THE SUPREME COURT OF APPEAL OF SOUTH AFRICA
JUDGMENT

Case No:  214/2010

In the matter between:

THE PREMIER OF THE WESTERN CAPE PROVINCE

FIRST APPELLANT
DR K DU PLESSIS

SECOND APPELLANT

v

JOHANNES HENDRIK LOOTS NO

RESPONDENT

Neutral citation:
The Premier of the Western Cape Province v Loots NO
(214/2010) [2011] ZASCA 32 (25 March 2011)

Coram:
Streicher, Brand, Maya, Shongwe and Theron JJA
Heard:
11 March 2011
Delivered:
25 March 2011

Summary:
Medical negligence – unsuccessful sterilisation operation –
unforeseen complications during birth process leaving mother
severely disabled – liability of medical doctor and his employer
– issues relating to negligence and remoteness of damage.

________________________________________________________________

ORDER
________________________________________________________________

On appeal from:  Western Cape High Court (Cape Town) (Traverso DJP sitting as
court of first instance):
The appeal is dismissed with costs.
________________________________________________________________

JUDGMENT
________________________________________________________________

BRAND JA (STREICHER, MAYA, SHONGWE and THERON JJA concurring)

[1] This appeal has its origin in a delictual claim for damages arising from an
unsuccessful sterilisation operation. But the claim is not for child-raising expenses
that ensued from unwanted conception as could be anticipated from precedent in
matters of this kind.1 Instead, it resulted from the harm suffered by the mother
during the subsequent birth process that went terribly wrong.

[2] The respondent brought the claim in the Western Cape High Court as
curator ad litem for Mrs Johanna Cecilia Erasmus. He was appointed in that
capacity because the tragic events giving rise to the claim left Mrs Erasmus brain
damaged and unable to manage her own affairs. The first appellant is the Premier
of the Western Cape who takes delictual responsibility for medical practitioners
employed by the Department of Health in that province. On 21 January 1999 the
second appellant was so employed as a clinical assistant in the Department of
Obstetrics and Gynaecology at the Tygerberg Hospital. On that day he performed
the sterilisation operation on Mrs Erasmus which ultimately led to these
proceedings.

1 See eg Administrator, Natal v Edouard 1990 (3) SA 581 (A); Mukheiber v Raath 1999 (3) SA 1065
(SCA).

[3] In the High Court the matter came before Traverso DJP. By agreement
between the parties she was asked to determine the issues pertaining to the
appellants’ liability first while the quantum of damages allegedly suffered by Mrs
Erasmus, stood over for later determination. At the end of the preliminary
proceedings she decided that the appellants were liable for such damages as the
respondent may prove at the resumed hearing of the matter. The present appeal
against that judgment is with the leave of this court.

[4] The background facts are quite straightforward and largely undisputed. In
fact, the appellants presented no evidence at the trial. At the time of the
sterilisation operation on 21 January 1999, Mrs Erasmus was one month short of
her 38th birthday. She and her husband already had three children and they
decided that they could not financially afford any more. She therefore went to the
Tygerberg Hospital to be sterilised. The operation performed by the second
appellant involved a laparoscopic occlusion of both fallopian tubes. It was later
discovered, however, that the second appellant had mistakenly occluded the round
ligaments of the patient instead of her fallopian tubes. This meant, of course, that
she had not been sterilised at all.

[5] As a result of second appellant’s mistake, the patient fell pregnant soon
thereafter. When this was confirmed in April 1999, Mrs Erasmus was about eight
weeks pregnant. At that time Tygerberg Hospital presented her with the option to
terminate the pregnancy, which she and her husband refused for religious reasons.

[6] The pregnancy was uneventful until 5 November 1999. On that date,
however, the tragic train of events started which left the patient in a permanent
vegetative state, completely unable to care or think for herself. First she was
admitted to Tygerberg Hospital for high blood pressure. Then followed an
emergency Caesarean section because of foetal distress. The baby was severely
compromised and did not survive.

