Brief Summary

Medical negligence — Duty of care — Claim for damages arising from death of patient due to alleged negligence of hospital staff — Plaintiff contended that medical personnel failed to provide adequate treatment and supervision to deceased, who suffered from severe alcohol withdrawal and psychosis, resulting in fatal fall from hospital premises — Defendants admitted to treating the deceased but denied negligence, asserting that reasonable care was exercised — Court found that the defendants had fulfilled their duty of care and that no causal negligence was established, thus dismissing the claim for damages.

Comprehensive Summary

Summary of Judgment

Introduction

This was a delictual claim for damages arising from alleged medical negligence in the management of a hospital patient who later died after falling from a hospital building. The proceedings took place in the High Court of South Africa (Eastern Cape Division, Gqeberha), before Bands AJ, and the judgment was delivered on 1 September 2022.

The plaintiff, Jeanine Carla Williams, sued the Member of the Executive Council, Department of Health, Eastern Cape (first defendant) and the Medical Superintendent of Livingstone Hospital, Gqeberha (second defendant). The claim arose from the death of the plaintiff’s husband, George Williams (the deceased), following a fall from the fifth floor of Livingstone Hospital.

Procedurally, the defendants filed an amended plea shortly before trial. A previously raised special plea concerning non-compliance with section 3 of Act 40 of 2002 was no longer in dispute because it had been withdrawn. At the parties’ request, the court made an order under Uniform Rule 33(4) separating the issues of liability (negligence and causation) from the remaining issues in the action, with the present judgment confined to the separated issues.

The general subject-matter of the dispute concerned whether the deceased—who was admitted with symptoms consistent with delirium tremens and psychosis—was managed with reasonable medical and nursing care, and whether any shortcomings in his management causally contributed to his fall and death.

Material Facts

It was common cause that the deceased died as a result of injuries sustained when he fell from the fifth floor of Livingstone Hospital. It was also admitted that the hospital records were compiled by employees of the defendants acting within the course and scope of employment, and that the documents were what they purported to be. Although the defendants did not formally admit the correctness of the records in a pre-trial minute, the court found that the trial was conducted on the basis that the contents were treated as factually correct by both parties, including during the evidence and argument.

Chronologically, the material facts accepted by the court were that the deceased, a known alcoholic whose last alcohol use was about four days before admission, presented to Livingstone Hospital on 3 October 2013 at 20h50. He complained of visual disturbance, dizziness, hallucinations, and sleeplessness, and he was admitted for further management of acute psychosis with possible delirium tremens.

On 4 October 2013, the deceased received 5 mg intravenous diazepam (Valium) at 12h45, which had no effect. By 15h10, he remained confused, restless, and “up and about”. The nursing staff did not inform the doctor on duty that the initial dose had no effect. At around 17h30, he was moved to the ward, still restless and confused, and he was observed walking up and down the ward.

At 18h00, he received a further 5 mg oral diazepam, also with no effect, and 2.5 mg oral haloperidol, again with no effect. At 22h00, a further 2.5 mg oral haloperidol was administered. A nursing note at 22h30 recorded that he was moving around the ward, hearing people talking at a back door, had removed his drip, went to the nurses’ station, and that staff followed him but were afraid of being assaulted. The note then recorded that he broke the outside entrance glass door of the nurses’ tearoom, went through it, and fell to the ground floor.

The deceased suffered polytrauma with hypovolemic shock and died at 00h15 on 5 October 2013.

The records further reflected that 1 mg intravenous Rivotril was prescribed but never administered, and it was unclear from the records when it was prescribed and why it was not given. An incident report reflected that the nurse contacted the doctor on duty, who could not attend the ward but ordered that Rivotril be administered intravenously.

The central factual dispute was not about the occurrence of the fall or the death, nor materially about what was recorded as having been administered, but about whether the treatment and monitoring reflected in the records met the acceptable standard of care for a patient with suspected delirium tremens and psychosis, and whether shortcomings in management were causally linked to the fatal fall.

Legal Issues

The court was required to determine whether the defendants’ employees (medical and nursing personnel) were negligent in their management of the deceased and, if so, whether that negligence was a factual cause of his death.

The dispute primarily concerned the application of legal standards to established facts, informed by expert evidence. In particular, the matter turned on competing expert analyses of whether the treatment administered—especially sedation and the escalation (titration) of medication—was consistent with accepted medical practice in the management of delirium tremens, and what inferences could properly be drawn from the established timeline of the deceased’s deterioration and behaviour.

