Motsoaledi announced that the national health review committee will visit the two hospitals.
The Health Ombud has released damning findings revealing that poor infrastructure, inadequate equipment, and mismanagement contributed to the deaths of psychiatric patients at two Northern Cape hospitals.
The investigation found that patients literally froze to death due to electricity failures and inadequate care.
Professor Taole Mokoena, the Health Ombud, presented the investigation findings on Wednesday at the Ronnie Mamoepa Press Room in Pretoria.
The probe examined cases involving two patient deaths and inadequate medical care at the Northern Cape Mental Health Hospital in Kimberley and Robert Mangaliso Sobukwe Hospital.
The investigation was initiated following a complaint lodged by Health Minister Dr Aaron Motsoaledi in October 2024 against the Northern Cape Mental Health Hospital.
Two patients die, others critically affected
The investigation established that two patients from the mental hospital died under preventable circumstances.
Seprien Mohoto died on 16 July 2024, at Robert Mangaliso Sobukwe Hospital after being referred from the mental hospital for treatment.
Tshepo Ndimbaza died suddenly at the mental hospital on 3 August 2024.
Three patients were referred from the mental hospital to Robert Sobukwe Hospital in critical condition.
These included John Louw, who was referred on 6 July 6, Mohoto on 13 July, and Petrus de Bruin on 30 July 2024.
According to the Health Ombud, three patients suffered from and died of hypothermia, and one died of multilobe pneumonia.
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Electricity failures lead to deaths
During the critical period, the Northern Cape Mental Hospital experienced severe electricity supply problems due to cable theft and vandalism of the electricity substation serving the hospital and adjacent properties.
“During this time when there was no electricity, patients were freezing to death literally,” Mokoena revealed.
The power failures had catastrophic consequences for patient care.
Nurses were forced to work in complete darkness, improvising by using their cellphone flashlights to see patients.
The health ombudsman revealed that electromagnetic locks became non-functional, forcing personnel to keep doors open using heavy objects, creating major security breaches that would have allowed mental health patients to wander around unsecured.
Health professionals had to resort to using their mobile phones for official communication due to the infrastructure failures.
Infrastructure in state of decay
The investigation revealed extensive infrastructure problems at the mental hospital.
Mokoena described poor infrastructure maintenance with broken windows creating security risks, blocked sewerage systems, leaking roofs, and sagging ceilings and walls.
“There’s also evidence of original poor workmanship during the construction of the then-new hospital,” he noted.
The hospital lacked emergency equipment and relevant drugs.
“The Northern Cape Mental Health Hospital lacks emergency resuscitation equipment and relevant drugs. Some equipment had flat batteries from not having been charged due to the lack of electricity. Thus, patients could not receive necessary emergency resuscitation with dire consequences,” Mokoena explained.
He cited specific examples where patients Ndimbaza and De Bruin needed resuscitation before being transferred to Robert Mangaliso Sobukwe Hospital, but did not receive it.
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Severe staff shortages compromise care
Both hospitals face acute staff shortages, particularly among professional nurses.
Mokoena revealed that some shifts operate without professional nurses, with enrolled nurses and nursing assistants placed in charge of high-acuity units.
“The mental hospital is experiencing acute staff shortages, especially among professional nurses. As a result, the hospital is working at 53% of its commissioned capacity,” Mokoena stated.
The shortage extends to both hospitals, where enrolled nurses and nursing assistants are inappropriately assigned to manage high-acuity units typically requiring professional nurse supervision.
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The investigation also found that nursing and medical staff failed to maintain up-to-date patient vital signs and demonstrated generally poor record keeping.
Both hospitals lack written protocols, standard operating procedures, and guidelines for patient management.
Management failures at provincial level
The Health Ombud attributed the crisis to poor professional leadership and inefficient management.
“Both hospitals lack professional leadership, and the management was inefficient and ineffective.
“This, in our view, stems from the fluidity and the instability of senior management at the provincial health department level, whereby nearly all senior managers or management posts are filled by acting personnel,” Mokoena explained.
Specific cases highlight system failures
The investigation detailed specific management failures in patient care.
Mohoto was referred from the mental hospital for presumed bowel obstruction to Robert Mangaliso Sobukwe Hospital following a telephonic consultation with the surgical department.
Upon arrival, chest and abdominal X-rays revealed no bowel obstruction but showed multilobe pneumonia instead.
A medical officer discharged the patient without treating the pneumonia.
The patient remained in the surgical recovery unit for three days without being seen by any senior doctor from the surgical department until shortly before his death.