[7] Wisdom of hindsight revealed that either shortly before, during or after the
Caesarean section, Mrs Erasmus must have developed what is known to medical
experts as amniotic fluid embolism (AFE). It occurs when foetal antigens entered
the maternal circulation. It is an unpredictable and unpreventable event which
occurs about one in 8 000 to 30 000 deliveries. Neither the exact mechanism of the
complication nor its clinical presentation requires elaboration, because it is not in
issue that in this case the AFE caused severe haemorrhaging and cardiac arrest,
which in turn led to brain anoxia and eventually to the irreversible brain damage
that Mrs Erasmus suffered.

[8] On behalf of the respondent, three witnesses were called at the trial. They
were Mrs Erasmus’ husband and two medical experts. The one was a neurologist,
Dr Flemming, who testified about the patient’s present condition. What it amounted
to is that among other things, she suffers from dementia with poor memory and
cognitive disability; she is virtually blind; and unable to walk and talk. This evidence
as to her present condition was confirmed in lay terms by her husband. As to the
future, Dr Flemming’s prognosis is that her condition is permanent. The other
medical expert was a specialist obstetrician and gynaecologist, Dr Dalrymple, who
testified about the laparoscopic sterilisation procedure performed by the second
appellant; what he was supposed to have done; and what he actually did.
Ultimately Dr Dalrymple expressed the opinion that the second appellant’s failure
to perform a successful sterilisation must be ascribed to negligence.

[9] Though the appellants also indicated their intention to call a gynaecologist,
Dr Van Helsdingen, by filing a summary of his expert evidence, he was in fact not
called. Neither did the second appellant give evidence himself. In the event, Dr
Dalrymple’s evidence stood largely uncontroverted. It can therefore be conveyed
without elaboration. According to Dr Dalrymple’s testimony, the round ligaments
are organs lying physiologically adjacent to the fallopian tubes. They are
distinguishable from the latter by two features. First, the fallopian tube is free at
one end while the round ligament is not. Secondly, the free end of the fallopian

tube resembles the petals of a flower that are known in medical parlance as
fimbriae.

[10] Dr Dalrymple further testified that one of the potential difficulties that may
confront a surgeon during the performance of a laparoscopic tubal occlusion, is an
obstructed view. But in this case, the second appellant’s contemporaneous notes
indicated that ‘visualisation was good’ and that he was able to identify the ‘fimbrial
end of the fallopian tubes’. Accordingly, so Dr Dalrymple testified, the second
appellant had no reason to place the fallopian rings on the round ligaments. Nor
did he have any reason not to verify, after the procedure, that the occluding rings
were indeed inserted in the right place.

[11] Dr Dalrymple agreed with the diagnosis expressed by Dr Van Helsdingen in
his expert summary  that Mrs Erasmus’  condition came about as a result of AFE.
He also agreed with Dr Van Helsdingen that AFE is an extremely rare condition. In
fact, he explained that though he knew about the condition, it was so rare that he
did not consider it as a possible cause when he prepared his own expert report.
That is why he did not at that stage refer to AFE at all, but mistakenly ascribed the
calamity suffered by Mrs Erasmus to maternal hypertension instead. In response to
a direct question in cross-examination he conceded that a doctor in the position of
second appellant would probably not have foreseen the complications of AFE as a
consequence of a failed sterilisation. This concludes the factual narrative.

[12] Of the various defences raised by the appellants in the high court they
persisted in only two on appeal. The first is that the second appellant was not
negligent with regard to the consequences of the failed sterilisation for which the
respondent seeks to hold him liable. The court a quo rejected this defence
essentially on the basis of Dr Dalrymple’s expert opinion that the second appellant
was indeed negligent. If the question posed is confined to whether the second
appellant applied the degree of professional skill and diligence expected of

members of his profession2 the correctness of Dr Dalrymple’s opinion can, on the
facts that he described, hardly be open to doubt.

