A new academic study of medical malpractice in South Africa has revealed startling sums to be paid for this from the public purse and highlights alarming shortcomings in the nursing profession.
Part of the study reveals that, over 11 years, neglect by nurses in delivering babies has led to three provinces’ health departments being sued for R120bn. The study focused on 400 malpractice cases in Gauteng, the Eastern Cape and the Western Cape between 2006 and 2016.
It was led by Prof Ethelwynn Stellenberg, a veteran Stellenbosch University nursing academic and researcher, and chair of the South African Medico-Legal Association.
Half the cases of malpractice were found in high court records in Gauteng and the Eastern Cape. The rest were from private hospital groups in Gauteng and the Western Cape that reluctantly allowed the researchers to work in their lawyers’ offices to extract clinical, legal, and circumstantial data, but on condition of anonymity. About 42 trial bundles were of cases heard in South African high courts or settled out of court.
The study’s findings were presented at a critical-care conference last week in Gqeberha.
We need a retraining of our educators … a paradigm shift involving integrity and ethical leadership
— Ethelwynn Stellenberg
Stellenberg tells the FM that improved “leadership capacity and management” will be needed to reduce the litigation, which has been a rapidly accelerating problem in recent years, consuming huge parts of provincial health-care budgets.
She cited cases of community-service nurses being left to run large primary health-care wards with little or no supervision, then being hauled over the coals by their seniors when patients died.
The study she supervised also identified other “adverse events”, preventable or unpreventable, relating to medical treatment, which can include medication side effects, injury, psychological harm or trauma, or even death. Adverse events can also include a patient slipping on a mopped floor, a porter tipping a patient out of a wheelchair or a patient being given the wrong food.
Of the adverse events leading to malpractice litigation, 90.1% are related to maternity. Most involved public sector midwives, with 193 cases of babies being born with cerebral palsy because of poor monitoring.
Nurses and doctors were responsible for 71% of adverse events in the public sector; in the private sector it was 43%. In the private sector, 53% of qualified nurses were involved, but only 12% in the public sector. Junior nurses were connected to 23% of adverse events in the private sector and just 2% in the public sector.
Altogether 89% of “extreme adverse events” occurred in the public sector, where 9% of linked deaths occurred. In the private sector it was 39% with 21% related to deaths.
Eighty percent of events that affected quality of life were found to be in the public sector, against 69% in the private sector. Permanent disability accounted for 71% of cases in the public sector against 25% in the private sector.
Failing to apply guidelines was a contributing factor in 91% of adverse events, with poor monitoring running at 75% and “clinical manifestations not picked up” at 73% of cases, says the study. “Failure to give treatment as indicated” and “an accumulation of admissions” contributed to half of all cases. Forty-two percent were due to an accumulation of errors, with a lack of knowledge and system failures. A lack of training accounted for 19% of all adverse events, says the study. Behavioural errors accounted for 27%.
Of all the long-term patient-care plans, that is, those resulting from harm suffered, 63% were completed in the private sector and 22% in the public sector. However, 64% of these plans had been implemented in the private sector — 15% below those being carried out in the public sector. Progress reports were at 41% in the private sector and at 14% in the public sector.
Stellenberg says: “Nurses have tick fever — they fill in the boxes but don’t know what they’re doing.”
Midwives were responsible for 84% of adverse events in the public sector and just 8% in the private sector.
Stellenberg and her team of PhD and master’s students recommend urgent midwifery training. “We need a retraining of our educators … a paradigm shift involving integrity and ethical leadership, and regular workshops on all phases of the nursing process,” she says.
“Many patients admitted to health establishments are subject to malpractice negligence not related to their actual health-care problem, resulting in extensive morbidity and mortality,” says Stellenberg. “Patients have a constitutional right to have access to quality health care, not to mention [that we have a] very explicit patient rights charter.”
Last month a rural-health conference at Chintsa near East London heard that accrued medico-legal suits against the Eastern Cape health department stood at R5.62bn — or 20% of the total budget (R28.1bn).
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