The second liposuction death was a misadventure, said the State Coroner. But it appears Dr Edward Foo, the surgeon involved, is not yet out of the soup.

The family said through their lawyer Miss Kuah Boon Theng, that they intend to take up a civil suit against Dr Foo and TCS at Central Clinic for negligence.

State Counsel Bhajanvir Singh told the media outside the courtroom that he will be sending the findings to the Singapore Medical Council for its action.

Ms Mandy Yeong, 44, was Head of Regional Market Development for Roche Diagnostic Asia Pacific. The mother of two, who weighed 68 kg had wanted fat taken from her abdomen to be used to smoothen the depressions in her thighs.

The treatment lasted two hours, from noon till 2 pm on 28 June last year. The records kept by the clinic stopped at 2.05 pm.

Between then and 2.54pm when the clinic called for an ambulance, Ms Yeong felt unwell, sat up, coughed a few times and collapsed. The clinic doctors and nurses tried to resuscitate her but failed, and called the ambulance.

Coroner Imran Abdul Hamid said he was concerned that the poor record keeping "unfortunately corresponded with the most crucial time" leading to Mr Yeong's collapse and death.

He said it was possible that Ms Yeong had been "hypoventilating for several minutes".

He made scathing remarks about the poor record keeping in which the time Ms Yeong collapsed was changed more than once. He said timing the collapse with the time the ambulance was called was "self-serving".

He said he believed staff who said the ambulance was called "after a while" and accepts that Ms Yeong collapsed at 2.30 pm. The call to the ambulance was made at 2.54pm.The 24 minutes between the two was an "unacceptable delay" he said.

But he said there was no foul plan and the death was a misadventure.

He then added: "I leave it to the family and the State to take whatever steps they think appropriate."