TABLE OF CONTENTS TABLE OF CONTENTS1 INDEX OF AUTHORITIES2, 3, 4, 5 TORT PROBLEM BASED LEARNING: QUESTION..6 PLEADINGS OF THE APPELLANT I. DR.

HARIS WAS NEGLIGENT FOR NOT SUSPECTING A TESTICULAR TORSION AND REFERING AMIN TO AN UROLOGIST, RESULTING IN HIS DEATH7

A. Dr. Haris owed Amin a duty of care as his doctor..7 B. Dr.Haris breached that duty of care owed to Amin8 1. The standard of care owed by a General Practitioner....8 2. Dr.Haris has Breached that Standard of Care...10 C. The breach of that duty of care by Dr.Haris resulted in Amins death..........................................................................................................11 1. Causation in Fact..11 2. The death of Amin was reasonably foreseeable...12 3. Egg-Shell Rule.13 4. The defence of contributory negligence cant be used by Dr.Haris.14 D. Compensation...15

PLEADINGS OF THE RESPONDENT I. DR. HARIS WAS NOT NEGLIGENT FOR NOT DIAGNOSING TESTICULAR TORSION..16 A. Dr. Haris owed Amin a duty of care as a doctor, general practitioner B. Dr. Haris did not breach the standard of care...16 1. Dr Haris acted in accordance to accepted current medical practice.16

2. Dr Haris did not breach the standard of care in duty to diagnose and treat...17 C. Amins death was not caused by the misdiagnosis of Dr.Haris...18 1. Lack of Causation in Fact.18 (i) Low probability of testicular torsion causing death to a person in a short period of time...19 2. There is a break in the chain of causation by Amin and Puan Julia.20 3. The death of Amin due to testicular torsion is not reasonably foreseeable by Dr Harris...21

II. ALTERNATIVE ARGUMENT: AMIN HAS CONTRIBUTED PARTIALLY TO HIS OWN DEATH DUE TO HIS NEGLIGENT ACT.23 A. Law of contributory negligence as defence in Malaysia.......23 B. Elements of contributory negligence..23 1. 2. Claimants negligence must be a contributory factor.24 The loss suffered by Amin is reasonably foreseeable...25

BIBLIOGRAPHY..27, 28, 29 ANNEX I (APPELLANT) ANNEX II (RESPONDENT)

INDEX OF AUTHORITIES STATUTES Civil Law Act 195623 CASES Anns and Others v London Borough of Merton [1978] AC 728.7 Barnett v Chealse & Kensington Hospital Management Committee [1969] 1 QB 428.11 Bolam v Friern Hospital Management Committee [1957] 2 ALL ER 118..8, 9 Bolitho v City & Hackney Health Authority (1997) 4 All ER 77116 Bradford v Robinson Rentals Ltd [1967] 1 All ER 267.13 Caparo Industries v Dickman and others [1990] 1 All ER 5687 Capps v Miller [1989] 2 All ER 333......24 Chelliah A/L Manickam & Anor v Kerajaan Malaysia (1997) 2 AMR 18567 Chin Keow v Government of Malaysia & Anor [1967] 2 MLJ 458, 17 Cork v Kirby Maclean Ltd [1952] 2 All ER 402.11, 19 Davies v Swan Motor Co (Swansea) Ltd [1949] 2 KB 291...14 Defreitas v OBrien and Connolly (1995) 6 Med LR.108 page 115..16 Donoghue v Stevenson [1932] AC 5627 Doughty v. Turner Manufacturing Co. Ltd [1964] I QB 518.22 Dulieu v White & Sons. Divisional Court, [1901] 2 KB 66914
3

Elizabeth Choo v Government of Malaysia & Anor [1970] 2 MLJ 171..9 Estate of Jeannette Tranor v Bloomsburg Hospital, 913 F.Supp. 388...10 F v R [1983] 33 SASR 189..9 Foo Fio Na v Dr. Soo Fook Mun [2007] 1 MLJ 593.9, 16 Froom v Butcher [1976] QB 286...24 Gordon v Wilson (1992) 3 Med LR401.18 Government of Malaysia & Ors v Jumat Bin Mahmud & Anor [1977] 2 MLJ 10313 Hunter v Hanley (1955) SLT 213...17 Hutchinson v. Leeds Health Authority (2000) unreported.22 Jaswant Singh v Central Electricity Board and Anor [1967] 1 MLJ 272...13 Jones v Livox Quarries LD [1952] 2 QB 60814, 23, 25 Kamalam a/p Raman & Ors v Eastern Plantation Agency Sdn Bhd & Anor [1996] 4 MLJ 6749 Kow Nan Seng v Nagamah & Ors [1982] 1 MLJ 128.9 Maynard v West Midlands Regional Health Authority [1984]1 WLR 634...17 Mohd Zukhairi Abd Ghapor v Quek Chiam Kee [2004] 1 MLJ 6.23 OConnell v Jackson [1972] 1 QB 27024 Overseas Tankship (U.K.) Ltd v Morts Dock & Engineering Co Ltd, [1961] AC 388................................................................................................................................13, 21 R v Bateman (1925) All ER Rep 45...8, 16
4

R v Blaue [1975] 3 All ER 446..14 Re Polemis (1921) 3 KB 560.21 Robitaille v Vancouver Hockey Club Ltd (1981) 124 D.L.R.(3d) 228..23 Roe v Minister of Health & Anor (1954) 2 All ER 131.16 Rogers v Whitaker [1992] 175 CLR 479.9 Sadler v Henry (1954) 1 BMJ 1331...18 Sidaway v Bethlem Royal Hospital Governors [1985] 1 All ER.9 Sivakumaran & Ors v Yu Pan & Anor [1995] 1 MLJ 12.13, 14 Smith v Leech Brain & Co., LTD and Anor., [1962] 2 QB 40514 Swamy v Mathews (1968) 1 MLJ 138...18 The Oropesa (1943) P32.20 Uniphone Sdn Bhd v Chin Boon Lit & Anor [1998] 6 MLJ 441.7 Whitehouse v Jordan [1980] 1 All ER 650..8 Wilsher v Essex Area Health Authority [1988] AC 1074......19

TORT PROBLEM BASED LEARNING: THE QUESTION Amin was playing with his friends at the football field on one Sunday evening. During the play, he suffered pains at his groin in an attempt to intercept the ball. He went home limping in agony. His mother, Pn. Julia took him to the hospital immediately and was attended by Dr Harris, a general practitioner. He applied some ointment on his stomach and groin and assured Amin and his mother that it is just a slight bruise caused by the ball. They went home with some antibiotics and ointment to be applied on the concerned area. Next day, Amin felt fine and went to the park to play football with his friends. The same night, Amin complained of severe pain in his testicle to Pn Julia. She found that the bruise has subsided and there was no further injury or bruise found anywhere else. She gave Amin a warm bath and his condition changed for the worse. Amin died soon after. It was found that Amin had a twised testicle also known as testicle torsion caused by the incident in the football field. Puan Julia planned to sue Dr Harris.

