By: Kaylen Moodley / Candidate Attorney / Mooney Ford Attorneys
Introduction
In this case, the Plaintiff, a 21-year-old female, instituted a claim for delictual damages against the Defendant, Elim District Hospital, alleging that the negligence of its medical staff (nurses, doctors, and employees) resulted in harm to her and the stillbirth of her child. The Plaintiff contended that the failure to provide appropriate care during her hospital admission led to the tragic outcome.
Background Facts
The Plaintiff had a history of a previous caesarean section (“C/section”) in 2014 for the delivery of a baby with macrosomia (infants with abnormally high weight). In 2018, she was pregnant again and began her regular check-ups at Tembisa Hospital, where she was diagnosed with mild anaemia. She was treated with Venofer as a supplement (an intravenous iron sucrose commonly used to treat iron deficiency anaemia). The estimated delivery date was set for the end of October or early November. The Plaintiff later decided to deliver her baby at Elim Hospital, where she had attended one appointment prior to her arrival on the 18th of October 2018.
On this visit, she presented symptoms of anaemia, along with a history of a previous C/section. Given these high-risk factors, she was admitted to Elim Hospital for monitoring from the 18th to the 25th of October. On the evening of the 25th of October, she began experiencing labour pains and was transferred to the labour ward.
The Incident
On the morning of 26th October 2018, the Plaintiff experienced sudden, severe abdominal pain, which she described as feeling like something had “burst” inside her. She called for help but did not receive immediate attention. After some time, the Plaintiff sought assistance from another patient, who helped her to the nursing station. Despite her complaints of pain, she was told to return to her bed and rest. She ultimately remained on a bench by the nursing station, where no further assistance was provided for several hours.
Later in the morning, when her condition worsened, the nurses noted that she was shivering and having difficulty breathing. Only then was an emergency caesarean section scheduled. Unfortunately, the baby was delivered as a stillborn due to a ruptured uterus, which had gone undiagnosed and untreated earlier that morning.
Expert Evidence
The Plaintiff’s expert, Dr. Songabau, an obstetrician and gynaecologist, criticised the management of the Plaintiff’s case, noting that maternal and foetal outcomes could have been improved with proper monitoring and intervention. Dr. Songabau opined that the failure to act on signs of impending uterine rupture, such as abdominal pain and foetal tachycardia, contributed to the loss.
On the other hand, the Defendant’s expert, Dr. Mbokota, asserted that uterine rupture is a known complication of labour following a previous C/section and cannot always be predicted or prevented. Dr. Mbokota contended that the hospital staff acted appropriately and promptly once the rupture was diagnosed, emphasising that the baby’s death was an unfortunate, albeit unavoidable, outcome.
However, the court found that the Defendant’s medical team failed to provide the appropriate standard of care. The Plaintiff’s condition was not adequately monitored, and her complaints were not addressed in a timely manner.
Legal Principles
The legal relationship between a medical practitioner and a patient is primarily established through contract, whereby the medical professional agrees to provide professional services, and the patient, in turn, agrees to pay for these services. This relationship is reinforced both contractually and in terms of delictual liability, wherein the medical practitioner has an inherent duty of care to the patient, especially when the patient is vulnerable, such as in the case of an indigent individual. This duty entails the obligation to provide appropriate care and to prevent harm to the patient and, where applicable, the patient’s unborn child.
To succeed in a claim for damages, the Plaintiff allege and prove the following:
- The existence of a contractual agreement or understanding.
- A negligent breach of that agreement.
- Causation (direct causal link between the breach and the damage).
- The resulting damages.
As a fundamental term of the contract between a medical practitioner and a patient, it is implied that the practitioner will exercise reasonable skill and care in line with the standards expected of professionals within their particular field. In determining what constitutes reasonable conduct, the court relies heavily on expert testimony from qualified physicians. However, ultimately, it is the court’s responsibility to determine whether the actions taken were reasonable under the circumstances. This principle is enunciated in Van Wyk v Lewis (1924 AD 438), where it was established that what is deemed reasonable is a matter for the court to decide.
