SGH neurosurgery head did not report patient’s death to coroner; cops alerted a year later

Dr Jai Prashanth Rao failed to report Tan Suan Lin’s death to the coroner in 2024. Tan had undergone brain surgery at Singapore General Hospital and died six days later. The reporting duty mattered because her death followed a difficult operation involving severe bleeding.

Rao testified that he mistakenly believed only deaths within 24 hours of surgery required mandatory reporting. He initially told Tan’s family that the case had to go to the coroner, but changed course after they objected to an autopsy. He issued a death certificate instead.

The National Neuroscience Institute informed the coroner in February 2025. Police were alerted the following month, in March. By then, more than a year had passed since Tan’s operation and death. No autopsy was performed because of the delay, limiting the later investigation into whether surgical bleeding contributed to her death.

A coroner is an official who examines certain deaths and determines, or helps establish, their cause and circumstances. A coroner’s inquiry is an independent fact-finding process. It can look at the medical history, treatment, evidence from witnesses and whether a death involved unusual or potentially preventable circumstances. This general explanation uses established knowledge beyond the article.

Tan Suan Lin’s inquiry concerns her death six days after a brain operation. The operation became difficult when the medical team could not stop the bleeding. Tan lost about three litres of blood, and the operation was stopped. Rao then told her family that her prognosis was poor.

The inquiry heard that a forensic pathologist considered bleeding complications during the surgical intervention a possible cause of death. It also examined why Rao issued a death certificate instead of reporting the case. State Coroner Adam Nakhoda will give his findings later.

Tan Suan Lin lost about three litres of blood during her brain operation on Jan 3, 2024. The amount shows how serious the bleeding became and helps explain why the operation could not continue. Her survival after the operation was brief: she died six days later.

The medical team faced difficulties stopping the bleeding during surgery for her large brain tumour. Rao stopped the operation and told Tan’s family that her prognosis was poor. The court later heard that a forensic pathologist considered bleeding complications during the surgical intervention a possible cause of death.

The six-day interval did not remove the need for reporting. Rao said he wrongly thought mandatory reporting applied only to deaths within 24 hours of surgery. The case was referred to the coroner in February 2025, and police were alerted in March. No autopsy was performed after the delay.

The death certificate identified “malignant neoplasm – brain, unspecified” as the cause of death. Rao said this wording was intended to show that Tan had died from a brain tumour. It described the underlying illness rather than a problem arising during treatment.

A forensic pathologist from the Health Sciences Authority gave a different possible explanation. The pathologist indicated that Tan may have died from bleeding complications during surgical intervention for the tumour. That possibility mattered because the operation involved uncontrolled bleeding, about three litres of blood loss and an early stop to surgery.

The difference created an important issue for the coroner’s inquiry. The certificate pointed to disease, while the forensic view raised a possible treatment-related complication. The case was reported late, and no autopsy was done. State Coroner Adam Nakhoda will issue findings after considering the evidence.

The case’s late referral had a direct investigative consequence: no autopsy was performed. An autopsy could have provided physical evidence about the cause of death, but the delay meant that opportunity was lost. The article states that no autopsy was done due to the delay.

Rao had initially told Tan’s family that he needed to report the death to the coroner. The family did not want her body to undergo an autopsy and sustain further cuts. Rao said compassion led him to issue a death certificate instead. NNI only informed the coroner in February 2025, and police were alerted in March.

The missing autopsy made it harder to resolve the difference between the certificate and the forensic pathologist’s view. The certificate named a malignant brain tumour, while the pathologist identified possible bleeding complications during surgery. The inquiry will still examine the available evidence, with findings due from State Coroner Adam Nakhoda.

A death after surgery may need reporting because the timing alone can raise questions about what happened during treatment. A doctor may reasonably believe that the underlying disease caused the death, yet an independent review can test whether a complication also played a role. This explanation uses established coroner practice beyond the article.

Tan had a large brain tumour, but her operation also involved severe bleeding. She lost about three litres of blood, the team stopped surgery, and she died six days later. Rao recorded a malignant brain tumour on the death certificate. A forensic pathologist later identified bleeding complications during surgical intervention as a possible cause.

Reporting therefore protects the investigation from relying only on one doctor’s conclusion. It can preserve evidence, allow witnesses to testify and support an autopsy when appropriate. An independent expert said the case should have been reported, while also empathising with Rao. The inquiry is continuing under State Coroner Adam Nakhoda.

An autopsy is a medical examination of a body after death. A pathologist examines the organs and tissues to identify disease, injury and the immediate cause of death. This general definition uses established medical knowledge beyond the article. It matters when the death certificate and other evidence point to different explanations.

In Tan’s case, the certificate named a malignant brain tumour. However, a forensic pathologist indicated that bleeding complications during the tumour surgery might have caused her death. An autopsy could potentially have examined the brain, surgical area and internal effects of blood loss for evidence supporting one explanation or the other.

An autopsy cannot always answer every question, but it can provide important physical evidence alongside medical records and testimony. Tan’s family did not want an autopsy, and the case was reported only in February 2025. The article states that no autopsy was performed because of the delay, leaving the inquiry without that evidence.