PLEADINGS FOR CLAIMANT

I.

DR.HARIS WAS NEGLIGENT FOR NOT SUSPECTING A TESTICULAR

TORSION AND REFERING AMIN TO AN UROLOGIST, RESULTING IN HIS DEATH.

A.

Dr. Haris owed Amin a duty of care as his doctor. The existence of duty of care was previously determined using the neighbour

principle 1 and the Anns Test,2 but finally the Caparos Test 3 was used as the determining test for the existence of duty of care. In Malaysia, the test used is the Caparos Test as stated by Kamalanathan Ratnam J. in the case of Uniphone Sdn Bhd v Chin Boon Lit & Anor.4 In our case, Dr. Haris is a professional (general practitioner) while Amin was his patient. When a doctor is consulted by a patient, the doctor automatically assumes a duty of care.5 It goes without saying that general practitioners (hereinafter referred to as GP) owe a duty of care to everyone on their patience list.6 Amin and Dr.Haris shared a direct and close relationship of proximity which was a doctor-patient relationship.7 Therefore it can be concluded clearly, that a

Donoghue v Stevenson [1932] AC 562, House of Lords, per Lord Atkin, persons who are so closely and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to the acts or omissions which are called in question. 2 Anns and others v London Borough of Merton [1978] AC 728, House of Lords, per Lord Wilberforce, 1. There was sufficient relationship of proximity between plaintiff and defendant and, 2. Court has to examine whether the consideration raised would reduce the scope of duty. 3 Caparo Industries v Dickman and others [1990] 1 All ER 568, House of Lords, per Lord Bridge, 3 elements need to be proven: (1) damage caused was reasonably forseeable, (2) the plaintiff and defendant has a close and direct relationship of proximity, and (3) it is just and reasonable to impose a duty of care. 4 [1998] 6 MLJ 441, High Court, para 19, In Caparo Industries Plc v Dickman & Ors [1990] 2 AC 605 , the House of Lords distilled the essence obtained from the earlier cited cases to establish a duty of care by interlocking three criteria for the court to consider 5 Michael Drury, Clinical Negligence in General Practice, Radcliffe Publishing, 2000, p.185. 6 Ibid. 7 Chelliah A/L Manickam & Anor v Kerajaan Malaysia (1997) 2 AMR 1856, High Court, per Jeffrey Tan J., p.1859, Doctors and members of other professions and callings must, therefore, exercise the standard of skill which is usual in their profession or calling, and it is no defence that they acted to the best of their skill if that falls below the required standard. 7

professional does owe a duty of care to his patient, as per Lord Hewart CJ in R v Bateman.8

B.

Dr.Haris breached that duty of care owed to Amin

1. The standard of care owed by a General Practitioner The standard of care that is demanded from a professional individual is higher than the ordinary man on the street.9 The primary question is whether in all circumstances the defendant acted with the skill and competence to be expected from a person undertaking his particular activity and professing his specific skill.10 The precedent case for medical negligence is Bolam v Friern Hospital Management Committee11. Mc Nair J in his directing to the jury stated that if a medical man who has taken step as what a reasonable competent medical man will take at the time, he will not be held liable for any mishaps.12 This principle was approved in the case of Whitehouse v Jordan13 where it was held that the doctor was not liable based on the opinion of other competent medical men.14 The Bolams test was followed in Malaysian cases as well. In the case of Chin Keow v Government of Malaysia & Anor,15 the Privy Council agreed with the trial judge

(1925) All ER Rep 45, If a person holds himself out as possessing special skill and knowledge, and he is consulted as possessing such skill and knowledge, by or on behalf of a patient, he owes a duty to the patient to use due caution in undertaking the treatment. 9 Norchaya Talib, Law of Torts in Malaysia, 3rd edition, Sweet & Maxwell Asia, 2003, p.149. 10 John Murphy, Street on Torts, 12th edition, Oxford University Press, 2007, p.115,116. 11 [1957] 2 ALL ER 118, Queens Bench Division, McNair J. 12 Ibid, p.121, In the case of a medical man negligence means failure to act in accordance with the standards of a reasonably competent medical men at the time. That is a perfectly accurate statement, as long as it is remembered that there may be one or more perfectly proper standards; and if a medical man conforms with one of those proper standards then he is not negligent. 13 [1980] 1 All ER 650, Court of Appeal, Civil Division. 14 Ibid, per Lord Denning MR, The great preponderance of opinion is that neither Mr Jordan nor the hospital were guilty of any negligence. Professor L B Strang (London), Professor J P M Tizard (Oxford), Dame Josephine Barnes (Charing Cross Hospital) and Professor Sir John Dewhurst (London) all say so. 15 [1967] 2 MLJ 45, Privy Council. 8

in adopting the test propounded by McNair J. in the Bolam case.16 In the case of Elizabeth Choo v Government of Malaysia & Anor,17 Raja Azlan Shah J. applied the bolams test when he stated that a professional will not be deemed to be negligent if he has taken steps that would normally be taken by others who are in the same position. 18 It was also applied in the case of Kow Nan Seng v Nagamah & Ors. 19 However, there was another case with a different view which mostly affected the standard of care of doctors in regards to providing information to patients rather than the treatment and diagnosing aspect. In Rogers v Whitaker,20 the court agreed with King CJ in F v R21 and Lord Scarman in the case of Sidaway v Bethlem Royal Hospital Governors22 and laid down the principle that a professionals conduct must conform to the standard of reasonable care demanded by the law, which is a question to be decided by the courts.23 This also includes diagnosis and treatment by doctors, which the court said must be provided according to the professionals skill or level.24 This case was applied in Kamalam a/p Raman & Ors v Eastern Plantation Agency Sdn Bhd & Anor, 25 where Richard Talalla J. stated that although evidence from medical experts will be taken into consideration, the courts are not bound by them.26 This was further affirmed in the case of Foo Fio Na v Dr. Soo Fook

16

Ibid, per Sir Hugh Wooding, para 6, For this purpose he adopted the test, in their Lordships' opinion quite rightly, which was propounded by McNair J. in Bolam v Friern Hospital Management Committee. 17 [1970] 2 MLJ 171, OCJ Kuala Lumpur. 18 Ibid, para 6. 19 [1982] 1 MLJ 128, Federal Court, Salleh Abas J., para 10, There may be differences of opinion as to the types of plaster casts to be applied in the treatment of the type of injuries sustained by the respondent, but the choice of a treatment which is the standard medical practice is not by itself a negligence, Bolam v Frien Hospital Committee [1957] 2 All ER 118 and Elizabeth Choo v Government of Malaysia & Anor [1970] 2 MLJ 171 . 20 [1992] 175 CLR 479, High Court of Australia. 21 [1983] 33 SASR 189, Supreme Court of South Australia, p.194, The ultimate question, however, is not whether the defendant's conduct accords with the practices of his profession or some part of it, but whether it conforms to the standard of reasonable care demanded by the law. That is a question for the court and the duty of deciding it cannot be delegated to any profession or group in the community. 22 [1985] 1 All ER 643, House of Lords, p.645-655. 23 Supra, Note 20, Mason CJ. 24 Ibid, In diagnosis and treatment, the patient's contribution is limited to the narration of symptoms and relevant history; the medical practitioner provides diagnosis and treatment according to his or her level of skill.
25
26

[1996] 4 MLJ 674, High Court Muar.

