’s widow and two sons who attended Wednesday’s hearing.

When asked if they had anything to say, the two sons raised a point from the findings that stated that each patient was given a call bell, which was placed on their bed.

There was no call bell affixed to the geriatric chair which Mr Koh was left in.

Mr Koh’s son took issue with a line in the findings that said a senior staff nurse may have decided not to give Mr Koh a call bell while he was in the chair in order to avoid triggering unnecessary false alarms as he was in a restless state.

The coroner said this was an issue with the hospital’s management and the family had to bring it up with the hospital if they had any concerns. It would not alter his findings in the case, he said.

A lawyer representing Tan Tock Seng Hospital was also at the hearing.