V.N obo P.N v Member of the Executive Council for the Department of Health and Social Development of the Eastern Cape Province [2021] ZAECPEHC 50 (31 August 2021)

This case involves a medical negligence claim brought by VN on behalf of PN against the Member of the Executive Council for Health and Social Development of the Eastern Cape, South Africa. The claim arises from a birth injury sustained by PN during delivery at Dora Nginza Hospital in Port Elizabeth in October 2009, which resulted in PN developing cerebral palsy due to hypoxic-ischemic encephalopathy, a condition caused by oxygen deprivation leading to permanent brain injury.

The plaintiff alleges that the negligence of the midwifery staff at the hospital, for whom the defendant accepted vicarious liability, led to PN's injury. The issues of negligence and causality were separated from other matters in dispute, focusing on whether the midwives acted negligently and whether their actions, if negligent, caused PN's brain injury.

The injury to PN is characterized as an acute profound hypoxic-ischemic brain injury occurring during the second stage of labor, involving a severe disruption of blood and oxygen supply to the brain. Expert witnesses agreed that such an injury typically occurs rapidly over a short period, with the disruption lasting between ten minutes to forty-five minutes.

The plaintiff's case centered on alleged failures by the midwives to monitor the labor adequately, to assess the fetus's condition correctly, and to intervene timely to prevent prolonged labor and oxygen deprivation. A specific allegation of negligence involved a security guard being asked to apply physical pressure to the plaintiff's abdomen to assist delivery, a method deemed inappropriate and unsafe by the plaintiff's experts.

The defendant's witnesses, including the midwives involved in PN's delivery, contested these allegations, providing evidence of standard monitoring and intervention practices. The defense also presented expert testimony challenging the plaintiff's claims about the cause and timing of PN's injury and the alleged negligence in post-birth resuscitation efforts.

The court's judgment focused on assessing the credibility of witnesses, the reliability of their testimonies, and the probabilities of the events as described by both parties. The judgment ultimately found that the plaintiff failed to prove, on a balance of probabilities, that the midwives' actions were negligent and that such negligence caused PN's injury. The court dismissed the plaintiff's claims without an order for costs.

The core legal principle underlying the decision in this case is that in a medical negligence claim, the plaintiff must prove, on a balance of probabilities, both the negligence of the healthcare providers and the causal link between that negligence and the injury sustained. Specifically, the plaintiff must demonstrate that the healthcare providers failed to meet the standard of care expected of reasonable professionals in similar circumstances and that this failure directly caused the injury in question. The judgment emphasises that mere occurrence of an injury during medical treatment, without clear evidence of deviation from accepted medical practice that directly causes the injury, does not suffice to establish negligence. Additionally, the judgment underscores the importance of credible, consistent evidence in establishing both negligence and causation, highlighting that speculative or inconclusive evidence cannot meet the burden of proof required in civil cases.

In its reasoning process, the court referred to several cases to elucidate principles related to the evaluation of expert evidence, the determination of negligence, and the establishment of causation in medical negligence claims. While the specific judgment provided does not include direct quotations or neutral citations for the case law it relies upon, it discusses general legal principles that are well-established in South African law and commonly referenced in similar contexts.

For instance, the judgment touches upon principles that can be traced back to foundational cases such as:

1. SFW Group Ltd and Another v Martell ET CIE & Others [2003] ZASCA 98; 2003 (1) SA 11 (SCA), which outlines the approach courts should take in resolving factual disputes and the evaluation of witness credibility and reliability.

2. Lee v Minister of Correctional Services [2013] ZACC 4; 2013 (2) SA 144 (CC), which discusses the tests for factual causation in the context of delictual liability, specifically the "but for" test.

3. Oppelt v Department of Health, Western Cape [2016] ZACC 6; 2016 (1) SA 325 (CC), which further elaborates on the principles of causation, including the distinction between factual and legal causation in medical negligence cases.

