Authored By: Ntombifuthi Precious Tlapu
- Case Title & Citation
Medi-Clinic Limited v Vermeulen (504/13) [2014] ZASCA 150; 2015 (1) SA 241 (SCA) (26 September 2014)
Medi-Clinic Limited v Vermeulen 2015 (1) SA 241 (SCA)
- Court Name & Bench
Supreme Court of Appeal of South Africa.² The bench consisted of Ponnan JA, Wallis JA, Pillay JA, Zondi JA (who penned the judgment), and Dambuza AJA.
- Date of Judgment
The judgment was delivered on 26 September 2014.
- Parties Involved
- Appellant: Medi-Clinic Limited, a private hospital group and the defendant in the court a quo.
- Respondent: Mr. George Vermeulen, a patient who suffered severe injuries while being treated at a hospital operated by the appellant. He was the plaintiff in the high court.
- Facts of the Case
The respondent was admitted to Medi-Clinic Nelspruit on 17 May 2007, gravely ill with cerebral malaria contracted in Mozambique.1 He was immediately treated in the Intensive Care Unit (ICU), where he remained until 24 July 2007.2 Upon admission, a Waterlow scale assessment scored him as being ‘at risk’ of developing pressure sores.3 His condition deteriorated significantly between 20 and 24 May 2007, a period termed the ‘critical period’.4 During this time, he was haemodynamically unstable, requiring inotropic support (adrenaline infusion) to sustain his blood pressure, and he developed renal failure necessitating dialysis.5
Despite nursing entries noting skin redness, by 25 May 2007, the skin on his sacrum had turned black, indicating a severe, established pressure sore.6 This sacral bedsore led to bilateral sciatic nerve injuries, resulting in paralysis and rendering the respondent wheelchair-bound.7 The respondent sued the appellant for damages, alleging that its nursing staff were negligent in failing to implement adequate preventative measures, such as regular turning, to avoid the onset of the pressure sore.8 The appellant defended the claim, contending that given the respondent’s critically ill state and predisposition to sores (he was obese and hypertensive), the development of the sore was unavoidable, and that turning him during the critical period would have endangered his life.9 The trial in the high court proceeded on the issue of liability only.10
- Issues Raised
The central legal issue before the Supreme Court of Appeal was:
- Whether the appellant’s nursing staff were negligent in their treatment of the respondent by failing to take adequate steps to prevent the development of the sacral pressure sore, which subsequently caused his sciatic nerve injury and paralysis.11
This overarching issue encompassed two key questions:
- Was the development of the pressure sore avoidable through reasonable nursing care?12 • If avoidable, was it medically advisable to implement such care (e.g., regular turning) given the respondent’s critically unstable condition during the relevant period?13
- Arguments of the Parties
- Arguments of the Respondent (Vermeulen):
The respondent argued that the pressure sore, or at least its severity, was entirely avoidable.14 He contended that the appellant’s nursing staff failed to implement a sufficient pressure care regimen, primarily by not turning him regularly to relieve pressure on his sacrum.15 Expert evidence for the respondent, led by Dr. Lebos (a surgeon) and Professor Nel (a nursing expert), suggested that turning was possible and necessary even for critically ill patients.16 Dr. Lebos opined that he would only abstain from turning a patient if convinced it would certainly cost the patient’s life, not merely because it was life threatening, and that blood pressure levels alone should not dictate the decision.17 They also argued that placing the respondent in a Lazy-Boy chair for prolonged periods later in his treatment, despite visible lesions, aggravated his injuries.18
- Arguments of the Appellant (Medi-Clinic):
The appellant accepted that regular turning was the standard method to prevent pressure sores but argued it was medically inadvisable and unreasonable in this specific case.19 The appellant’s defence rested on the expert testimony of Professor Coetzee, a critical care specialist.20 He testified that during the critical period, the respondent’s mean blood pressure was dangerously low, often falling below 60 mmHg.21 For a known hypertensive and obese patient like the respondent, Professor Coetzee argued that a safe mean blood pressure for turning would be around 90 mmHg, a level that was not achievable during the critical period.22 Turning him at such low pressures risked causing acute myocardial injury, ventricular fibrillation, and death.23 He concluded that the pressure sore was an unavoidable consequence of the respondent’s critical illness, poor perfusion due to low blood pressure, and obesity, rather than negligent nursing.24 Regarding the Lazy-Boy chair, it was argued this was a necessary part of respiratory treatment after extubation.25
- Judgment / Final Decision
The Supreme Court of Appeal upheld the appellant’s appeal and dismissed the respondent’s cross-appeal on costs.26 The order of the North Gauteng High Court was set aside and replaced with an order dismissing the respondent’s (plaintiff’s) claim with costs, including the costs of two counsel.27
- Legal Reasoning / Ratio Decidendi
The court’s reasoning focused on the correct legal test for establishing medical negligence and its application to the expert evidence presented.
