The Health Ombud report, released by Professor Taole Mokoena, has revealed alarming findings following an investigation into the treatment, complications, and deaths of psychiatric patients at the Northern Cape Mental Health Hospital (NCMHH) and the Robert Mangaliso Sobukwe Hospital (RMHSH).

The report highlights issues such as prolonged damage to electricity infrastructure, patients freezing to death, acute staff shortages, dangerous medical negligence, and poor facility conditions, including broken windows and leaking roofs.

The investigation was initiated following a complaint lodged by Minister of Health Dr Aaron Motsoaledi after complications and deaths of psychiatric patients in Northern Cape hospitals last year.

This follows the referral of three patients – John Louw, Cyprian Mohoto, and Petrus de Bruin – from NCMHH to RMHSH in critical condition in July 2024.

The investigation revealed that two patients from NCMHH had died. One of them, Mohoto, passed away on July 16, 2024 at RMHSH after being referred from NCMHH for treatment. Another patient, Tshepo Mdimbaza, died unexpectedly at NCMHH on August 3, 2024.

According to the Health Ombud, the deaths and illnesses occurred when NCMHH was experiencing severe electricity supply issues caused by theft and vandalism of electrical infrastructure. The hospital was relying on a diesel-powered generator.

Cold exposure and medical failings

The investigation found that patients were exposed to extreme cold during outages. One patient died of hypothermia, others developed pneumonia and stroke complications.

“Patients were freezing to death,” Mokoena said yesterday.

According to the report, Mdimbaza died from hypothermia. Mohoto developed multilobar pneumonia and subsequently passed away. Louw suffered a stroke due to severe hypothermia, while De Bruin also experienced hypothermia.

The report noted that pyjamas and blankets procured were of ‘poor design and flimsy material’, incapable of providing sufficient warmth, and general linen was lacking.

“Nurses were forced to work in the dark using cellphone torches, and electromagnetic locks were non-functional, creating major security risks,” said Mokoena.

Shortages, poor leadership, and staff burnout

The report further found that NCMHH lacked emergency resuscitation equipment and relevant drugs. “Thus, patients could not receive the necessary emergency resuscitation with dire consequences – for example, patient Mdimbaza at NCMHH and De Bruin before transfer to RMHSH.”

Staff were reportedly operating at only 53% capacity, with junior nurses running high-acuity units without adequate supervision or professional leadership.

Mokoena said patient vital signs were not properly recorded, and general record keeping was poor.

He also criticised the time it took NCMHH to restore its electricity infrastructure, stating it took a year, compared to just a month at nearby private hospitals.

“These shortcomings have not been allowed to prevail; the patients who died could still be alive today,” he said.

Misconduct referrals and national review committee

Motsoaledi said there may be grounds for professional misconduct charges against medical staff and recommended referring them to the Health Professions Council of South Africa.

He also slammed leadership at the hospitals. “My conclusion is that… leadership is not working together. I don’t think they even have management meetings or mortality meetings.”

Motsoaledi announced the establishment of a National Mental Health Review Committee to comprehensively investigate and restart hospital management processes. – SAnews.gov.za

Watch as the Health Ombud releases its findings:

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