The court provided a detailed framework for the assessment and evaluation of expert evidence, underlining the importance of not just the credibility and qualifications of the expert witnesses, but also the logical consistency, relevance, and reliability of their opinions. The court outlined that expert opinion must be based on facts that are either common cause, established by evidence, or observed by the expert themselves. The opinion must assist the court in determining an issue by providing specialised knowledge.

The court distinguished between different types of conflicts in expert evidence, such as conflicts regarding the assumed facts, the analysis of established facts, and the inferences drawn therefrom. It stressed the importance of evaluating the reasoning process of the expert, including the premises from which the reasoning proceeds, to ensure that the opinion is logical and consistent with established facts.

The court also highlighted that the cogency of an expert opinion depends on its consistency with proven facts and the reasoning by which the conclusion is reached. An expert's opinion must not be speculative, internally contradictory, or based on a misinterpretation of the facts. The court is not bound to accept an expert's opinion if it lacks a logical basis or if the expert's methodology is flawed.

Furthermore, the court considered the qualifications and experience of the expert witnesses, the support of their opinions by authoritative literature, the measure of equivocality with which the opinions are expressed, and the impartiality of the experts. The court's task is to determine the probative value of expert evidence and make its own findings regarding the issues raised, justifying its preference for one opinion over another through a careful evaluation of the evidence.

In summary, the court underscored the critical role of expert evidence in legal proceedings, while also setting stringent criteria for its evaluation to ensure that such evidence is both reliable and relevant to the matter at hand.

The court referenced several cases to establish the principles for evaluating expert evidence. Below is a summary of each case mentioned, along with the context in which the court relied on them for evaluating expert evidence:

1. Cross on Evidence 7th Ed and Schmidt & Rademeyer Law of Evidence: These references, while not cases, are authoritative texts on evidence law. They highlight that expert opinion must be based on observed facts and that such opinions are admissible if relevant to the issues in the matter. The court used these texts to emphasise that expert opinions must assist the court by providing specialized knowledge relevant to the case at hand.

2. Ruto Flour Mills (Pty) Ltd v Adelson (1) 1958 (4) SA 235 (T): This case discusses the admissibility of expert opinion evidence, noting that it is only admissible if it is relevant to the issues in the case and has probative value. The court referenced this case to underline the necessity of expert evidence being relevant and helpful in resolving the issues before the court.

3. Menday v Protea Assurance Co Ltd 1976 (1) SA 565 (E) and Coopers (South Africa) (Pty) Ltd v Deutsche Gesellschaft Für Schädlingsbekämpfung Mbh 1976 (3) SA 352 (A): These cases establish that expert opinion evidence is necessary when the issues require special skill and knowledge beyond that of the court. The court used these cases to support the principle that expert evidence should guide the court to a correct decision on specialised matters.

4. AM and Another v MEC for Health, Western Cape (1258/2018) [2020] ZASCA 89 (31 July 2020): This case discusses the role of expert witnesses in providing the court with knowledge and criteria necessary for the court to form its own judgment. The court referenced this case to highlight the duty of expert witnesses to assist the court with their specialised knowledge.

5. Michael and Another v Linksfield Park Clinic (Pty) Ltd and Another 2001 (3) SA 1188 (SCA) and Oppelt v Department of Health 2016 (1) SA 325 (CC): These cases emphasize the importance of the logical basis of expert opinions and that the court is not bound to accept expert testimony if it lacks such a basis. The court used these cases to stress that expert opinions must be logically consistent and based on a sound methodology.

6. MEC for Health and Social Development, Gauteng v TM obo MM (380/2019) [2021] ZASCA 110 (10 August 2021): This case further elaborates on the evaluation of expert evidence, noting that the cogency of an expert opinion depends on its consistency with proven facts and the logical reasoning leading to the conclusion. The court referenced this case to underline the need for expert opinions to be logically consistent and based on established facts.

These cases and references collectively provide a comprehensive framework for the evaluation of expert evidence, emphasizing the need for such evidence to be relevant, based on observed facts, logically consistent, and presented by qualified and impartial experts. The court relied on these principles to assess the expert evidence presented in the case at hand.