South Africa: Lessons In Patient Care: Negligence And Accountability In The Gauteng Health System

A recent court ruling has held the Gauteng MEC for Health accountable for a case involving the amputation of a patient's leg. The failure to call a paramedic to provide evidence played a significant role in the judgment. This case raises important questions about the responsibility of healthcare institutions and the need for timely and appropriate medical care. It serves as a reminder of the importance of patient well-being and the duty to provide adequate healthcare services.

Facts

On 10 December 2016, the plaintiff was involved in an altercation that resulted in him twisting his knee. He alleged that he was immediately taken to the Chiawelo Clinic by his friend, where the nurses attended to him promptly. At around 02h00 on 11 December 2016, he was taken by an ambulance to Chris Hani Baragwanath Hospital.

The plaintiff arrived at the hospital at approximately 02:45, but it was not until 04:30 that a medical student examined him. The medical student observed swelling in the plaintiff's knee and a lack of blood flow to his right foot. However, the initial doctor who attended to the plaintiff noted that there was still some sensation in his lower limb.

An X-ray showed that the plaintiff had not fractured his knee. Thereafter, at 11h45 the plaintiff was seen by an orthopaedic surgeon and was promptly referred to Dr Sechaba Palweni, a registrar who was working as a vascular surgeon.

By the time the vascular surgeon saw the plaintiff, his right foot was cold. The vascular surgeon immediately diagnosed the plaintiff with a blockage of a blood vessel in his knee that cut off the blood supply to his lower limb. Furthermore, the vascular surgeon identified the plaintiff's injury as a type of injury where there was no arterial blood flow in the limb and where there was mild to moderate muscle weakness. This meant that there was a real risk that the plaintiff would lose his lower leg, and the leg may only be saved if the blood flow was immediately re-established. Therefore, the vascular surgeon and other surgeons at the hospital performed several operations in an attempt to re-establish blood flow to his limb. However, their efforts were unsuccessful and the plaintiff's leg was amputated from above the knee on 27 December 2016.

The action for damages

The plaintiff launched a claim for damages against the Gauteng MEC (the "MEC") for Health and Social Development, alleging that the hospital staff's late and negligent identification of his injury led to the amputation of his right leg. He argued that if the staff had identified the injury in a timely manner, amputation would have been unnecessary. The Johannesburg High Court had to determine whether the hospital staff acted negligently and if their negligence caused the amputation. The MEC denied negligence, suggesting that the plaintiff's own delay in seeking treatment was responsible for the amputation.

Negligence

The plaintiff claimed that the medical staff negligently failed to take prompt action to save his right leg after being assessed by a medical student. He argued that there was a seven-hour delay in treatment after the X-ray was performed before he was referred to the orthopaedic surgeon. Professor Martin Veller, an expert witness for the plaintiff, testified that the standard of care required immediate action after the initial assessment. He also highlighted the insufficiency of the X-ray, stating that the lack of blood flow in the plaintiff's right foot indicated a real risk. The vascular surgeon agreed that immediate action was necessary following the medical student's observation. Despite expert testimony from Dr. Sabatta Tsotesti, who supported the MEC, the court was not convinced that the seven-hour delay was not negligence.

The High Court, concluded that on a balance of probabilities, it has been established that the hospital staff's failure to attend to the plaintiff promptly amounted to negligence.

Causation

The High Court also had to consider whether the seven-hour delay in treating the plaintiff was, on a balance of probabilities, to blame for the amputation of the plaintiff's right leg.

The MEC argued that the plaintiff did not sustain the injuries at 01h20 as claimed, but rather the injury was probably sustained at around 22h00 on 10 December 2016. However, because the plaintiff was drunk at a party, he only went to the hospital when the pain became too great to ignore. The MEC therefore contended that it is the plaintiff's delay in seeking medical treatment that led to the amputation of his leg. The High Court, had to consider when the plaintiff sustained his injury.

Two medical notes indicated that the plaintiff's injuries were sustained at 22h00 on 10 December 2016. If this was true, it would mean that there had been a lack of blood flow in the plaintiff's right foot for six hours by the time he was seen at the Baragwanath hospital. Therefore, according to the joint minutes drafted by the two expert witnesses, Dr Tsotetsi and Professor Veller, this would mean that the plaintiff came to the Baragwanath hospital at a time when amputation was more likely to be performed.

The first medical note that mentioned 22:00 was written by the paramedic who transported the plaintiff from the Chiawelo clinic to the hospital. However, since the paramedic did not testify in court, the note was considered inadmissible. The second note referring to 22:00 was from the vascular surgeon. Unfortunately, the vascular surgeon could not recall if the plaintiff himself stated that the injury occurred at 22:00. The court did not accept the claim that the plaintiff had informed the vascular surgeon about the timing of the injuries at 22:00. The court reasoned that "there is an obvious difference between directly recalling that the plaintiff told him that the injury was sustained at 22h00, and inferring from his notes that the plaintiff must have done so". Furthermore, the High Court held that it is likely that the vascular surgeon simply replicated the notes that were made by the paramedics.

On the other hand, the plaintiff argued that on the night of 10 December 2016, he only drank four 330ml bottles of Castle Lite beers between 19h00 and 21h00. Therefore, in his version, he had not had a drink for four hours before he sustained his injuries at around 01h20. This was unchallenged. Furthermore, it was unchallenged that he had instant and excruciating pain when he sustained his injury. The court concluded that it is improbable that the four bottles that he consumed could have anaesthetised the plaintiff to a point where he only sought medical treatment after three hours. Therefore, on a balance of probabilities, the court found that the plaintiff's injury was sustained at around 01h20 on 11 December 2016.

Considering the evidence on the time the plaintiff sustained his injury, and the state of his leg on arriving at the hospital (it was agreed that it was capable of being saved), the court concluded that, on a balance of probabilities, it is clear that the negligence of the Hospital's staff caused the plaintiff to lose his leg.

The plaintiff was successful in proving that the loss of his leg was caused by the hospital staff's wrongful and negligent failure to promptly treat his injury on arrival. He was successful in his claim for damages against the MEC.

As public health facilities face immense pressure and challenges, this judgment should serve as a wake-up call for all healthcare professionals. It emphasises the need for continuous improvement and vigilance in delivering quality healthcare services and upholding accountability in the face of medical negligence.

Moving forward, it is crucial for the healthcare system to prioritise patient safety, establish robust protocols, and ensure effective communication amongst medical professionals.

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