Ibid, p.686, I should emphasize that while due regards will be given to the evidence of medical experts, I do not accept myself as being restricted by the establishment in evidence of a practice accepted as proper by a responsible body of medical men skilled in that particular art to finding a doctor is not guilty of negligence if he has acted in accordance with that practice. In short I am not bound by the Bolam principle. 9

Mun 27 , but the Federal Court also mentioned the importance of medical opinions in deciding a medical negligence case.28 In this case, Dr.Haris is a GP and therefore the standard of care owed by him is a standard of care owed by a reasonable competent GP. GPs must differentiate on clinical evidence and in the absence of full investigations those patients who may be safely treated at home from those who need referral for secondary care. 29 They undertake initial investigations and refer those whom are in need of specialist attention.30 They must also provide competent and appropriate advice.31 A GP can also be liable when he has failed to refer a patient to the correct specialist.32 Testicular torsion is a surgical emergency and it occurs mostly in adolescent boys.33 Symptoms of testicular torsion includes sudden or severe pain in one testicle, swelling of the scrotum, nausea and vomiting, abdominal pain, a testicle thats positioned higher than normal or at an odd angle or sudden testicle pain that goes away without treatment. 34 Unless the clinician is 100% sure it not testicular torsion, it should be considered an emergency and arrangements for a surgical exploration should be made.35. 2. Dr.Haris has Breached that Standard of Care. Delay in diagnosis of a serious condition and referral to a specialist is one of the most common clinical areas leading to a claim of negligence.36 A GP should consider the
27

[2007] 1 MLJ 593, Federal Court, per Siti Norma Yaakob J., p.612, On this basis, we are of the view that the Rogers v Whitaker test would be a more appropriate and a viable test of this millennium then the Bolam Test. 28 Ibid, Therefore, there is a need for members of the medical profession to stand up to the wrong doings, if any, as is the case of professionals in other professions. In so doing, people involved in medical negligence cases would be able to obtain better professional advice and that the courts would be appraised with evidence that would assist them in their deliberations. 29 John Garfield and Christopher J. Earl, Medical Negligence: The Cranium, Spine and Nervous System, WileyBlackwell, 1999, p.66. 30 Medical Case Notes Assessment Ltd, Medical Negligence Expert Reports for the UK and Ireland, Kent, http://www.medicalcasenotes.co.uk/General_Practice.htm. 31 Michael Drury, Clinical Negligence in General Practice, Radcliffe Publishing, 2000, p.185. 32 F of Jeannette Tranor v Bloomsburg Hospital, 913 F.Supp. 388 (M.D. PA. March 15, 1999), District Court, McClure District Judge. 33 Dr.Damian C . Crowther, General Practice Notebook, The Cambridge Institute of Medical Research, Cambridge. 34 Erik P Castle M.D, Mayo Foundation for Medical Education and Research. 35 Kaplan, Kaplan Medical USMLE Step 3 Qbook, Kaplan Publishing, 4th edition, 2008, p.592. 36 Medical Case Notes Assessment Ltd, Medical Negligence Expert Reports for the UK and Ireland, Kent, http://www.medicalcasenotes.co.uk/General_Practice.htm. 10

possibility of torsion in any adolescent with a painful or swollen scrotum.37 Amin had two of the symptoms which are pain at the groin and at the abdomen. Dr.Haris should have immediately referred Amin to an urologist for confirmation and an emergency operation. However he failed that standard of care by treating it as a normal bruise. C. The breach of that duty of care by Dr.Haris resulted in Amins death. 1. Causation in Fact. A But for test of "BUT FOR the existence of A, would B have occurred?" can be carried out to justify Dr. Harriss actions. This test can be first seen in the case of Cork v Kirby Maclean Ltd.38 It was then applied in Barnett v Chelsea & Kensington Hospital Management Committee,39 where it was held that the deceased would have died even if the defendants did not commit negligence.40 Testicular torsion is a surgical emergency which needs immediate attention.41 If Amin was treated within 6 hours, he would have a 90% chance to save his testicles.42 However if it left to a period of above 24 hours, the chances of saving the testicles is next to none.43 When a patient presents himself with abdominal pain only and not scrotal pain, then delay and consequent orchidectomy 44 are likely. It is essential that general practitioners know that patients with testicular torsion may have no scrotal pain at all, but only pain in the abdomen. There had been many cases in which one feels abdominal pain initially but no scrotal pain but later develops testicular torsion and in cases like this,

37 38

Sara Bird, Medicolegal Adviser at MDA National, Australian Family Physician, Volume 32, No.7, 2003, p.527. [1952] 2 All ER 402, Court of Appeal, Lord Denning, If you can say that the damage would not have happened but for a particular fault, then that fault is in fact a cause of the damage; but if you can say that the damage would have happened just the same, fault or no fault, then the fault is not a cause of the damage. 39 [1969] 1 QB 428, Queens Bench Division. 40 Ibid, per Nield J., For these reasons, I find that the plaintiff has failed to establish, on the grounds of probability, that the defendants' negligence caused the death of the deceased. 41 Wampler SM, Llanes M, Common Scrotal and Testicular Problems, Prim Care 2010, Department of Family Medicine, University of Michigan; Timothy J Rupp (MD, FACEP, FAAEM), Testicular Torsion in Emergency Medicine, Southwestern Medical Centre, University of Texas. 42 Ibid. 43 Ibid. 44 The removal of the testicles. The penis and the scrotum, the pouch of skin that holds the testicles, are left intact. 11

patients normally ends up having the said testicle excised.45 Williamson46 reported that 11% of patients had no scrotal pain, 39% had some pain in the lower abdomen and 19% experienced inguinal pain. Cass 47 stated that 12.5% of 49 patients experienced only abdominal or inguinal pain and 52.5% had scrotal pain with some radiation to these regions. Pain initially confined to the abdomen was noted by Greaney48 in 11% of 19 cases. Although testicular torsion occurs in all age groups, torsion is most common in adolescents. Testicular torsion causes a massive loss of blood flow to the testicle.49 When blood flow to an internal organ is cut off, it can cause internal gangrene. 50 In a study of testicular torsion, all the patients who were presented beyond 48 hours of onset of symptoms had their affected testicles non-viable and 58 of those patients who were presented, 20(34.5%) had gangrenous testicles.51 Gangrene is serious and potentially life threatening condition that arises when a considerable mass of body tissues dies.52 Amin had already seeked medical advice from Dr. Harris after he felt pains to his groin area but yet Dr.Haris did not take extra measures to detect the possibility of testicular torsion. If Dr. Haris had done his job and referred Amin to a specialist, an emergency surgery could have been done to save his testicle. This in turn would have prevented any sort of infection and saved Amins life. Amin would not have passed away but for Dr.Hariss negligence. 2. The death of Amin was reasonably foreseeable. A defendant will only be liable if it is reasonably foreseeable that his conduct will result in some damage to the plaintiff. There have been two competing views of the test

