South Africa Grapples With Billions in Medical Negligence Costs

South Africa's medical-negligence crisis is exposing failures far beyond individual doctors and nurses, with experts warning that weak leadership, poor adherence to clinical guidelines, inadequate documentation, staff shortages, and a lack of reliable data are allowing preventable harm to remain invisible. The warning comes as the Eastern Cape reports that its estimated medico-legal liability has almost halved, from R38 billion to just under R19 billion over five years. But experts caution that a lower projected compensation bill does not necessarily mean fewer patients are being harmed. Former Health Ombud Professor Malegapuru William Makgoba says South Africa still lacks a reliable national picture of how many patients die or suffer serious harm because of failures in healthcare. Keep up with the latest headlines on WhatsApp | LinkedIn "We still have no idea what the contribution of the medical profession is to mortality." Professor Alex van den Heever, chair of Social Security Systems Administration and Management Studies and an adjunct professor at the Wits School of Governance, says the country's estimated medical-negligence liability should be treated as a warning about healthcare delivery rather than simply a financial problem. "The legal process is the consequence of the failure to prevent negligence," he says. The concerns come ahead of the South African Medical Legal Association 's (SAMLA) annual conference in Gauteng, where experts will discuss medico-legal risk, patient safety and accountability in healthcare. Billions in potential liability National Treasury puts provincial medico-legal contingent liabilities at R57.6 billion for 2024/25, down from R62.5 billion the previous year. The figures represent potential future obligations rather than money already paid. Actual provincial settlements average about R1.5 billion annually. The Eastern Cape has sought to reduce its exposure partly by providing some injured patients with future care in public facilities instead of paying large lump sums for anticipated medical and rehabilitation costs. But that approach depends on the state's ability to provide the promised care over the patient's lifetime. A Supreme Court of Appeal judgment on February 11, 2026, highlighted the risk. The court overturned an Eastern Cape High Court order substituting public healthcare and undertakings to pay for lump-sum compensation for a child injured through negligence. The province had conceded liability. The appeal court found that the evidence did not justify confidence that lifelong treatment and future payments would reliably be provided. The scale of medico-legal claims has also prompted government intervention. The South African Law Reform Commission's investigation into medico-legal claims was initiated following requests from the Department of Health and the Minister of Justice and Correctional Services, amid concern about escalating medical-negligence claims and their financial impact on the public health sector. The commission released its final report and proposed legislation on 29 September. Warning signs in maternity care Eastern Cape midwife and nurse educator Dr Luleka Gcawu's research shows how failures at ward level can become medico-legal cases. A woman with abnormal blood pressure may be assessed but the required intervention does not follow. An abnormal foetal heart rate may fail to trigger the prescribed response. Monitoring may occur less frequently than guidelines require, or observations may be made without being recorded. "Sometimes the woman's BP is checked as per guidelines - but not documented," Gcawu says. She says training alone does not guarantee compliance. Some healthcare workers fail to implement updated guidelines despite having received training. Her research identified behavioural factors including poor patient relationships and failure to respond appropriately to identified problems, alongside system pressures. She also points to shortages of nurses, mi