My husband died suddenly just over a year ago after planned elective surgery performed by an expert surgeon in a highly rated private hospital. The surgery was successful, but he developed post-operative complications, which were poorly managed, and he did not survive.(1–3) However, my experience of the private healthcare system from this very sad episode was a shocking revelation. The manner in which patients and their families are treated is appalling. The total lack of professionalism, compassion and basic humanity which my family experienced following my husband's death was absolutely astounding. I have always believed the healthcare in South Africa to be world class, particularly in the private sector, but there are major systemic problems that cannot be ignored.
As a bereaved family member in the private sector, you are entirely on your own. Once the terrible news has been broken, that is the end of all communication. The last conversation I had with the surgeon was literally at my husband's death bed. To my surprise, the boutique private hospital did not have a morgue. The only communication I had from the hospital was a phone call on the day of my husband's death asking if they could “put him in the fridge, as they did not have a morgue”. That was it – no condolences, no follow up to see how we were coping, no debriefing, no counselling, no explanation, no support whatsoever from either the medical practitioners or the hospital – absolutely nothing. The surgeon should have met with me and my family to discuss what went wrong and the need for an autopsy and inquest – a legal requirement for a procedure-related death. Although I understand that my husband died from his complications, I have no idea why they happened. He was fit and well when he went in for the procedure.
I learned that there is almost nothing that you, as a spouse or family member, can do to get answers or restitution for your loved one's death. It is extremely difficult to negotiate with the various official bodies, including the Health Profession's Council of South Africa (HPCSA) and hospital complaints department. There is no single person or place to assist you. Every question is answered with a legal rebuttal, frequently with the response this cannot be addressed due to patient confidentiality. Once you start to ask questions, you are no longer a bereaved relative to be treated with respect and compassion, but one becomes an enemy to be defeated. This was particularly evident during a webinar that I participated in recently.(4) Dr. R. Chetty was arguing against reporting medical malpractice in the press. He used the metaphor of a boxing match between the doctor (the victim) and the patient (who has nothing to lose). This is not a friendly exchange, but a bitter fight for survival with no holds barred. Compassion and humanity go out of the window, misogyny and gas-lighting rear their ugly heads. Your integrity and veracity are questioned. The pain and devastation of your loss are not considered at all. You, as the patient, are completely alone with no support or funding, up against the well-resourced expert lawyers of private healthcare system. The establishment has one purpose – to defeat you, the patient or the family of the patient. The unspoken message is that the doctor or hospital staff cannot possibly be wrong and you, the patient, should not dare to challenge the status quo. The lawyers take over and carefully scrutinize every aspect of the case, while bringing convoluted legal arguments forward such as “accelerated benefit” and “contributory negligence”. This insinuates that I caused the early death of my husband for financial gain. As a grieving widow, the emotional impact of such onslaught is almost unbearable! What kind of people are these? Is this how we treat bereaved patients and their families, by adding to their pain and heartache?
Private practitioners are not accountable to anyone. Private practitioners are independent contractors and not employees of the private hospitals, so they do not answer to an employer for their actions. There is almost no system of peer review in private healthcare and hospitals do not make their outcome statistics public. In academic institutions, doctors work together as a team, and morbidity and mortality reviews are standard practice. Morbidity and mortality review should be mandatory in all private hospitals and statistics on hospital and practitioner performance should be available for public scrutiny.
My husband's passing was a procedure-related death with a legal requirement for a medico-legal autopsy and inquest.(5) The medico-legal process is the responsibility of the surgeon and hospital, not the bereaved family. If properly implemented, this process actually ensures review and accountability of private practitioners. Unfortunately, there is a serious lack of knowledge and commitment to the process among medical practitioners generally, but more concerningly among anaesthetists.(6) Ironically, the lack of a medico-legal autopsy is used in the practitioner's defence as the cause of death cannot be proven.
The South African National Editors’ Forum hosted a webinar on reporting medical malpractice.(4) Private practitioners argue that they are running a business for the purpose of financial gain. Negative press impacts on the doctor's reputation and therefore the ability to generate income. During the webinar, bereaved patients were referred to as “disgruntled’. Nobody spoke of the patient's pain or the fact that the doctor may very well be at fault.
