Mother wins appeal against Eastern Cape Health Department in cerebral palsy case

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In an important decision, the Supreme Court of Appeal (SCA) reaffirmed that medical practitioners and institutions are expected to follow a certain standard of care that does not cause harm to their patients. In SN obo ON v MEC for Health: Eastern Cape [2025], the court ruled that the MEC was vicariously liable for the wrongful and negligent conduct of its hospital staff in the child’s brain damage.

The case at a glance

The appellant, who was a mother acting on behalf of her minor child, claimed damages from the MEC for Health: Eastern Cape because of a brain injury suffered during birth in a labour ward at a public hospital.

In the initial active phase of labour, the foetal heart rate (FHR) was stable at 142 beats per minute. Examination revealed that the labour was progressing well and that the maternal condition was good. The maternity case record (MCR), however, did not show any further assessment after 10am. At 11am the FHR revealed no decelerations, at 11.15am the mother was fully dilated and began bearing down at 11.30am. The appellant’s son was born at 12pm.

The complications summary of the labour revealed that the cord had been wrapped thrice around the baby’s neck. The one-minute appearance, pulse, grimace, activity & respiration (Apgar) score was 7/10. The first examination on the neonatal page was completed at 12.30pm, and the baby was described as lethargic and floppy with a weak Moro reflex (spreading of arms in response to a sudden loss of support) and didn’t cry. The baby had to be resuscitated with an oxygen mask. The baby was critically ill, had to be cyanosed, and required supplementary O₂, nostalgic feeding, and head cooling.

The baby was diagnosed with a hypoxic-ischaemic encephalopathy (HIE), which is a deficiency of blood in the body partly due to a functional or actual obstruction of a blood vessel. A hypoxic event in a baby occurs when there is a sustained reduction in the supply of O₂ to the brain.

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The case before court

The mother’s position

The mother argued for damages from the MEC because of the negligence of its employees and/or hospital staff in failing to:

• Initiate blood sugar or pressure monitoring of her after admission to the hospital.
  
• Take the required steps to ensure proper, timeous, and professional assessment monitoring and management of her.
  
• Prevent the occurrence of complications when this could have been done by exercising reasonable care and diligence.
  
• Perform accurate and proper monitoring of the FHR.
  
• Record an accurate partogram (maternal and foetal data) and FHR with sufficient frequency.
  
• Detect that the baby was in foetal distress.

The MEC’s defence

• It denied every aspect of negligence.
  
• In admissions in joint minutes between the medical experts, it stated that the Department of Health guidelines for maternity indicate that the necessary standard of care required that:

  1. The FHR should be checked at half-hourly intervals in the first stage of labour before, during and after a contraction.
     
  2. The checking of the FHR every five minutes after the second push in the second stage of labour.
     
  3. The FHR monitoring was substandard, as not checked in accordance with these guidelines.
     
  4. It is unknown whether the FHR abnormalities were present or not in the first or second stage of labour.
     

• Therefore, the MEC admitted that the hospital staff’s monitoring of the mother during labour was negligent and substandard, and that even in that event the brain damage resulting from the HIE was caused by an unknown sentinel event (an unexpected incident that results in permanent harm).

The key issues to be decided

• Negligence: Whether the acute profound hypoxic event (O₂ deficiency) that occurred intrapartum (the period spanning childbirth, specifically from the onset of labour through the delivery of the placenta) was preventable or foreseeable to the nursing staff of the hospital.
  
• Causation: Whether the conduct of the nursing staff was the cause of the baby’s CP.

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The High Court’s ruling

The Eastern Cape High Court found in favour of the MEC, in that:

• The monitoring of the mother by the nurse was not substandard as the court accepted the nurse’s evidence that the assessment and examination of the mother were done at correct intervals, that the FHR was always normal, that there was no indication of foetal distress, and that there were no warning signs that the foetus’s well-being was at risk.
  
• The cord that was wrapped thrice around the baby’s neck was not tight, as the nurse managed to put her finger between the cord and his neck to clamp and cut the cord.
  
• It rejected the evidence of the mother’s obstetrician and gynaecologist (OBGYN) as being confusing and not fact-based.
  
• The loose nuchal cord (a common condition where the umbilical cord is wrapped around a foetus's neck, typically without causing complications) did not cause the acute profound brain damage.
  
• Therefore, the court dismissed the mother’s claim with costs.

The mother sought leave to appeal the decision of the High Court to the SCA, which was granted.

The Supreme Court of Appeal’s ruling

The SCA found that the High Court had erred in concluding that the views genuinely held by the mother’s OBGYN were unreasonable and had further misdirected itself in absolving the MEC’s employees and/or hospital from liability for the negligent medical treatment based solely on the evidence of the MEC’s OBGYN that the treatment was in accordance with sound medical practice.

The SCA held that:

• On the probabilities, the baby’s brain injury was caused by the cord around the neck.