45 46

C.R.R. Corbett, St.Baer, B.M. Grimmett, Journal of the Royal College of General Practitioners, January 1986. Williamson RCN, Torsion of the Testis and Allied Conditions, British Journal of Surgery, 1976, Volume 63, Issue 6, p.465-476. 47 Cass AS, Cass BP, Veeraraghavan K, Immediate Exploration of the Unilateral Acute Scrotum in Young Male Subjects, J Urol 1980, 124: 829-832. 48 Greaney MG, Torsion of the Testis: A Review of 22 cases, British Journal of Surgey, 1975, Volume 62, Issue 1, p.57-58. 49 Clifford Spanierman MD, Testicular Torsion, 2007, Lutheral General Hospital of Oak Brook. 50 Causes of Gangrene, Mayo Clinic Staff, Mayo Clinic. 51 Ibingira C B R., Makerere Management of Testicular Torsion in Mulago Hospital over a 5-Year Period, University Medical School, Uganda. 52 Carol Porth, Essentials of Pathophysiology, Lippincott Williams & Wilkins, 2007, p.41. 12

of remoteness.53 The test being used now was formulated in The Wagon Mound,54 where the test used was the reasonable foresight test.55 The test in The Wagon Mound is a new approach to issue of remoteness. This test was approved and used in Malaysia in the case of Jaswant Singh v Central Electricity Board and Anor56 and Government of Malaysia & Ors v Jumat Bin Mahmud & Anor57. What must be foreseeable is the type of damage, not the nature of the damage,58 or even the extent of the damage.59 The risk of Amin contacting a testicular torsion is rather high as it occurs mostly in adolescents. As said earlier, GPs should know that a patient with testicular torsion may have no scrotal pain at all, but only pain in the abdomen.60 Based on the medical opinions and statistics given earlier, there is high chance that the testicle will die if surgery is not done within 12 hours. The consequence of Amin suffering a testicular torsion is reasonably foreseeable to any doctor. The fact that it lead to his death is irrelevant as the type of damage was foreseeable. 3. Egg-Shell Rule If one does something tortuous that results in anothers injury, then this rule is applied. The general maxim is that the defendant must "take their victims as they find them". Like for example if one is stabbed and refused to partake in blood transfusion and
53

Sir Henry Percy Winfield, John Anthony Jolowicz, Tom Ellis Lewis, Winfield on Tort, 7 th edition, Sweet and Maxwell, p.207. 54 Overseas Tankship (U.K.) Ltd v Morts Dock & Engineering Co Ltd, [1961] AC 388, Judicial Committee. 55 Ibid, per Viscount Simonds, But if it would be wrong that a man should be held liable for damage unpredictable by a reasonable man because it was "direct" or "natural," equally it would be wrong that he should escape liability, however "indirect" the damage, if he foresaw or could reasonably foresee the intervening events which led to its being done 56 [1967] 1 MLJ 272, OCJ Kuala Lumpur, Gill J., The last question which I have to consider is whether the damage suffered by the plaintiff was a reasonably foreseeable consequence of the defendants' negligence. 57 [1977] 2 MLJ 103, Federal Court, Raja Azlan Shah J., Since that case the principle that the damage sustained must not only be caused by the wrongful act, but must be damage of a class or character reasonably foreseeable as a possible result of that act is now firmly established. 58 Bradford v Robinson Rentals Ltd, [1967] 1 All ER 267, Devon Assizes, per Rees J., The question which I have to consider is whether the plaintiff has established that the injury to his health by "frostbite" (and I use the lay term for convenience), which is admittedly unusual in this country, is nevertheless of the type and kind of injury which was reasonably foreseeable. The law does not require that the precise nature of the injury must be reasonably foreseeable before liability for its consequences is attributed. 59 Sivakumaran & Ors v Yu Pan & Anor, [1995] 1 MLJ 12, High Court Shah Alam, KC Vohrah J., quoting The Wagon Mound, The Judicial Committee were not, I think, saying that a man is only liable for the extent of damage which he could anticipate, always assuming the type of injury could have been anticipated. 60 C.R.R. Corbett, St.Baer, B.M. Grimmett, Journal of the Royal College of General Practitioners, January 1986. 13

dies, the assailant would still be held liable.61 Also if an employee comes into contact with a dangerous molten metal and dies soon after, the employers would be held liable as long as the initial injury was foreseeable.62 Foresee ability of the action is important as for example, committing suicide after suffering injuries from an accident is said to be unforeseeable.63 If one suffers from nervous shock because a vehicle crashes through the wall of the premise then the driver of the vehicle will be held liable.64 In this case, Amin came to Dr.Haris with a testicular torsion. His failure to refer Amin to specialist resulted in Amins death due to the testicular torsion not being treated immediately. Therefore Dr.Haris is still liable for the full extent of the damage. 4. The defence of contributory negligence cant be used by Dr.Haris. Contributory negligence requires the element of fault65 and a standard of care. According to the case of Jones v Livox Quarries LD66, the Court of Appeal held that the plaintiff had a standard of care that he should have followed if he wanted to prevent the eventual death. 67 So the act of riding upon one of these vehicles at the risk of a man falling off, or the danger of his becoming trapped in some part of the machine was clearly prohibited by the employers in the first place shows the lack of care.68 With that it should be made clear that both Amin and Pn. Julia had no part in contributing to Amins death. Pn. Julias action of giving Amin a warm bath or Amins action of playing football after
61 62

