It was about 6am in Galway, Ireland, when Dr David Breen, chairman of the Lung Cancer Group of the Republic of Ireland's National Cancer Control Programme, testified in the High Court in Singapore via videoconference on Zoom.
He was appearing as an expert witness for the late Noor Azlin Abdul Rahman in the High Court on Aug 24 at a hearing to assess the damages Changi General Hospital (CGH) was liable to pay to her family for its negligence.
Ms Noor Azlin died in April last year, aged 39, after she had succeeded in the lawsuit against CGH that claimed its negligence had delayed the detection of her lung cancer and led to an adverse medical outcome.
Her estate is seeking some $6.75 million in damages.
Dr Breen, who is also consultant chest physician at Galway University Hospitals, was brought in to consider the expert evidence of Professor Goh Boon Cher, who was asked to provide an independent expert opinion for the hospital by its lawyer, Senior Counsel Kuah Boon Theng.
The aim was to help the court determine what damages, if any, would flow from the findings made in the Court of Appeal's judgment against CGH.
This included gauging the impact or effect of the period of delay in diagnosis referred to in the Court of Appeal's judgment on Ms Noor Azlin's treatment and prognosis, and whether the efficacy of the treatment she received and the risk of relapse and expected survival would have been affected by the period of delay.
Prof Goh, who also testified and had been cross-examined before Justice Belinda Ang in the hearings spread over the past two weeks, is a senior consultant at the National University Cancer Institute, Singapore.
A key issue raised at the hearing was whether the delay in the diagnosis of Ms Noor Azlin at the hospital had little impact on the outcome of her condition and the treatment she received.
Dr Breen, in his affidavit filed in March, explained the "true opportunity" of being spared the grave consequence for Ms Noor Azlin was not at the time of the chest X-ray performed in July 2011 and issued in August 2011 or the time lapse between August and December 2011.
"The real issue was the chest radiographs performed in 2007 and 2010 when there was an abnormality detected but not further acted on.
"It is this period of four years that had the biggest impact on the overall outcome in this patient's clinical course."
He suggested that, if diagnosed in 2007 or 2010, the overall likelihood would be that the disease would have been at an earlier stage, and the prognosis better.
At the hearing, he backed his point up with graphs documenting that survival decreases with every increase in stage that a patient is diagnosed with.
The hearings ended last Friday, and lawyers for the hospital and Mr Vijay Kumar Rai for the estate will follow up with written submissions to assist in the court's decision.