• The baby’s brain injury could have been prevented by proper monitoring by the nursing staff to determine whether there were FHR decelerations.

• The cord probably tightened around the baby’s neck, causing the brain injury during the critical period between 10.30am, when the birthing process began, and 11.30am, when the mother started bearing down, when there was a failure to monitor.

• The nursing staff did not take the reasonable and necessary steps to monitor the baby’s FHR.

• The evidence given by the nursing staff pointed to substandard monitoring that did not accord with the standards set out in the guidelines.

• It was very concerned that although the nurse recorded in the MCR that the cord around the neck was a complication, she did not indicate whether the cord was tight or loose. She also did not indicate whether the meconium (the earliest stool of a baby typically passed shortly after birth) was thin or thick, which is indicative of foetal distress.

• It did not accept the evidence of the nurse that she remembered putting her finger under the cord and cutting it, yet this is not recorded in the hospital records. These records formed the only basis for the rest of the evidence she gave, as she did not have her own recollection of the birthing events. Her version was rejected as being not reliable, honest, trustworthy, nor credible.

• The evidence given by the mother’s OBGYN was consistent with the probabilities on the evidence viewed as a whole. Nuchal cords wrapped around the neck of foetuses occur frequently, but few result in CP births, as they are generally identified early.

• A proper standard of monitoring by nurses showing a reasonable standard of care would have picked up when the baby was in distress as shown by decelerations. This would have allowed for timeous interventions to prevent the baby’s brain damage.

• Therefore, the MEC’s employees had been negligent, and further that their conduct had caused the baby’s brain injury.

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Accordingly, the court ruled that:

• The High Court’s order dismissing the mother’s claim on behalf of her child was set aside, and the appeal was upheld with costs.
  
• The MEC was ordered to pay the mother’s as well as the child’s eventual proven damages, given that the losses sustained by the family had still to be quantified.

Legal implications

This decision reaffirms that medical practitioners are compelled to follow and reinforce the standards of care required of medical professionals, particularly in the context of record keeping, patient communication, and duty to exercise thorough medical and clinical judgment.

Their conduct must:

• Comply with the Department of Health’s own guidelines on the standard of care expected of its healthcare professionals.

• Meet the standard of a reasonably skilled and careful practitioner in the particular field and in similar circumstances, as well as adhere to the general level of skill, care and diligence possessed and exercised at that time by the members of that specific branch of the profession to which that practitioner belongs.

• In cases involving CP in babies, a failure to adequately monitor the mother and foetus during labour, in a situation that leads to foetal deoxygenation distress and the development of a hypoxic event, amounts to substandard care on the part of nurses and doctors for which they can be held liable.

Practical implications

For hospitals and medical practitioners, this case underscores the need to render treatment that meets the required professional guidelines and that is well-documented. The standard to be met is that of a reasonable medical practitioner faced with the circumstances at hand.

For patients, especially in our country where people have no alternative but to attend public health facilities, the ruling reaffirms that these facilities cannot render substandard treatment without facing potential liability for the damages caused.

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Key takeaways

For patients

• Know your rights and act promptly: Patients are entitled to healthcare delivery systems that recognise their dignity and rights as demanded by the Constitution.

• Assessment of liability is important: The assessment and determination of whether a negligent act has been committed, that is, the factual and legal cause of the injury sustained, is a complex endeavour in medical negligence cases, and is an important hurdle to be cleared in claims by the appointment of the necessary medical experts.

• Quantify your damages accurately: According to the common law once-and-for-all rule, all losses arising from negligent conduct must be claimed once, for both the certain losses that have already been incurred, as well as for any uncertain future losses, which might not yet even have occurred at the date the claim has to be lodged. This again requires the appointment of the necessary medical experts to determine the exact extent of the claim.

For medical practitioners

• Ensure legal compliance: The standard of care rendered must align with statutory provisions such as the Health Professions Council of South Africa Guidelines and the South African Maternity Guidelines, etc, and record keeping must align with provisions such as the National Archives of South Africa Act, the Promotion of Access to Information Act, etc.

• Obligation to keep accurate records: The person in charge of a health establishment must ensure that a health record containing such information as may be prescribed is created and maintained at that health establishment for every user of health services. The medical records are critical to evaluating the standard and extent of care afforded to a patient, and absent these medical records there is no objective record of the actual care rendered, which can draw negative inferences from the courts.

• Avoid a failure to monitor: The risk of substandard monitoring can lead to missing something that practitioners would be expected to act on to prevent bad outcomes for patients. A failure to properly monitor in accordance with the requisite guidelines, especially in birthing cases, places the foetus at a serious risk of severe injury that can result in profound consequences.

The SCA’s decision in SN obo ON v MEC for Health: Eastern Cape reiterated the position that where there is a sufficiently close connection between the negligence of medical institutions and the damage caused to patients, then those medical institutions can be held liable to compensate the victims for their damages and resultant devastating emotional consequences.