R v Blaue, [1975] 3 All ER 446. Smith v Leech Brain & Co., LTD and Anor., [1962] 2 QB 405, Queens Bench Division. 63 Sivakumaran & Ors v Yu Pan & Anor, [1995] 1 MLJ 12. 64 Dulieu v White & Sons. Divisional Court, [1901] 2 KB 669, Kennedy J, It may be admitted that the plaintiff in this American case. if she had not been pregnant at the time; . But what does that fact matter? If a man is negligently run over or otherwise negligently injured in his body, it is no answer to the sufferer's claim for damages that he would have suffered less injury, or no injury at all, if he had not had an unusually thin skull or an unusually weak heart. 65 Davies v Swan Motor Co (Swansea) Ltd, [1949] 2 KB 291 Court of Appeal, Bucknill LJ, The doctrine of contributory negligence cannot be based upon a breach of duty to the negligent defendant. It is difficult to suppose that a person owes a duty to anyone to preserve his own property. He may not recover if he could reasonably have avoided the consequences of the defendant's negligence." 66 [1952] 2 QB 608, Court of Appeal. 67 Ibid, per Denning LJ, If a man carelessly rides on a vehicle in a dangerous position, and subsequently there is a collision in which his injuries are made worse by reason of his position than they otherwise would have been, then his damage and the damages recoverable by him fall to be reduced accordingly. 68 Ibid, per Singleton LJ, It was submitted to us that the prohibition against riding upon one of these vehicles The plaintiff, in riding on the traxcavator, was disobeying the orders of his employers. In so doing he was exposing himself to danger. 14

consulting the doctor cannot be said to have contributed to the death as they lack the elements of fault and standard of care. Since Dr.Haris advised them it was only a bruise, giving a warm bath and playing football are normal acts if someone suffered a bruise. They could have contributed to the damage only if Dr.Haris had not been negligent and informed Amin on the true nature of his injury, but unfortunately this was not the case.

D. Compensation. The best compensation for a case of tort involving testicular torsion would be of monetary and could rise to an amount of 13,000 in damages if it involves excision of testicle.69. In some cases, if the general practitioner had failed to refer the patient to an urologist that could have helped salvage the testis, the general practitioner would be charged with $50,000 Australian Dollars worth of damages inclusive of legal costs.70 So if death were to occur instead of an excision of testicle then the damages that would be faced by Dr. Haris, who was the general practitioner that failed to refer Amin to an urologist for treatment, would be much higher than the amounts mentioned above. The Claimant submits that the honorable court orders the Respondent to pay the Claimant RM 1,000,000 as monetary compensation for the death of Amin.

69 70

JMW: Manchester Solicitors; Testicular Torsion in Compensation. Australian Family Physician, Vol. 32, No. 7, July 2003, Pg 528. 15

PLEADINGS FOR RESPONDENT I DR. HARIS WAS NOT NEGLIGENT FOR NOT DIAGNOSING

TESTICULAR TORSION A. Dr. Haris owed Amin a duty of care as a doctor, general practitioner. Referring to R v Bateman71, per Lord Hewart CJ, "if a person holds himself out as possessing special skill and knowledge, and he is consulted as possessing such skill and knowledge, by or on behalf of a patient, he owes a duty to the patient to use due caution in undertaking the treatment..

Thus Dr. Haris concedes that Dr. Haris owes Amin a duty of care as a doctor. B. Dr. Haris did not breach the standard of care72. 1. Dr Haris acted in accordance to accepted current73 medical practice. Accepted practice in this context means a practice accepted as proper by a responsible body of medical opinion74. If the doctor complied, there is strong evidence that the doctor is not negligent regardless of whether there is more than one accepted practice by other bodies of opinion. However, the judges may scrutinise medical opinions75 and medical expert evidence may be rejected by the courts if they do not stand up to analysis76.

71 72

(1925) All ER Rep 45 Foo Fio Na v Dr Soo Fook Mun & Assunta Hospital (2007) 1 MLJ 593, Bolam v Friern Hospital Management Committee (1957) 2 All ER 118 73 Roe v Minister of Health & Anor (1954) 2 All ER 131 Denning LJ, We must not look at the 1947 incident with 1954 spectacles. 74 Defreitas v OBrien and Connolly (1995) 6 Med LR.108 page 115 Otton LJ, There was evidence. That a small number of tertiary specialist could constitute a responsible body of medical opinion The issue whether or not to operate could not be determined by counting heads a small number of specialist (could constitute) a responsible body (which in fact found)the defendants decision justified. 75 F v R (1982) 33 SASR 189 (S.C of South Australia), page 194 King CJ, professions may adopt unreasonable practices The court has an obligation to scrutinize professional practices to ensure that they accord with the standard of reasonableness imposed by law.. The ultimate questions, however, is not whether the defendants conduct accords with the practices of his profession or some part of it, but 16

There are multiple reasons for acute testicular pain including inflammatory reasons due to trauma. The first cause of trauma is aggression with projectiles and forceful objects.77 Dr. Haris is a general practitioner78 and when attending to Amin he was informed of the incident with the ball. Thus, Dr.Haris applying ointment to the stomach and groin of Amin is a reasonable action taking into account the circumstances of occurrence. 2. Dr Haris did not breach the standard of care in duty to diagnose and treat A doctor is required by law to exercise the reasonable care and skill in making a diagnosis however, a wrong diagnosis does not itself amount to negligence79 if the doctor has observed the required standard.80

whether it conforms to the standard of care demanded by the law. That is a question for the court and the duty of deciding it cannot be delegated to any profession or group in the community. 76 Bolitho v City & Hackney Health Authority (1997) 4 All ER 771, page 778 Lord Browne-Wilkinson, In my view the court is not bound to hold that a defendant doctor escapes liability for negligent treatment or diagnosis just because he leads evidence from a number of medical experts who are genuinely of opinion that the defendants treatment or diagnosis accorded with sound medical practice. . In particular, in cases involving, as they so often do, the weighing of risks against benefits, the judge before accepting a body of opinion as being responsible, reasonable or respectable, will need to be satisfied that, in forming their views, the experts have directed their minds to the question of comparative risks and benefits and have reached a defensible conclusion on the matter. Lord Woolf MR, page 46 the judge had to make his own findings on balance of probabilities on this issue of fact in order to proceed to the next step in answering the question of negligence or no negligence Applied in Malaysia in the case of, Kamalam a/p Raman & Ors v Eatern Plantation Agency (Johore) Sdn Bhd Ulu Tiram Estate Ulu Tiram, Johore & Anor (1996) 4MLJ 674 Richard Talalla J, . I should emphasize that while due regard will be had to the evidence of medical experts, I do not accept myslf as being restricted by the establishment in evidence of a practice accepted as proper by a responsible body of medical men skilled in that particular art to finding a doctor is not guilty of negligence if he acted in accordance with that practice. In short, I am not bound by the Bolam principle. 77 Jeanette M Potts, Genitourinary pain and inflammation : Diagnosis and Management, 2008, Humana Press, Page145 78 Bent Guttorm Bentzen, Charles Bridges-Webb, Lynn Carmichael, Julio Ceitlin, Richard Feinbloom, David Metcaalf, Ian McWhinney, Kumar Rajakumar, The Role of the General Practitioner/Family Physician in Health Care Systems : A Statement from WONCA, 1991. The general practitioner functions as a generalist who accepts everyone seeking care, whereas other health providers limit, access to their services on the basis of age, sex, and/or diagnosis. 79 Maynard v West Midlands Regional Health Authority [1984]1 WLR 634 Lord Scarman,
80

