Health Ombud report reveals failures at Pretoria hospital after death of psychiatric patient

The death of a 35-year-old woman in a fire at Dr George Mukhari Academic Hospital in Ga-Rankuwa has raised serious patient safety concerns in a report released on March 24.

The patient, who had a long-standing mental illness dating back to adolescence, was admitted to the psychiatric ward for only four days in 2024, when she lost her life after a fire broke out on the evening of June 20.

Gauteng Department of Health spokesperson Motalatale Modiba confirmed the patient died after being admitted to the hospital on June 20.

“She was placed in a seclusion room as part of her prescribed treatment,” said Modiba, who continued, “At around 18:35, a smouldering small fire broke out [in] the seclusion room,” he said.

On March 24, the Health Ombud’s Professor Taole Mokoena released a report that found that the tragedy was preventable and resulted from systemic failures at the hospital, including negligence and lapses in patient care.

The report stated that the patient was placed in a seclusion room during her stay. While in isolation, a fire broke out, claiming her life. Investigations found that delays in both accessing the seclusion room keys and responding to the fire ‘significantly contributed to her death’.

“The healthcare practitioners who were involved were negligent. Their conduct resulted in harm that could have been prevented,” the report stated.

“Access to the seclusion room was significantly delayed, resulting in a delay of approximately 20–30 minutes before the door was opened,” the report said.

The Ombud’s report also highlighted legal and procedural irregularities in the patient’s admission. Stating that required medical assessments were not conducted according to legal standards.

The report detailed inhumane treatment during her admission. The patient was excessively restrained, denied food and medication as punishment, and her reports of sexual assault were ignored.

“The allegation of sexual assault could not be substantiated due to investigative failures; however, the healthcare workers’ inaction constituted negligence and a breach of legal and ethical obligations, that the patient was physically assaulted,” the report stated.

Fire safety failures were another critical concern. The patient was not properly searched before being placed in seclusion, allowing a lighter to remain in her possession. The seclusion room was far from nurses, lacked proper monitoring, and the door was locked with keys unavailable during the emergency.

“Fire safety systems were overdue for maintenance; detectors and sprinklers were non-functional, CCTV and evacuation plans were inadequate, exits were padlocked, and staff were untrained in evacuation procedures,” the report said.

Investigations also pointed to broader systemic failures, including staff shortages, poor infrastructure, falsified records, and inadequate oversight.

“The current infrastructure and systems fail to meet minimum mental health care standards,” the report noted.

The ombud concluded that the care provided did not meet required standards, compromising the patient’s rights, dignity, and safety.

The report outlined recommended actions, including disciplinary measures against implicated staff, referral to the Health Professions Council and South African Nursing Council, infrastructure improvements, enhanced staff training, and the installation of fire-safe equipment. Failure to implement these measures could result in the hospital losing its psychiatric unit licence.

The Gauteng Department of Health has been approached for comment.

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