Defence in Malherbe case points to tampering with records

Lynn Shaw HERALD REPORTER

THE alleged tampering with crucial medical records and the inadequate manner in which nurses at St George‘s Hospital monitored hysterectomy patient Ilse Malherbe came under the spotlight yesterday when the defence delivered its closing argument in the Port Elizabeth High Court.

GP anaesthetist Mike Botha and specialist gynaecologist Marcus van Heerden are accused of negligently causing Malherbe‘s death after she underwent a routine hysterectomy in 2004.

She was the wife of radiologist Daan Malherbe.

Defence advocate Graham van der Spuy said Malherbe‘s hospital record had been altered in the presence of the hospital‘s management and its attorney.

He mentioned that a state witness, Sister Beatrix (Maritz) Cooper, who monitored Malherbe in the ward before she died, had conceded in court that she altered the hospital record by adding information after the patient‘s death.

He said the defence had obtained a copy of the record in its original form before it had been altered.

Van der Spuy said Cooper had had no choice but to explain herself. He said a page from the hospital record had been thrown away on the instruction of their attorney.

“Cooper‘s justification that she had simply been transferring notes from elsewhere in the file fell flat. Nothing can serve as justification for tampering with the record. This was dishonest and unprofessional.

“Had the defence not been fortunate enough to notice the changes, this would not have come out in court. The hospital management‘s denying that the changes were made was even more shocking.

“This leads one to wonder what else is not truthful in the record. There could have been other aspects that were tampered with that we don‘t even know about.”

Van der Spuy said Cooper and the hospital had stood to benefit from changing the record because it would have covered up the grossly inadequate monitoring of Malherbe. Because the records had been tampered with, the defence was of the opinion that the court did not have all the facts.

On the day Malherbe died, there were 21 patients in the ward and only two nursing sisters, one of whom went off duty at 2pm. Even though Van Heerden had given the nurses an instruction to monitor Malherbe every 30 minutes, this was not done.

A sister in the ward did nothing when a nursing assistant twice reported that Malherbe had very low blood pressure.

The defence said the court should believe Van Heerden above Cooper, because Cooper was a single witness who on her own admission had tampered with hospital records.

The trial resumes today.