Hunter v Hanley (1955) SLT 213 page 217 Lord Clyde, 17

Dr. Haris had made an error of diagnosis, not amounting to negligence. There are basic duties the doctor must execute before a reaching a final diagnosis. First, consider the patients medical history and give full consideration81. Second, ask the patient relevant questions and listen to the account of the illness. Third, in cases of doubtful diagnosis, it is good practice to refer the patients to a specialist for further consideration.82
83

In this case, Dr Haris a general practitioner, did know of the account of the illness as Dr.Haris assured Amin that the pain was a bruise caused by the ball. Dr.Haris did not diagnose testicular torsion as Amin did not present the symptoms of testicular torsion84. Amin felt uneasiness at his groin after the ball struck him whereas testicular torsion presents itself as sudden onset of pain, waking the patient from sleep.85 Dr Hariss diagnosis of a slight bruise caused by the ball is based on the fact that bruises are the effects of external violence applied to the body86 causing pain. Diagnosis is the identification of a disease by means of its symptoms.87 Thus, as Amin did not display the symptoms of testicular torsion, it is impossible for Dr. Haris to diagnose testicular torsion. Where symptoms do not indicate the illness from which the patient is in fact suffering, the doctor cannot be blamed for failing to identify the specific

in the realm of diagnosis and treatment there is ample scope for genuine difference of opinion and one man is clearly not negligent merely because his conclusions differs from that of other professional men. 81 Chin Keow v Government of Malaysia (1967) 2 MLJ 45 82 Gordon v Wilson (1992) 3 Med LR401 83 Mason, JK & Smith M, Law and Medical Ethics, London : Buttersworth, 1994, page 204 84 Nathan W Mick, Jessica Radin Peters, Daniel Egan, Eric S. Nadel, Blueprints Emergency Medicine, page 148 Common signs of testicular torsion are testicular enlargement and tenderness, erythema and swelling of scrotum, horizontal lie instead of the normal vertical orientation, elevated high-riding testis in the scrotum due to twisting and shortening of spermatic cord, ipsilateral loss of cremasteric reflex with torsion. 85 John Reynard, Simon Brewster, Suzanne Biers, Oxford Handbook of Urology, 2006, Oxford University Press, University of Oxford, page 26 86 Spencer Thomson, Dictionary of Domestic Medicine and Household Surgery, page 75 87 Swamy v Mathews (1968) 1 MLJ 138, page142 Ong FJ, Diagnosis is the identification of a disease by means of its symptoms. It is apodeictic that the disease or diseases affecting a patient should be identifiable before the nature of the treatment therefore can be properly considered. 18

illness.88 Hence, it is not a case of doubtful diagnosis but misdiagnosis due to lack of symptoms.

C. Amins death was not caused by the misdiagnosis of Dr.Haris 1. Lack of Causation in Fact Establishing causation is concerned with the physical connection between the defendants negligence and the plaintiffs damage.89 The plaintiff has to show that the damage he suffered was caused by the defendants negligence and that in the absence of the breach, he would not have suffered the injury.90 In medical malpractice context, the patient must demonstrate that there was a reasonable medical probability91 that the doctors negligence cause the patients injuries. For Puan Julia to successfully sue Dr Harris in an action of medical negligence, the onus is on her92 to prove that there is a factual causation between Dr Harriss failure to suspect testicular torsion on Amin and Amins death. To establish factual causation between Dr Harriss alleged negligence in failing to suspect testicular torsion during the first consult with Amin, subsequently causing his death the next day, the but for test93 must be applied: but for Dr Harriss failure to suspect testicular torsion to be suffered by Amin and referred him to a specialist

88 89

Sadler v Henry (1954) 1 BMJ 1331 Jones, M.A, Medical Negligence, London:Sweet & Maxwell, 1991, page 163 90 Logie, JG, Proof of Causation in Medical Negligence Cases, 1988 (SLT), page 25 91 Perrochet, L, Smith SJ & Colella U, Lost Chance Recovery and the Folly of Expanding Medical Malpractice Liability (1992), VolXXVII, No 3, Torts & Insurance Law Journal, page 615 Reasonable medical probability means more than 50 percent chance that the negligence caused the injury. 92 Wilsher v Essex Area Health Authority, [1988] AC 1074, para 7, page 12, Lord Bridge of Harwich, The conclusion I draw from these passages is that McGhee v. National Coal Board [1973] 1 W.L.R. 1 laid down no new principle of law whatever. On the contrary, it affirmed the principle that the onus of proving causation lies on the pursuer or plaintiff. 93 Cork v Kirby Maclean, [1952] 2 All ER 402, para 3, page 6, Lord Denning, we recognize that there may be many causes of a damage, and we ask: what were the causes of it? What faults were there which caused the damage? 19

accordingly, would Amin have died the next day? The answer is no. The reasoning of this answer is as follows. (i) Low probability of testicular torsion causing death to a person in a short period of time It is absurd to say that the misdiagnosis of Dr Haris resulted in Amins death, as delay in treating testicular torsion results in the loss of testicular function.94 It is highly unlikely that testicular torsion can cause the death of a person in less than 48 hours.95 Hence, even if Dr Harris failed to suspect a case of testicular torsion early, this has no link with Amins death as testicular torsion itself is not lethal in a short period of time. Without a conclusive post mortem report presented by the appellant, it is prejudicial to Dr Harris to conclude that Amins death is caused by testicular torsion which is highly improbable in nature. 2. There is a break in the chain of causation by Amin and Puan Julia Where the act of another person or even the plaintiff himself without which the damage would not have occurred, intervenes between the defendants negligence and the plaintiffs damage, the court must decide whether the defendant is responsible or whether the intervening act constitutes novus actus interveniens96.97 The intervening act here was by Puan Julia, the plaintiff. A plaintiffs conduct if based on religious, moral, social, economic, emotional or economic factors will not be regarded as unreasonable so as to break the chain of