[13] But the argument relied upon by the appellants in support of this defence
was somewhat more nuanced. For its legal basis the argument rested on the so-
called concrete or relative approach to negligence. According to this approach it
cannot be said that someone acted negligently because harm to others in general
was reasonably foreseeable.3 A person’s conduct can only be described as
negligent with reference to specific consequences. Yet, the relative approach does
not require that the precise nature and extent of the actual harm which occurred
was reasonably foreseeable. Nor does it require reasonable foreseeability of the
exact manner in which the harm actually occurred. What it requires is that the
general nature of the harm that occurred and the general manner in which it
occurred was reasonably foreseeable. At some earlier stage there was a debate as
to whether our courts should follow the relative approach as apposed to the so-
called abstract or absolute approach to negligence. But it now appears to be widely
accepted by academic writers, on good authority, that our courts have adopted the
relative approach to negligence as a broad guideline, without applying that
approach in all its ramifications.4

[14] For the factual basis of their argument the appellants relied on the
proposition that the harm which the patient actually suffered was not of a general
kind reasonably foreseeable. That proposition, in turn, rested mainly on the
concessions by Dr Dalrymple as to the unforeseeability of AFE. The general harm

2 See eg Van Wyk v Lewis 1924 AD 438 at 444; Blyth v Van den Heever 1980 (1) SA 191 (A) at
221A.
3 Which would be sufficient on the so-called abstract or absolute approach. See eg Groenewald v
Groenewald 1998 (2) SA 1106 (SCA) at 1112H-J.
4 See eg Sea Harvest Corporation (Pty) Ltd v Duncan Dock Cold Storage (Pty) Ltd 2000 (1) SA 827
(SCA) paras 21-22; Mkhatswa v Minister of Defence 2000 (1) SA 1104 (SCA) paras 19-22;
Neethling, Potgieter & Visser Law of Delict 5 ed (2006) 126-129; 8(1) Lawsa 2 ed sv ‘Delict’ (J R
Midgley and J C van der Walt) para 117; Jonathan Burchell Principles of Delict 92 et seq; Neethling
& Potgieter ‘Die toets vir deliktuele nalatigheid onder die soeklig’ 2001 THRHR 476 at 483-484; J
Scott ‘The Definition of Delictual Negligence Revisited: Three Recent Judgments of the Supreme
Court of Appeal’ 2000 De Jure 362.

consequent upon a failed sterilisation, so the argument went, was pregnancy and
the general risks associated with that condition. But the harm that actually occurred
resulted from AFE which was not reasonably foreseeable. Consequently, so the
argument concluded, neither the harm suffered by the patient nor the manner in
which it occurred, are included in the category of what can be regarded as
generally foreseeable consequences.

[15] I do not agree with this argument. As the appellants readily conceded,
pregnancy was a generally foreseeable consequence of a failed sterilisation.
According to Dr Dalrymple’s testimony – which remained unchallenged –
pregnancy is a dangerous condition associated with a myriad of potential
complications. One of these complications was AFE. Although the particular
complication is rare, it must be included under the general rubric of complications
which was reasonably foreseeable. It follows that, in my view, the second appellant
was negligent with regard to the harm that Mrs Erasmus had suffered.

[16] The second defence advanced by the appellants was founded on the
contention that the causal link between the second appellant’s negligence and the
harm suffered by Mrs Erasmus was too tenuous to justify the imposition of delictual
liability on them for that harm.  In this regard it has by now become well settled that
in the law of delict, causation involves two distinct enquiries. First there is the so-
called factual causation which is generally conducted by applying the ‘but for’ test
as described by Corbett CJ in International Shipping Co (Pty) Ltd v Bentley.5 As to
the harm suffered by Mrs Erasmus, it is common cause that it resulted from her
pregnancy. ‘But for’ the failed sterilisation, the inherent likelihood is that she would
not have fallen pregnant. It follows that ‘but for’ the second appellant’s negligence,
Mrs Erasmus would not have suffered the harm. Factual causation is therefore not
the real issue.

5 1990 (1) SA 680 (A) at 700E-G.

[17] The real issue turns on the second enquiry under the rubric of causation,
namely, whether the second appellant’s negligent conduct is linked sufficiently
closely or directly to the harm suffered by Mrs Erasmus for legal liability to ensue.
This matter is referred to by some as remoteness of damage and by others as
legal causation. Regarding this issue it has been held by this court that the criterion
in our law for determining remoteness is a flexible test, also referred to as a supple
test.6 In accordance with the flexible test, issues of remoteness are ultimately
determined by broad policy considerations as to whether right-minded people,
including judges, would regard the imposition of liability on the defendant for the
consequences concerned as reasonable and fair.