Expert testimony must be scrutinised based on the guidance provided by the Supreme Court in Michael and Another v Linksfield Park Clinic (Pty) Ltd and Another (2001), where it was clarified that the issue of reasonableness and negligence is for the court to determine, even in the presence of conflicting expert opinions. The court does not simply consider the credibility of the experts, but rather the reasoning behind their opinions. The Supreme Court further stressed that in evaluating expert evidence, the court must ensure that the expert’s opinions are grounded in logical reasoning, as outlined in Bolitho v City and Hackney Health Authority (1997). The court stated further that “The court is not bound to absolve a defendant from liability for allegedly negligent medical treatment or diagnosis just because evidence of expert opinion, albeit genuinely held, is that the treatment or diagnosis in issue accorded with sound medical practice. The court must be satisfied that such opinion has a logical basis, in other words, that the expert has considered comparative risks and benefits and has reached “a defensible conclusion”
The Court also pointed out in Michael and Another v Linksfield Park Clinic that experts tend to assess likelihoods in terms of scientific certainty, but in a legal context, it is important for experts to express probabilities in more practical terms, such as the chance of an event occurring. This distinction between scientific and judicial standards of proof is essential, and the court must assess the balance of probabilities based on the totality of evidence, not on the standards applied by the experts themselves.
Regarding the facts of the case at hand, there was an agreement between the Plaintiff and the medical practitioners. This established a duty of care towards the Plaintiff and her unborn child, further underpinning the contractual and delictual obligations of the medical staff involved.
The central inquiry in this case is whether fault (negligence can be attributed to the Defendants conduct). Determining whether negligence occurred involves a two-pronged test. As articulated by Holmes JA in Kruger v Coetzee (1966), the first step is to assess whether the harm was reasonably foreseeable. The second step is to consider whether a reasonable person in the Defendant’s position would have taken steps to prevent the harm and whether the Defendant failed to take such steps.
In cases where medical professionals fail to meet the standard of care that would be reasonably expected from others in the same field, it typically constitutes negligence. This standard is in line with the principles set out in Van Wyk v Lewis (1924), where Innes CJ explained that a medical practitioner is not required to exercise the highest possible level of skill, but must instead act with reasonable skill and care. The court will assess the general skill level and diligence exercised by members of the medical profession at the relevant time.
The Mukheiber v Raath case (1999) provided further clarification on the test for negligence, as it relates to foreseeability, causation, and the Defendant’s failure to take reasonable steps to avoid harm. This formulation narrows the focus of foreseeability by connecting it to the specific consequences produced by the Defendant’s actions, thus helping to eliminate complications arising from remoteness.
In considering whether the Defendant acted negligently, the court must ask whether a reasonable medical practitioner, in similar circumstances, would have acted in the same manner, or whether the Defendant’s conduct fell short of what would be expected from an average professional.
Ultimately, the legal test for determining whether a medical practitioner has acted negligently is not abstract but involves a practical examination of whether the Defendant’s actions met the reasonable standards of skill, care, and judgment expected in the field of medicine. The crucial question is whether the Defendant’s conduct was in line with the actions of average medical professionals, or if it exhibited a manifest departure from the expected standards of care.
Court’s Findings
The court found that the medical staff at Elim Hospital failed to exercise the reasonable level of care required under the circumstances. The Plaintiff was classified as a high-risk patient with a history of C/section and ongoing complications such as anaemia. Despite being monitored and admitted for her condition, the medical staff did not adequately address her symptoms, particularly on the morning of 26th October when she experienced signs of uterine rupture.
The court concluded that had the medical team responded promptly to the Plaintiff’s complaints, an emergency C/section could have been performed earlier, potentially saving the child’s life. The Defendant’s failure to act in a timely manner amounted to gross negligence.
Conclusion
The court ruled in favour of the Plaintiff, holding the Defendant 100% liable for the damages resulting from its medical negligence. The Defendant’s failure to properly monitor and treat the Plaintiff, especially given her high-risk status, directly led to the stillbirth of the child. The court awarded the Plaintiff damages and the costs of the suit.
Photo by Arseny Togulev on Unsplash