The court began by reaffirming the principles established in Michael & another v Linksfield Park Clinic (Pty) Ltd & another, which built upon the classic test in Van Wyk v Lewis.28 A medical practitioner is not expected to exercise the highest degree of skill but is bound to employ reasonable skill and care judged against the standard of their professional branch.29 However, where expert opinions conflict, a court must evaluate whether the opinions are founded on logical reasoning.30 The court emphasised that a practitioner is not negligent if they act in accordance with a practice accepted as proper by a responsible, reasonable, and respectable body of professional opinion, even if another body holds a contrary view.31
Crucially, drawing from English authority (Bolam v Friern Hospital Management Committee and Bolitho v City and Hackney Health Authority), the court held that for a body of opinion to be considered ‘reasonable’ or ‘responsible’, it must be demonstrated to have a logical basis.32 In particular, where the practice involves weighing risks against benefits, the experts must have directed their minds to this comparative exercise and reached a defensible conclusion.33 A court is entitled to reject an opinion that cannot be logically supported.34 This represents a nuanced application of the traditional Bolam test, ensuring that deference to medical expertise is not blind but is contingent upon the opinion surviving logical judicial scrutiny.35
Applying this test, the court found that the high court had erred by simply preferring the evidence of Dr. Lebos over that of Professor Coetzee without subjecting both to the required rigorous logical analysis.36 The court identified several flaws in Dr. Lebos’s approach:
- It seemed to proceed from an incorrect premise that all bedsores are avoidable, effectively suggesting res ipsa loquitur, which is impermissible in medical negligence cases.37
- It advocated for preventative measures ‘at all costs’ without a sufficient comparative assessment of the life-threatening risks (myocardial injury, death) versus the benefits (preventing a sore) in the respondent’s specific clinical context.38 His approach was deemed absolutist and failed to engage with the granular, real-time risk calculations required in intensive care.39
- It dismissed the critical importance of the respondent’s haemodynamic instability and low blood pressure as relevant factors, which Professor Coetzee logically explained were paramount.40 Dr. Lebos’s assertion that there was “no figure” for a safe blood pressure for turning was found to be an untenable position that ignored established physiological principles.41
In contrast, the court found Professor Coetzee’s opinion to be logical and defensible.42 He provided a detailed explanation of why the respondent’s blood pressure levels made turning unsafe, he factored in the respondent’s comorbidities (hypertension, obesity), and he conducted a clear risk benefit analysis, concluding that the risk of death from turning outweighed the risk of developing a sore.43 His evidence demonstrated that his cautious approach was founded on a logical application of cardiovascular physiology to the patient’s specific, dire circumstances.44 As his view represented a responsible body of medical opinion, the appellant’s conduct following this approach could not be deemed negligent.45 The respondent had therefore failed to discharge the onus of proving negligence.46
- Conclusion / Observations
Medi-Clinic v Vermeulen is a significant judgment that provides a clear and authoritative restatement of the test for medical negligence in South African law, particularly in complex cases involving conflicting expert opinions. It firmly embeds the Bolitho requirement of ‘logical defensibility’ into South African jurisprudence, moving beyond a mere counting of expert heads and mandating a deeper, more critical engagement by courts with the substance of expert evidence.47 The case serves as a crucial reminder that courts must engage deeply with the reasoning behind expert opinions, especially when they involve a weighing of life threatening risks.48 It also underscores the difficult choices healthcare professionals must make in critical care settings and affirms that tragic outcomes, while deeply unfortunate, are not necessarily attributable to fault if the treatment provided aligns with a logically sound body of professional expertise.49 The judgment thus strikes a vital balance between protecting patients’ rights and safeguarding medical professionals from liability for unavoidable misadventures in high stakes environments, ensuring that the practice of medicine is not unduly hampered by defensive practices born out of a fear of litigation.50
Reference(S):
1 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [1].
2 The Medi-Clinic Case
3 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [9].
4 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [10].
5 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [11].
6 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [12].
7 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [1].
8 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [2].
9 The Medi-Clinic Case
10 The Medi-Clinic Case
11 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [3].
12 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [14].
13 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [15].
14 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [14].
15 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [2], [14].
16 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [16], [22].
17 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [22], [27].
18 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [17].
19 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [15].
20 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [16].
21 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [23], [24].
22 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [23].
23 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [23], [28].
24 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [24].
25 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [30].
26 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [34].
27 The Medi-Clinic Case
28 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [3], [4].
29 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [3].
30 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [4], [5].
31 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [5].
32 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [6], [7], [8].
33 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [7], [25].
34 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [8], [26].
35 The Medi-Clinic Case
36 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [26].
37 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [27].
38 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [27], [31].
39 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [27].
40 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [23], [27], [28].
41 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [22], [27].
42 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [29], [31].
43 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [23], [29].
44 The Medi-Clinic Case
45 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [31].
46 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [32].
47 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [8], [26].
48 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [25].
49 Medi-Clinic v Vermeulen 2015 (1) SA 241 (SCA) [33].
50 The Medi-Clinic Case