[18] But, as also appears from the authorities to which the flexible approach
owes its origin and development, its adoption did not result in a total discard of the
variety of tests, such as foreseeability, adequate causation or direct consequences
that were applied in the past. These tests still operate as subsidiary tests or
pointers to what is indicated by legal policy. Stated somewhat differently, according
to the flexible test, the existing criteria of foreseeability, directness and so forth
should still be applied, but in a flexible manner so as to avoid a result which most
right-minded people will regard as unjust and unfair.7

[19] In line with this general approach, the appellants first relied on the direct
consequences theory. As developed in English law, a key element of this theory is
the concept of a novus actus interveniens. For this element alone can break the
causal link between cause and consequences.8 By its nature, a novus actus
interveniens or independent intervening event, can take many forms, including

6 See eg International Shipping Co (Pty) Ltd v Bentley supra at 701A-F; S v Mokgethi 1990 (1) SA
32 (A) at 40I-41D; Smit v Abrahams 1994 (4) SA 1 (A) at 15A-G; Sea Harvest Corporation (Pty) Ltd
v Duncan Dock Cold Storage (Pty) Ltd 2000 (1) SA 827 (SCA) at 847D-G; 8(1) Lawsa 2 ed para
132; Neethling, Potgieter and Visser op cit 171 et seq.
7 See eg Fourway Haulage SA (Pty) Ltd v National Roads Agency Ltd 2009 (2) SA 150 (SCA) para
34.
8 See eg P Q R Boberg The Law of Delict 440-442; Neethling Potgieter and Visser op cit 189 et
seq; J C van der Walt & J R Midgley Principles of Delict 3 ed paras 134-135.

conduct on the part of the plaintiff following upon the wrongful act of the defendant.
The independent intervening cause relied upon by the appellants for its argument
was the decision by Mrs Erasmus not to accept the offer of an abortion tendered
by the Tygerberg Hospital when she was about eight weeks into her pregnancy.

[20] The appellants rightly accepted that the decision not to have an abortion
could not eliminate the second defendant’s negligence as a factual cause of the
harm. It has already been determined that, but for that negligence, the harm would
not have ensued. The fact that the refusal of an abortion became another factual
cause of the same consequence does not detract from this reality. Yet it is
recognised in principle that even where the plaintiff’s conduct does not break the
factual chain, it can still interrupt legal causation. But in order to qualify as a novus
actus interveniens in the context of legal causation, the plaintiff’s conduct must be
unreasonable. Reasonable conduct on the part of the plaintiff cannot free the
defendant from the imputation of liability. Even unreasonable conduct on the part
of the plaintiff will not always absolve the defendant. Whether it will do so, depends
on the facts of the particular case.9

[21] The initial question is thus whether the decision by Mrs Erasmus and her
husband to refuse an abortion can be described as unreasonable. The appellants
contended that it was.10 I do not agree with this contention. Because of their
financial position, Mrs Erasmus and her husband tried to prevent another
pregnancy by seeking a sterilisation. As a direct result of the second appellant’s
negligence, they were confronted with an option they tried to avoid. That option
was between having another child that they could no afford or to have an abortion.
For religious reasons they found the latter choice unacceptable, so they opted for
the former. Had Mrs Erasmus been advised that for medical reasons the

9 See eg Mafesa v Parity Versekeringsmaatskappy Bpk (in likwidasie) 1968 (2) SA 603 (O) at
605D-E; S v Mokgethi 1990 (1) SA 32 (A) at 44B-47H; Road Accident Fund v Russell 2001 (2) SA
34 (SCA) paras 20-25; Groenewald v Groenewald 1998 (2) SA 1106 (SCA) at 1114.
10 The appellants sought to find support in the decision of the English Court of Appeal in Emeh v
Kensington and Chelsea and Westminster Area Health Authority [1984] 3 All ER 1044 CA. Save
that the decision also related to the refusal of an abortion – which was incidentally held to be
reasonable – I find very little in common between the two cases on their facts.

continuation of the pregnancy could be dangerous to her own health and that of
her unborn child, the position might have been different. But according to the
evidence of her husband, this was not the case. On the contrary, Mrs Erasmus
experienced no health problems with her previous three pregnancies and she had
been advised of no medical reason to think that this one would be different. In
these circumstances I find nothing unreasonable about the decision of the
Erasmus couple to continue with the pregnancy. It follows that application of the
direct consequences test seems to point to liability on the part of the appellants for
the harm that Mrs Erasmus suffered.