A further issue arose (late in argument) about whether the contents of the hospital records had been admitted as correct facts. The court treated this as part of the evidential framework underpinning the expert opinions, and determined whether the factual basis for expert reasoning was sufficiently established.

Court’s Reasoning

The court first addressed the role and evaluation of expert evidence. It restated that a court decides factual issues and does not delegate decision-making to experts, whose function is to assist the court within their specialised knowledge. Expert opinion must be grounded in an established factual basis, whether common cause or proved by evidence, and where the facts are not agreed they remain assumptions lacking probative value unless proved.

Applying those principles, the court held that the trial was conducted on the shared premise that the hospital records provided the factual chronology of observations, treatment, and events. The defendants’ late contention that the contents were not admitted was rejected as inconsistent with the way the matter had been litigated and argued, and as an attempt to avoid the consequences of deficiencies in the defendants’ evidence.

The court then evaluated the conflict between the experts, identifying the dispute as one concerning both the analysis of established facts and the standard of care in the relevant circumstances. It approached this by assessing the cogency, internal consistency, and logical fit of each expert’s reasoning against the established factual record, rather than by treating the issue as one of mere credibility.

On the accepted facts, the court considered the deceased’s presentation and diagnosis as involving suspected delirium tremens, described in evidence as a medical emergency requiring immediate and adequate management. The plaintiff’s expert (Dr Harris) relied on published medical guidelines and explained the need for frequent monitoring, repeated reorientation, and—crucially—adequate medication to control agitation and promote sleep. Her evidence emphasised that treatment commonly requires titration of benzodiazepines to achieve a state of light dozing while still arousable, coupled with monitoring until the delirium tremens abates.

The court contrasted this with the defendants’ expert (Dr Walsh), whose evidence, in the court’s view, did not coherently reconcile the persistent agitation and lack of response recorded in the notes with an opinion that management was sufficient. The court highlighted concessions by Dr Walsh that stronger sedation was required in the circumstances and, importantly, that the records contained no evidence of a proper titration process.

The court accepted Dr Harris’s evidence as well-reasoned, logically consistent with the common cause chronology, and supported by published guidelines. It rejected the sufficiency conclusion advanced by Dr Walsh as illogical and inconsistent with the accepted facts and the concessions made. On that basis, the court found that the conduct of the treating medical and nursing personnel fell materially short of accepted practice.

Turning to negligence, the court applied the general delictual test articulated in Kruger v Coetzee, namely whether a reasonable person in the defendant’s position would foresee the reasonable possibility of harm and would take reasonable steps to prevent it, and whether the defendant failed to take such steps. It also noted the need to avoid hindsight bias when assessing negligence. The court considered that medical and nursing personnel are judged against the general level of skill and diligence exercised by members of their profession in similar circumstances.

On the facts accepted and the preferred expert evidence, the court found that the plaintiff had proved negligence in that staff failed properly to sedate and manage the deceased so as to restrict his movements and adequately treat his condition, and failed to exercise the necessary care and skill expected of reasonable medical and nursing personnel.

The court then addressed causation. It applied the “but-for” test for factual causation, emphasising that the test is one of common sense and practical judgment and that a plaintiff need only establish that it is more likely than not that the harm would not have ensued but for the wrongful and negligent conduct. The key enquiry was whether the deceased would have died but for the negligent failure adequately to treat and sedate him.

The court reasoned that, had the deceased’s medication been properly titrated to achieve a calm and lightly dozing state, he would not have been pacing in a confused, restless, and disoriented condition. In that calmer state, he could have been monitored appropriately until the delirium tremens abated. On a balance of probabilities, the court concluded that if this state of affairs had been achieved, the deceased would not have fallen from the fifth floor, and the fatal outcome would therefore not have occurred.

Outcome and Relief

The court declared that the first and second defendants were liable jointly and severally for such damages as might be agreed or proved arising from the incident that formed the subject of the claim, with the remaining issues postponed for later determination in accordance with the earlier separation order.

The defendants were ordered to pay the costs of the hearing of the issues determined in the judgment, jointly and severally, including the qualifying fees of the plaintiff’s expert, Dr Candice Harris.

