Basic nursing failures, including missed warning signs, poor monitoring and unqualified staff in intensive care are behind catastrophic patient harm and the claims that follow.
That was the conference message from nursing expert, Emeritus Associate Professor Ethelwynn Stellenberg of the Department of Nursing and Midwifery, Stellenbosch University, and national chairperson of the South African Medico-Legal Association, reprots Chris Bateman for MedicalBrief. Presenting case studies under the conference theme, "The Human Factor in Medical Error: Ethics, Accountability and the Law Beyond Technology,” Stelleberg said the country's medico-legal crisis was a patient-safety crisis.
"Prevent the harm before we argue about the claim," she urged, adding that quality care "is not an aspiration but a professional obligation."
Stellenberg set out three cases of what she called substandard care. Each ended in irreversible harm.
Toddler left with brain damage
An 18-month-old child with croup was admitted to casualty. Only the child's temperature was measured, despite respiratory distress. A heart rate above 180 beats a minute was not acted on, and the doctor was not told. In intensive care, secretions were not suctioned as required. A nurse took blood for analysis to the laboratory and left the patient. On her return, the child's pulse had dropped from above 180 to about 50. The child went into cardiac arrest.
A doctor arrived 20 minutes later. By then, the presentation said, brain damage had set in. The child developed cerebral palsy less than 48 hours after admission. (Gauteng High Court (Johannesburg), 2012)
Paralysis after spinal surgery
A 66-year-old woman walked into hospital for spinal surgery. She returned from theatre at about 18:00 and complained of numbness in both legs. She could not move them. A registered nurse questioned whether she had really walked in, rather than examining her. An enrolled nurse did the assessment and care plan. The registered nurse did not evaluate them. The plan did not include monitoring leg movement and sensation, or drainage from the surgical wound. The patient’s weakness worsened. She received painkillers and frequent position changes. By 01:25 she could not move her feet or toes, and only then was the surgeon consulted. She was back in theatre by 04:00 to drain a haematoma.
She developed cauda equina syndrome, which is irreversible. It caused paralysis of the lower limbs and loss of bowel and bladder control. Stellenberg’s presentation referred to a Free State High Court (Bloemfontein) case.
Amputation after bypass surgery
A 57-year-old man with chest pain was advised by two cardiologists to have conservative treatment. A cardiac surgeon disagreed and operated on a Saturday. The surgery was not an emergency. An intra-aortic balloon pump catheter was placed through the left femoral artery. After surgery, nurses did not properly monitor the limb for poor blood supply, suspected to have been compromised by the catheter. A Doppler device showed poor pulses in one foot. However, left, and right foot observations were recorded the wrong way round. These were neither reported nor interpreted. The catheter was removed on Sunday afternoon. The patient complained of severe leg pain to nurses and the surgeon, who was reportedly watching cricket. The complaints were ignored. He developed compartment syndrome, a perfusion injury, and by Monday the leg was dead. It was amputated above the knee.
He was awarded more than R4m, plus all other costs.
"Can R4m replace a limb?" Stellenberg asked, adding: "observation is not clinical reasoning.”
Her second presentation looked at why deterioration goes unrecognised. It said the question is not simply whether observations were recorded but rather, "whether somebody understood what they were telling us".
"Nurses must observe, assess, interpret, escalate and reassess, and ask: What do these findings mean when I put them together? – the purpose of observation is not documentation – it is prevention of harm."
She also challenged how hospitals decide who cares for which patient. Staffing should weigh five factors:
- qualification
- competence
- experience
- supervision
- patient acuity
"The question is not: 'Who do we put in bed? – It should be: What does this patient need?'"
A path from the bedside to the courtroom
Stellenberg traced how a missed warning sign becomes a legal claim.
The steps she listed were missed deterioration, inadequate care, delayed intervention, preventable harm, permanent disability lifelong care, medico-legal claim.
"The claim is the end of the story; the patient-safety failure came first," she averred.
Stellenberg warned that the cost is not only financial:
"A life changed. A family changed. A carer created. A future lost."
She added: "Behind every medico-legal claim is a human being."
She said the cases share one thread: basic nursing care was violated. She listed:
- poor monitoring and poor interpretation of clinical signs
- incompetence and poor training
- incorrect documentation
- failure to communicate with doctors and surgeons.
- failure to use ICU-trained staff.
- dismissive attitudes toward patients and families
She also criticised the use of assistant nurses, caregivers, and enrolled nurses in intensive care. She said this was "clearly a matter of chasing profits" through "cheap labour, less expenses".
Calls for action
Stellenberg’s set of recommendations were:
- Hire quality nursing staff to reduce adverse events.
- Keep substandard staff out of intensive care.
- Train registered nurses who work in ICUs to the level of ICU-trained staff.
- Stop chasing profits at the expense of safe care.
- Introduce continuing professional development (CPD) for nurses urgently.
She said professional nurses learn critical analytical thinking, drawing on anatomy, physiology, pathophysiology, chemistry, and physics. Non-professional nurses do not acquire these skills.
"The science of nursing is not 'carrying bedpans or having tick fever,'" she said, the latter an allusion to the widespread practice of ticking of pre-listed requirements without proper investigation or thoughtful engagement.