Clinical Death, Legal Invisibility

Abstract Background Preventable deaths and severe harm in African health systems are frequently recorded as isolated “complications” or individual negligence, which obscures structural determinants of risk. The 2025 suspension of emergency services at HJ Hospital and Centre Médical Diamant in Kinshasa, following the death of Divine Kumasamba after delayed care linked to payment demands, illustrates how financial barriers and organisational cultures limit access to life-saving treatment. Similar patterns appear in obstetric violence in Kisangani, landmark Kenyan cases, South Africa’s medico-legal crisis, and under-litigated negligence in Nigeria. Methods We applied the health axis of the DSM-H (Diagnostic and Statistical Manual of Human Structural Pathologies, 2025) to 17 purposively selected case units: emblematic African cases or studies (DRC n=4, Kenya n=3, South Africa n=3, Nigeria n=3) and high-income comparators (USA/UK n=4). Four syndromes were coded: Paywall Triage Harm (PTH), Structural Neglect (NS), Gendered Clinical Violence (VCG), and Legal Invisibility of Victims (IJV). Each has five observable criteria, a gravity scale (0-3), and an institutional responsibility index (0-4). Two coders (one DSM-H developer, one independent health jurist) coded all cases; Cohen’s kappa was 0.74-0.84 before consensus. Technical details and theoretical background are presented in the Supplementary Appendix. The 17 case units are treated as structural probes rather than statistical units for prevalence estimation. Findings Across 12 African case units, 70% presented at least two syndromes of moderate-to-high gravity. NS was present in 10/12, VCG in 8/8 obstetric units, PTH in 5/6 emergency-care units, and IJV in 7/12. Northern comparators showed analogous patterns of NS and VCG affecting minoritised patients despite higher resources, with Black women facing maternal mortality ratios two to four times those of white women. Interpretation Fault-focused medico-legal frameworks in the DRC and elsewhere under-detect institutional pathologies. The DSM-H health axis offers a measurable taxonomy that complements law by making structural harm visible and actionable. Integrating such tools into regulation, clinical governance, and legal education could shift responses from individual blame to preventable systemic reform.