Cases Cited

The Member of the Executive Council for Health, Eastern Cape v MM obo ELM (Eastern Cape Local Division, Bhisho, Case No CA&R 8/2021, Full Bench judgment by Van Zyl DJP, Schoeman J and Noncembu AJ concurring).

Twine and Another v Naidoo and Another [2018] 1 All SA 297 (GJ).

Van Wyk v Lewis 1924 AD 438.

S v Gouws 1967 (4) SA 527.

Menday v Protea Assurance Co Ltd 1976 (1) SA 565 (E).

Coopers (South Africa) (Pty) Ltd v Deutsche Gesellschaft Für Schädlingsbekämpfung MBH 1976 (3) SA 352 (A).

Price Waterhouse Coopers Inc v National Potato Co-op Ltd [2015] 2 All SA 403 (SCA).

Kennedy v Cordia (Services) LLP [2016] 1 WLR 597 (SC).

JA obo DMA v The Member of Executive Council for Health, Eastern Cape [2022] 2 All SA 112 (ECB); 2022 (3) SA 475 (ECB).

Kruger v Coetzee 1966 (2) SA 428 (A).

S v Bochris Investments (Pty) Ltd and Another 1988 (1) SA 861 (A).

Meyers v Member of the Executive Council, Department of Health, Eastern Cape (1010/2019) [2020] ZASCA 3 (4 March 2020).

NTH v Member of the Executive Council for Health, Gauteng Province (57301/15) [2021] ZAGPPHC 208 (8 February 2021).

International Shipping Co (Pty) Ltd v Bentley 1990 (1) SA 680 (A).

Simon & Co (Pty) Ltd v Barclays National Bank Ltd 1984 (2) SA 888 (A).

Minister of Police v Skosana 1977 (1) SA 31 (A).

Chapelkin and Another v Mini (103/2015) [2016] ZASCA 105 (14 July 2016).

ZA v Smith 2015 (4) SA 574 (SCA).

Minister of Safety and Security v Van Duivenboden 2002 (6) SA 431 (SCA); [2002] 3 All SA 741 (SCA); [2002] ZASCA 79.

Minister of Finance and Others v Gore NO 2007 (1) SA 111 (SCA); [2007] 1 All SA 309 (SCA); [2006] ZASCA 98.

Lee v Minister of Correctional Services 2013 (2) SA 144 (CC); 2013 (2) BCLR 129 (CC); [2012] ZACC 30.

McGregor and Another v Member of the Executive Council for Health, Western Cape (1258/2018) [2020] ZASCA 89 (31 July 2020).

Legislation Cited

Institution of Legal Proceedings Against Certain Organs of State Act 40 of 2002, section 3.

Rules of Court Cited

Uniform Rule 33(4).

Uniform Rule 37.

Held

The court held that, on the established factual record and the preferred expert evidence, the treating medical and nursing personnel employed by the defendants failed to manage the deceased’s condition to the standard expected of reasonable practitioners in comparable circumstances. In particular, the deceased was inadequately sedated and his medication was not properly titrated despite recorded agitation, confusion, and lack of response to administered medication.

The court further held that this negligent management was a factual cause of the deceased’s fall and death. On a balance of probabilities, had proper titration achieved a calm and lightly dozing state with appropriate monitoring until the delirium tremens abated, the deceased would not have been pacing and disoriented in the ward and would not have fallen from the fifth floor.

LEGAL PRINCIPLES

Expert evidence is opinion evidence derived from inferences drawn from facts, and it must have an established factual basis to carry probative value. Courts must evaluate the reasoning process underpinning expert opinions, including internal consistency, logical fit with the proved or common cause facts, and methodological soundness, and must not permit experts to supplant the court’s decision-making role.

In medical negligence claims, negligence is assessed with reference to the reasonable foreseeability of harm and the reasonable preventative steps expected of a person in the defendant’s position, applying the standard articulated in Kruger v Coetzee. Professionals are assessed against the general level of skill and diligence ordinarily exercised by members of their profession in similar circumstances, while guarding against hindsight.

Factual causation is determined using the “but-for” test, applied as a matter of common sense and practical reasoning rather than mathematical certainty. In omission cases, the enquiry is whether, more likely than not, the harm would not have occurred but for the defendant’s wrongful and negligent failure to take reasonable steps.

Williams v Member of the Executive Council, Department of Health, Eastern Cape and Another (2958/2016) [2022] ZAECQBHC 26; [2023] 1 All SA 562 (ECP) (1 September 2022)