94

American Academy of Pediatric, American College of Emergency Physicisians, APLS : Pediatric Emergency Medicine, 2007, Jones and Bartlett Publishers, United States, Page 389 95 Graham, Sam D.; Keane, Thomas E; Glenns Urologic Surgery, p 448, 451; Puri, Prem; Hollwart, Michael; Pediatric Surgery: Diagnosis and Management, p 932; 96 The Oropesa (1943) P32, page 39 Lord Reid, .. a new cause which disturds the sequence of events, something which can be described as either unreasonable or extraneous or extrinsic. 97 Jones, M.A, Medical Negligence, page 425 20

causation. It must be cases of obvious disregard of care by the plaintiff that would amount to a novus actus interveniens98. In the present case, Amin was taken by Puan Julia to the hospital as she found him in seething pain after being struck by the ball. He has been treated by Dr.Haris and was sent home with the ointment and antibiotics. The next day, Amin had gone to the park to play football with his friends again. That same night, Amin was in severe pain again and instead of taking Amin to the hospital, she gave him a warm bath. The law imposes obligations upon parents to secure medical treatment for their child.99 Puan Julia failed as a parent to provide appropriate health care, for Amin. Puan Julia did not take Amin to the hospital for the second time when he was screaming in pain but instead Puan Julia only gave him a warm bath. This caused adverse effect on Amin and subsequently his death. 3. The death of Amin due to testicular torsion is not reasonably foreseeable by Dr Haris. The principle on remoteness of damage, deals with harm which occurs in some weird or unpredictable situations. In a system of fault liability, holding a person liable for the unpredictable and freakish consequences of his negligence may seems unfair because of a sense of disproportion between the fault and the harm. Other than that, in this system, which depends upon foreseeability of the damage as a test of the defendants breach of duty, it may seem unfair to hold the defendant responsibility for all the damage that his negligence has caused, even where the damage is of a different type or occurred in a different manner from that which would normally be expected. There are two broad approaches to the issue of remoteness. Firstly, a defendant is liable for all direct consequences of his negligence, no matter how unusual or

98 99

Dr. Puteri Nemie Jahn Kassim, Medical Negligence Law in Malaysia, 2003, ILBS, Malaysia page 118. Jo Bridgeman, Parental Responsibility, Young Children and Healthcare Law, 2007, Cambridge University Press,UK, page 91 21

unexpected.100 This approach was held to be wrong subsequently. The second approach holds that a person is only responsible for the consequences that could reasonably have been anticipated, even where he has undoubtedly caused the damage in question.101 Theoretically, the test of remoteness in the tort of negligence is the foreseeability of the harm; if the damage was unforeseeable, it is too remote. The court must determine precisely what it is that has to be foreseen, and decisions about what falls within the realms of the foreseeable and what may legitimately be ignored in the sequence of events have a vital bearing upon the application of the rules on remoteness. 102 The damage would have been considered to be too remote is illustrated by the decision of the Court of Appeal in Doughty v. Turner Manufacturing Co. Ltd 103. The damage will be too remote if it is not of the same type or kind as the harm that could have been foreseen like in the case of Hutchinson v. Leeds Health Authority104. In this case, Dr.Haris carried out his responsibility as a general practitioner to diagnose, treat Amins injuries and prescribed the medication necessary for it according to the presenting symptoms. Although Dr.Haris had misdiagnosed Amin, the diagnosis was based on the symptoms presented. Hence, the damages are too remote by virtue that Dr Haris cannot reasonably foresee the possibility of Amins death.

100 101

Re Polemis (1921) 3 KB 560 Wagon Mound (No 1) (1961) AC 388 102 Jones, Micheal, Medical Negligence, Sweet & Maxwell, 2003,p 436-437. 103 [1964] I QB 518 Fact: in which an asbestos cover was knocked into a bath of molten liquid. Shortly after, due to a chemical reaction between the asbestos and the liquid which was unforeseeable at the time, there was an eruption of the liquid which burned the claimant who was standing nearby. It was held that burning by an unforeseeable chemical eruption was not a variant of burning by splashing, which was within the foreseeable risk created by knocking the cover into the liquid. 104 (2000) unreported Bennett J held that, it would also be an affront to common sense if, having established that the defendants were in breach of duty in falling to call in the surgical team to investigate a highly abnormal bowel function in a patient who was very ill, the claimants action failed because it was not foreseeable that the bowel perforation might occur in the posterior rectal wall rather than in some other part of the bowel. 22

II

ALTERNATIVE ARGUMENT: AMIN HAS CONTRIBUTED PARTIALLY TO HIS OWN DEATH DUE TO HIS NEGLIGENT ACT Assuming that Dr.Harris is still found to be liable in causing Amins death, this

defence shall be pleaded accordingly. Contributory negligence means the failure by a person to use reasonable care for his safety of himself or his property so that he becomes the author of his own wrong.105 A. Law of contributory negligence as defence in Malaysia The law providing for contributory negligence in Malaysia is as per section 12(1) of Civil Law Act 1956106. Accordingly, this section does not absolve the defendant from the liability of negligence completely. It merely attempt to reduce the extent of damages that the defendant has to bear due to not only his own negligence, but also some extent of negligence on the part of the plaintiff as well. B. Elements of contributory negligence In short, the gist of contributory negligence is therefore the unreasonable behavior of the claimant with regard to his own safety which results in foreseeable damage to himself.107 This principle can be seen in the case of Jones v Livox Quarries Ltd.108 In the case of Robitaille v Vancouver Hockey Club Ltd109, the plaintiff was a hockey player under the club. As part of the services, the club provides medical care to their employment and in fact players were discouraged from consulting their own doctors. After plaintiff had suffered a minor spinal contusion, during a game, his complaints were ignored. Had reasonable attention to be paid to his own welfare, he
105 106

Mohd Zukhairi Abd Ghapor v Quek Chiam Kee [2004] 1 MLJ 6, para 14. Per Seah SCJ Section 12(1): Where any person suffers damage as the result partly of his own fault and partly of the fault of any other person or persons, a claim in respect of that damage shall not be defeated by reason of the fault of the person suffering the damage, but the damages recoverable in respect thereof shall be reduced to such extent as the Court think just and equitable having regard to the Claimants share in responsibility for the damage. 107 Foong Nan v Sagadevan [1971] 1 MLJ 24 108 [1952] 2 QB 608. Facts : Claimant disobeyed his employers instructions by riding on the back of a traxcavator, that was hit at the back by another vehicle causing the claimant to be injured. 109 (1981) 124 D.L.R.(3d) 228 23

would have a full medication examination immediately, his injuries would have recovered, and he would not have played in a game in a week later in which the injury was severely aggravated, resulting in permanent disability. Plaintiff sued hockey club, alleging that the disability was caused by the neglect of the club to obtain proper care and medical treatment for him. However, it was held that plaintiff was contributory negligent to the extent of 20% in not acting reasonably to protect his own health and well-being. With regards of the cases illustrated, the following elements have to be proven by the respondent in order for the defence to succeed: 1. Claimants negligence must be a contributory factor110 It is necessary for the respondent to prove that the applicant had committed a negligent act that has contributed to his damage or injuries.111 This has always been a factual argument, not a legal one.112 The defense will succeed if the damage sustained by the claimant had been totally constituted by the risk he exposed himself into by virtue of his negligent conduct.113 Examples of clear cases that used the defense of contributory negligence include the following: a moped driver who does not wear a crash helmet114, or simply fails to fasten it securely115, and a car passenger who does not wear a seatbelt116. Therefore, looking into the facts of the case again, Amin, have he had taken reasonable care of himself after the accident and examination by Dr. Haris, he would have avoided the seriousness of the condition the next day. Amin did not take another reasonable step which is to go for further examination after the complaint. Instead,