The function of the HPCSA is to “protect the public and guide the profession”. Patients and their relatives who are not satisfied with medical care are able to report the medical practitioner to the HPCSA. The whole process is unclear and extremely slow. A verdict can take between 12 and 18 months after the initial complaint. The doctor has to respond personally to the Council, without legal representation, but the whole presentation is carefully prepared by a skilled legal team usually from the Medical Protection Society. The doctor also has the benefit of expert witnesses. The patient, on the other hand, is completely unaided, without any such legal support. The patient is not given an opportunity to engage with the Council, so cannot interrogate the doctor's response or provide additional information. Sadly, expert witnesses have a conflict of interest as they are paid substantial amounts for their opinion, potentially leading to biased opinions. Once the HPCSA has made a ruling, the matter is final. You, as the patient, can appeal the decision in the high court at your own cost, which is extremely expensive.
A common belief is that a patient can sue for millions in any case of medical negligence. This is not true. In a civil case, the financial settlement is determined by loss of financial support caused by the death of the patient, not the degree of negligence. There is often no loss of financial support and so it is not possible to sue. Litigation for pain and suffering is possible, but the financial settlement is determined by the loss of income due to the pain and suffering. Litigation is very costly, so unaffordable for the individual person and civil litigation for medical negligence is done on a contingency basis. Legal firms will only take on a case that is guaranteed a successful outcome with a large financial settlement.
Mediation between the patient and or relatives and doctor and hospital is frequently suggested as a solution to many of these problems. Mediation, however, can only be successful if approached with sincerity and sensitivity by all parties. The doctor and hospital must be willing to admit culpability and apologize, while the patient and or family must be open to forgiveness and understanding. Doctors and nurses can and do make mistakes; they are human too after all. Often patients and their relatives want their pain and loss to be acknowledged, as well as an explanation of what went wrong and a sincere apology, rather than money. Too often, a patient's death is simply brushed off. The impact of a death on the bereaved family is devastating, and this must be recognized by the caregivers. Unfortunately, the current level of legal involvement in the medical negligence arena results in rapid escalation to confrontation. As soon as a patient lodges a complaint, the doctor is advised to stop communication.
There is an alarming tendency for private practitioners to abdicate their responsibility of care to the patient and their family. The doctor remains responsible for the medical care of the patient, even after discharge from the hospital. Providing a cell phone number and telling the family “to call me if worried” is not adequate clinical care. Clinical medicine is just that – clinical, meaning physical assessment of the sick person. Practitioners wishing to practice remote control medicine must provide the patient and family with clear written instructions on danger signs.
Issues in private health care are not limited to the medical practitioners as nursing care leaves much to be desired. Just because you pay large amounts of money does not guarantee quality nursing care. Completing observation charts in advance and failure to appreciate danger signs are some of the problems I encountered with my husband's hospitalization.
A minority of the intensive care units (ICU) in the private sector are run by intensivists. The physician or surgeon admits the patient to the ICU and continues to manage the critically ill patient, without any additional training or expertise in the management of critically ill patients. In academic hospitals, dedicated intensivists, registrars and consultants run the ICU. In private hospitals, nurses who frequently have little or no ICU qualification, run the ICU, thus in many instances, private intensive care equates to expensive and intensive monitoring, not intensive care.
In conclusion, unfortunately expensive private health care does not necessarily equate to excellence. There are major systemic problems in private health care. Currently there is almost nothing that a relative can do to ensure accountability for your loved one's demise. Civil litigation is complex and expensive and frequently not possible in the case of death. The HPCSA is extremely slow and variable. The law regarding procedure-related death is poorly implemented. Private practitioners are not held accountable to anyone. Morbidity and mortality reviews are lacking. There is a lack of patient advocacy and support. Lawyers are far too involved in medical care which impacts negatively on compassionate patient care and communication.
This terrible experience happened unexpectedly to me and my family. What will you do when it happens to you?