[22] Next, the appellants relied on the reasonable foreseeability test. Their
argument in this regard rested on the concession by Dr Dalrymple that the
complication of AFE that led to the harm was so rare that it would not have been
foreseen by the reasonable surgeon. The respondent’s answer to this argument
was that although the occurrence of AFE was not reasonably foreseeable, it
formed part of a reasonably foreseeable harm of a general kind.

[23] Under the rubric of negligence I have already agreed with the respondent’s
proposition that the occurrence of AFE forms part of the complications associated
with pregnancy that were foreseeable as harm of a general kind. I do not believe,
however, that the foreseeability criterion in the context of legal causation can be
exactly the same. Once we accept, as we must,11 that foreseeability plays a role in
determining both negligence and legal causation, logic dictates that the same
criterion cannot find application  in both instances. After all, repetition of exactly the
same tests on two occasions can serve no purpose other than to confuse.
Moreover, the different roles performed by the enquiries into fault, on the one hand
and imputability of harm on the other, are so fundamentally different, that the
appropriate criteria can hardly be the same.12 Unfortunately our law as it stands
does not provide a clear picture of the content of the foreseeability criterion in the

11 See eg Sea Harvest Corporation v Duncan Docks Cold Storage supra paras 21-22.
12 Cf the reasoning by Streicher JA in Sea Harvest Corporation supra para 3.

context of legal causation.13 But as I see it, if it means anything, it must mean
foreseeability of the actual harm as opposed to harm of a general kind.14

[24] On this basis, I accept that because of the unforeseen intervention of AFE,
the actual harm suffered by Mrs Erasmus was not a reasonably foreseeable
consequence of second respondent’s negligence. On the other hand, AFE is not
unknown to the medical science. Although it is rare, it has happened before and
will probably happen again. It is therefore not the kind of ‘freakish occurrence’ that
has never happened before, as was the case, for instance, in S v Bochris
Investments (Pty) Ltd;15 Sea Harvest Corporation16 and Mkhatswa v Minister of
Defence17 where the consequences were held too remote for the imputation of
liability.

[25] A further argument raised by the appellants as to why they should not be
held liable for the harm suffered by Mrs Erasmus, is that even if the sterilisation
operation had been performed without negligence, it was not a failsafe operation.
According to the medical evidence, the risk of pregnancy remained. If Mrs
Erasmus became pregnant under these circumstances the appellants would not
have been liable for the consequences. Accordingly, so the appellants argued,  it is
unreasonable and unfair to hold them liable for consequences which might have
occurred in any event. I think there are two answers to this argument. First, the fact
that Mrs Erasmus was not sterilised obviously resulted in a marked increase in the
risk of pregnancy. Second, it hardly lies in the mouth of a defendant whose
wrongful conduct caused a particular harm, to argue that the harm could in any
event have resulted from other causes. If it were otherwise, the defendant who

13 See eg Sea Harvest Corporation (Scott JA) para 22; Neethling Potgieter and Visser supra 188.
14 In this context ADJ van Rensburg, ‘Normatiewe Voorsienbaarheid as aanspreeklikheids-
begrensingsmaatstaf in the Privaatreg’ 1972 THRHR 56  suggests the criterion that, in order to be
imputed to the wrongdoer the actual harm must have been foreseeable with a ‘genoegsame graad
van waarskynlikheid’ ie a sufficient degree of probability.
15 1988 (1) SA 861 (A) at 867D.
16  Supra para 27.
17 2000 (1) SA 1104 (SCA) para 25.

negligently caused a motor vehicle accident could argue that accidents happen
every day.

[26] Despite  the arguments to the contrary raised by the appellants, I therefore
conclude that in all the circumstances, considerations of reasonableness, justice
and fairness dictate that they should be held liable for the harm suffered by Mrs
Erasmus. Since that is also the conclusion arrived at by the High Court, the appeal
cannot succeed.