“His condition had been deteriorating without anyone, neither the nurses [nor] doctors taking note of this fact and resuscitating him. If his pneumonia had been treated, he might well had been still alive today,” Mokoena stated.
Meanwhile, Ndimbaza was found unresponsive in his bed at the mental hospital, suffering from hypothermia and hypoglycemia.
Mokoena said his resuscitation was inadequately executed due to a lack of equipment.
“The post-mortem determined the cause of death was exposure to the elements.”
Two other patients referred to Robert Sobukwe Hospital received appropriate management before being discharged back to the mental health hospital.
De Bruin had his hypothermia and hypoxia reversed, while Louw underwent a successful craniotomy but remains bedridden with dense hemiplegia.
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Additional procurement irregularities and recommendations for urgent action
The Health Ombud team noted additional problematic findings, including superfluous furniture procurement, purchase of golf carts, and inappropriate hospital beds.
It also found delays in commissioning ECT machines, the absence of clinical audits in both hospitals, and overcrowding at Robert Sobukwe Hospital’s accident and emergency department.
The Health Ombud recommended that the Northern Cape MEC and head of the health department urgently address staff shortages through recruitment and retention drives.
Mokoena suggested appointing non-South Africans where no qualified locals are available for certain positions.
He said the provincial health department should take appropriate action against the provincial supply chain management for failing to address quality issues with pyjamas and garments supplied by Tropical Enterprise.
The investigation recommended redirecting superfluous equipment to other hospitals that can utilise the materials effectively.
Mokoena also recommended that both hospitals develop comprehensive standard operating procedures, guidelines, and protocols to guide health personnel in patient management.
Minister calls for professional council investigation
Health Minister Dr Aaron Motsoaledi expressed concerns about the findings and announced plans to refer the matter to professional councils for further investigation.
He announced that the national health review committee will visit the two hospitals.
“I’m wondering why some are being referred for training; they’ve been trained [before, and] they’ve passed. In-service training is important but I’m not sure whether we should sentence people just for training when they’ve done something that is so grossly wrong. I’d like to refer the whole stuff to the health profession’s council and the nursing council,” Motsoaledi said.
The minister emphasised that professional councils must determine whether the actions were professionally appropriate.
He stated that the failures were unacceptable even by his standards as someone who hasn’t practised medicine in more than 30 years.
Infrastructure problems date back to construction
Motsoaledi revealed that infrastructure problems at Kimberley Mental Hospital stemmed from its original construction.
“Coming to the issues of infrastructure, it was unfortunate [that] when this hospital was built, it was chaos; in fact, some people are serving sentences because of what happened when Kimberley Mental Hospital was built,” he stated.
Years ago, senior engineers discovered that one of the multi-storey buildings lacks proper foundation.
The minister emphasised that cable thieves should understand they are committing murder in addition to theft.
He said when load shedding initially began, the department instructed hospitals to hire engineers to maintain electrical systems and generators.
“For vandalism to occur years later and find that the hospital cannot stand on its own is not surprising,” Motsoaledi said, calling the situation clear negligence on issues that could have been prevented with proper guidance.
Progress on solutions already underway
The minister noted that some problems have already been addressed, including the hiring of nurses.
However, he highlighted ongoing procurement issues, particularly regarding linen quality from Tropical Enterprise.
“I am happy that some of the problems have already been resolved. Like the hiring of nurses, I know it has started, but there is another issue that I cannot fail to mention: the issue of buying linen. You said there must be a forensic investigation professor on procurement. Now you are mentioning Tropical Enterprise, which produces poor quality pyjamas,” Motsoaledi said.
He proposed utilising Department of Labour units in Silverton and other provinces, staffed by people with disabilities, that produce high-quality garments and pyjamas.
These units, present in all provinces except Mpumalanga, consistently produce excellent quality items.
R6.7 billion allocated for healthcare improvements
Following a comprehensive assessment, the department identified needs totalling R1.4 million, including beds, linen, mattresses, and pressure mattresses, costing R1.3 billion.
According to Motsoaledi, the Minister of Finance allocated an additional R6.7 billion to the health department in the recent budget.
Motsoaledi said he met with MECs to plan the allocation of these funds. The first priority involves hiring 1,200 doctors, 200 nurses, and 250 other healthcare professionals.
The second priority addresses purchasing the R1.4 million articles, including linen, pyjamas, and other essential supplies.
The recommended interventions, coupled with additional funding, aim to prevent similar tragedies in the future.
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