Poor adherence to clinical guidelines, inadequate documentation and healthcare workers’ attitudes towards patients are among the leading contributors to medical malpractice litigation in South Africa.
This is according to veteran Eastern Cape midwife and nurse educator Luleka Gcawu.
Gcawu, a senior trainer in the Eastern Cape Department of Health who has worked with the South African Medical Legal Association (SAMLA) to develop validated guidelines aimed at preventing malpractice litigation in nursing, said behavioural factors identified in research could account for more than half of the factors contributing to litigation.
She cited failures to provide appropriate care, poor patient relationships, and failure to respond appropriately when patients describe problems. The findings emerged from a 2016/17 study conducted by Gcawu, SAMLA chair Prof Ethelwynn Stellenberg and two other researchers to identify factors contributing to malpractice litigation in nursing practice.
Gcawu said the study found that nurses and midwives sometimes failed to act on clinical warning signs despite established protocols. A woman with abnormal blood pressure, for example, might be assessed but not referred to a specialist, reported to a senior nurse, or advanced midwife. Similarly, an abnormal foetal heart rate might not trigger the required intervention. Clinical monitoring was also sometimes conducted less frequently than stipulated by guidelines, she said, while observations were occasionally made but not documented.
“Sometimes the woman’s BP is checked as per guidelines – but not documented,” Gcawu said.
She attributed these failures partly to staff shortages and system pressures, but also to individual behaviour and attitudes. Training alone did not guarantee compliance. Some staff failed to implement updated guidelines despite having received training, while others displayed what she described as an attitude of “I don’t care”.
The wider system compounded the problem. Gcawu identified shortages of nurses and trainers, inadequate resources, leadership instability and difficulties securing ambulances for patient transfers as contributing factors. Nurses leaving the public health service were not always replaced while shortages were also affecting the ability to train inexperienced staff. Patient-to-nurse and student-to-educator ratios were incompatible with quality-assurance requirements.
Gcawu estimated that nurse-educator capacity in the Eastern Cape was at only about 40% of what was required.
“Sometimes training is scheduled, but midwives are not released to attend. They need to look after patients. And there are not enough trainers,” she says.
Gcawui singled out instability in senior leadership as one of the biggest systemic obstacles, citing a high number of acting appointments and, in some cases, people occupying positions without the necessary experience or qualifications. She also raised concerns about political appointments, saying they could contribute to leadership instability and poor decision-making. The resulting system failures could aggravate adverse events and increase exposure to medico-legal claims.
She also pointed to burnout and overwork as contributors to poor staff behaviour. Some nurses, she contends, may have entered the profession primarily for financial reasons rather than as a vocation.
The study also identified patient behaviour as a factor in some cases, although Gcawu said this was less significant than healthcare-worker and system-related factors. Examples included patients failing to collect medication or not following family-planning advice.
The findings have informed SAMLA training and guidelines introduced to help prevent malpractice litigation. Gcawu said training had made a difference, although she could not attribute any specific reduction in litigation directly to the guidelines because they had not yet undergone a formal implementation evaluation. Available statistics suggested a modest decline in litigation, she said, but overall levels remained high.
Gcawu said the guidelines needed to be more robustly tested with frontline nurses to assess implementation and identify improvements. She also endorsed concerns that South Africa’s maternal health outcomes reflected broader failures in the healthcare system. National Department of Health data put the institutional maternal mortality ratio at 105.2 deaths per 100,000 live births in 2023, compared with 71.8 in the Western Cape and between 101.5 and 166.6 in the other provinces.
For Gcawu, preventing medico-legal harm therefore requires more than training individual healthcare workers.
“It needs administration by the department to employ more people,” she said, while emphasising the need for stable leadership, adequate resources, effective supervision, and consistent implementation of clinical guidelines.
She said SAMLA’s educational programmes were making an important contribution but were not reaching enough healthcare workers, with time and financial constraints often preventing attendance.She said that restoring patient safety required addressing both the systems in which nurses work and the behaviour of individual healthcare professionals.
Her message was blunt: clinical guidelines only protect patients when healthcare workers have the resources, supervision, and professional commitment to follow them.