110
111

John Murphy, Streets on Torts, 12th Edition, 2007, Oxford University Press, page 172 The Liability of Railway Companies For Negligence Towards Passengers (1893) by Parsons, Albert 112 John Murphy, Streets on Torts, 12th Edition, 2007, Oxford University Press, page 172 113 [1952] 2 QB 608. 114 OConnell v Jackson [1972] 1 QB 270 115 Capps v Miller [1989] 2 All ER 333 116 Froom v Butcher [1976] QB 286 24

Amin went on to play football with his friends in the park. Without proper care and rest, his conditions worsen and lead to his death. 2. The loss suffered by Amin is reasonably foreseeable. It is essential that the claimants lack of care should be a contributory factor to his damage, and this means not only that his fault should be a cause in fact of his loss, but that the loss is within the broad scope of the risk created by his fault.117 The case of Jones v Livox Quarries Ltd118 illustrates this point of risk. It was held that the claimant was contributory negligent, and affirmed that contributory negligence was applicable to injury that was reasonably foreseeable as a consequence of the claimants behavior. Thus, relating back to the case, it is reasonably foreseeable if Amin returned to the field the next day to play right after the treatment, an injury is highly likely to be incurred upon him. Here, the extent of the damage is irrelevant and all it has to be proven is that some sort of injury will be the outcome of the plaintiffs act.119 With this, this element is proven accordingly. Conclusively, with both elements of the defence of contributory negligence satisfied, it can be used accordingly to reduce the amount of damages or compensation imposed upon Dr.Harris. Medical care to their employment and in fact players were discouraged from consulting their own doctors. After plaintiff had suffered a minor spinal contusion, during a game, his complaints were ignored. Had reasonable attention to be paid to his own welfare, he would have a full medication examination immediately, his injuries would have recovered, and he would not have played in a game in a week later in which the injury was severely aggravated, resulting in permanent disability. Plaintiff sued hockey club, alleging that the disability was caused by the neglect of the club to
117 118

TORT, 18th Edition by Winfield and Jolowicz, page 368 [1952] 2 QB 608 119 Ibid 25

obtain proper care and medical treatment for him. However, it was held that plaintiff was contributory negligent to the extent of 20% in not acting reasonably to protect his own health and well-being. Relating the same principle from this case to the current case, Amin who did not go to seek for further examination when he complained of the severe pain the next day has contributed to his damage and injury, in this case his death. Therefore it is proven that Dr. Haris cannot be fully liable of the damages.

Total Number of Words of Substance for BOTH pleadings: 4645 words

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BIBLIOGRAPHY Australian Family Physician, Vol. 32, No. 7, July 2003 American Academy of Pediatric, American College of Emergency Physicisians, APLS : Pediatric Emergency Medicine, 2007, Jones and Bartlett Publishers, United States Bent Guttorm Bentzen, Charles Bridges-Webb, Lynn Carmichael, Julio Ceitlin, Richard C.R.R. Corbett, St.Baer, B.M. Grimmett, Journal of the Royal College of General Practitioners, January 1986. Cass AS, Cass BP, Veeraraghavan K, Immediate Exploration of the Unilateral Acute Scrotum in Young Male Subjects, J Urol 1980 Clifford Spanierman MD, Testicular Torsion, 2007, Lutheral General Hospital of Oak Brook. Causes of Gangrene, Mayo Clinic Staff, Mayo Clinic Carol Porth, Essentials of Pathophysiology, Lippincott Williams & Wilkins, 2007 Dr.Damian C . Crowther, General Practice Notebook, The Cambridge Institute of Medical Research, Cambridge Dr. Puteri Nemie Jahn Kassim, Medical Negligence Law in Malaysia, 2003, ILBS, Malaysia Erik P Castle M.D, Mayo Foundation for Medical Education and Research. Feinbloom, David Metcaalf, Ian McWhinney, Kumar Rajakumar, The Role of the General Practitioner/Family Physician in Health Care Systems : A Statement from WONCA, 1991 Graham, Sam D.; Keane, Thomas E; Glenns Urologic Surgery, p 448, 451; Puri, Prem; Hollwart, Michael; Pediatric Surgery: Diagnosis and Management
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Ibingira C B R., Makerere Management of Testicular Torsion in Mulago Hospital over a 5-Year Period, University Medical School, Uganda John Garfield and Christopher J. Earl, Medical Negligence: The Cranium, Spine and Nervous System, Wiley-Blackwell, 1999 JMW: Manchester Solicitors; Testicular Torsion in Compensation Jeanette M Potts, Genitourinary pain and inflammation : Diagnosis and Management, 2008, Humana Press Jones, M.A, Medical Negligence, London:Sweet & Maxwell, 1991 Jo Bridgeman, Parental Responsibility, Young Children and Healthcare Law, 2007, Cambridge University Press,UK Kaplan, Kaplan Medical USMLE Step 3 Qbook, Kaplan Publishing, 4th edition, 2008 Logie, JG, Proof of Causation in Medical Negligence Cases, 1988 (SLT) Mason, JK & Smith M, Law and Medical Ethics, London : Buttersworth, 1994 Medical Case Notes Assessment Ltd, Medical Negligence Expert Reports for the UK and Ireland, Kent MG, Torsion of the Testis: A Review of 22 cases, British Journal of Surgey, 1975, Volume 62, Issue 1 Michael Drury, Clinical Negligence in General Practice, Radcliffe Publishing, 2000 Murphy, Street on Torts, 12th edition, Oxford University Press, 2007 Nathan W Mick, Jessica Radin Peters, Daniel Egan, Eric S. Nadel, Blueprints Emergency Medicine Parsons, AlbertThe Liability of Railway Companies For Negligence Towards Passengers
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Perrochet, L, Smith SJ & Colella U, Lost Chance Recovery and the Folly of Expanding Medical Malpractice Liability (1992), VolXXVII, No 3, Torts & Insurance Law Journa Sara Bird, Medicolegal Adviser at MDA National, Australian Family Physician, Volume 32, No.7, 2003 Sir Henry Percy Winfield, John Anthony Jolowicz, Tom Ellis Lewis, Winfield on Tort, 7th edition, Sweet and Maxwell Spencer Thomson, Dictionary of Domestic Medicine and Household Surgery (1893) Winfield and Jolowicz, TORT, 18th Edition, Sweet and Maxwell, 2006 Wampler SM, Llanes M, Common Scrotal and Testicular Problems, Prim Care 2010, Department of Family Medicine, University of Michigan; Timothy J Rupp (MD, FACEP, FAAEM), Testicular Torsion in Emergency Medicine, Southwestern Medical Centre, University of Texas. Williamson RCN, Torsion of the Testis and Allied Conditions, British Journal of Surgery, 1976, Volume 63, Issue 6

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