[27] It follows that the appeal is dismissed with costs.

..……………………..
F D J BRAND
JUDGE OF APPEAL

APPEARANCES:

APPELLANTS:

R T WILLIAMS SC (with her C McDonald)

Instructed by: The State Attorney, Cape Town

The State Attorney, Bloemfontein

RESPONDENTS:

J S SANER

Instructed by: De Vries Shield Chiat, Cape Town

Rosendorf Reitz Barry, Bloemfontein
THE SUPREME COURT OF APPEAL
REPUBLIC OF SOUTH AFRICA

MEDIA SUMMARY – JUDGMENT DELIVERED IN THE SUPREME COURT OF APPEAL

From:
The Registrar, Supreme Court of Appeal
Date:
25 March 2011
Status:
Immediate

THE PREMIER OF THE WESTERN CAPE PROVINCE

FIRST APPELLANT
DR K DU PLESSIS

SECOND APPELLANT

v

JOHANNES HENDRIK LOOTS NO

RESPONDENT

Please note that the media summary is intended for the benefit of the media and
does not form part of the judgment of the Supreme Court of Appeal

1.
On 25 March 2011 the SCA dismissed the appeal of the Premier of the
Western Cape against the judgment of the Cape High Court in favour of the
respondent, Mr J H Loots.

2.
The matter has its origin in a claim for damages arising from an unsuccessful
sterilisation on Mrs Erasmus  which was due to the negligence of the operating
surgeon. The failed sterilisation resulted in a pregnancy which in turn led to a
birth process that went terribly wrong and which left the patient, Mrs Erasmus,
brain damaged, mentally disabled, virtually blind and unable to walk or talk.

3.
The operation was performed by a surgeon employed by the Department of
Health in the Western Cape for which the Premier takes legal responsibility. Mr
Loots instituted the action for damages in his capacity as curator ad litem for
Mrs Erasmus. He was appointed in that capacity because Mrs Erasmus was
unable, because of her mental disability, to manage her own affairs.

4.
The main defence raised on appeal was in essence that the causal link
between the unsuccessful operation and the harm suffered by Mrs Erasmus
was too remote to justify the imposition of liability on the doctor and his
employer, the Premier.

5.
In support of this defence it was argued on behalf of the Premier that Mrs
Erasmus could have avoided the pregnancy that eventually gave rise to her
damages, by undergoing an abortion which was offered to her by the hospital
free of charge.

6.
With regard to this argument the court essentially held that since Mrs
Erasmus’ refusal of an abortion was based on her religious and moral beliefs,
the refusal could not be found to be unreasonable. In consequence, the legal
position is that the refusal cannot be regarded as an interruption of the causal
connection between the negligently performed operation and the harm that Mrs
Erasmus eventually suffered.

7.
A further argument raised on behalf of the Premier as to why she should not be
held liable for the harm suffered by Mrs Erasmus, was that even if the
sterilisation operation had been performed without negligence, it was not a
failsafe operation. According to the medical evidence the risk of pregnancy
would remain. If Mrs Erasmus became pregnant under these circumstances,
neither the surgeon nor the Premier would have been liable for the
consequences. Accordingly, so the argument went, it is unreasonable and
unfair to hold them liable for consequences which might have occurred in any
event. But the SCA held that there are two answers to this argument. First, the
fact that Mrs Erasmus was not sterilised obviously resulted in a marked
increase in the risk of pregnancy. Second, that it hardly lies in the mouth of a
defendant whose wrongful conduct caused a particular harm, to argue that the
harm would in any event have resulted from other causes. If it were otherwise,
the defendant who negligently caused a motor vehicle accident could argue
that accidents happen every day.

8.
The final argument on behalf of the Premier and the surgeon was that the
complications suffered by Mrs Erasmus during the birth process were
unforeseen and rare. Though recognising that this was so, the Supreme Court
of Appeal agreed with the High Court that demands of fairness and
reasonableness dictated that the doctor and his employer should be held liable
for the harm that Mrs Erasmus suffered.