The Health Ombud reveals patient safety lapses at George Mukhari and Netcare Femina hospitals, citing procedural errors, poor training, and inadequate infrastructure that contributed to the deaths of a psychiatric patient and neonate.
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The Health Ombud, Professor Taole Mokoena, has revealed findings from two investigations into patient deaths in Gauteng, highlighting serious lapses in care, governance, and patient safety in both the public and private hospitals.
Speaking at a media briefing in Pretoria on Monday, Mokoena said, “It is the responsibility of the Health Ombud to uncover the truth, ensure accountability, and drive improvements to protect patients across the health system.”
The first investigation concerned on the death of 35-year-old psychiatric patient Lerato Mohlamme at Dr George Mukhari Academic Hospital.
She died after a fire broke out in the psychiatric unit where she was being held in seclusion. Professor Mokoena said the investigation, which was requested by the South African Human Rights Commission, revealed multiple procedural, clinical, and ethical failures.
“The admission process did not follow the prescribed requirements where two doctors should have independently examined the patient and committed the patient to the psychiatric hospital,” he said.
“Mechanical restraints were applied improperly, prescribed medicines were deliberately withheld as a form of punishment, and the patient was denied food while she was in seclusion.”
He added that the seclusion room was poorly located, far from the nurses’ station, lacked adequate monitoring, and fire safety concerns raised by other patients were dismissed by staff.
Mokoena said Mohlamme had a cigarette lighter in her possession, which likely caused the fire. Emergency exits were locked or inaccessible, disaster preparedness was inadequate, and mattresses in the unit were not fire-retardant.
Post-mortem results confirmed she was alive when the fire broke out, suffering severe burns and elevated blood carbon monoxide levels, he said.
Mokoena said the investigation uncovered “systemic violations of the rights of mental health care users, including punitive practices, inadequate infrastructure, insufficient staffing, and limited knowledge of the Mental Health Care Act.”
He stressed that “protecting the dignity, safety, and rights of mental health care users is not optional; it’s a constitutional and legislative imperative.”
The Ombud recommended refurbishing the psychiatric unit, procuring fireproof mattresses, strengthening compliance with the Mental Health Care Act, improving staff training, and enhancing governance.
He said the Health Professions Council of South Africa and the South African Nursing Council will be asked to initiate professional conduct investigations against implicated staff.
The second investigation examined the death of neonate Moatlegi Masoka at Netcare Femina Hospital, following a complaint by the child’s mother, Maria Lala Masoka.
Professor Mokoena said the investigation found that adrenaline had been administered intravenously instead of by nebulisation, compounded by poor communication among healthcare professionals.
“The investigation found critical errors that occurred when the adrenaline was administered intravenously instead of by nebulisation due to poor communication between and among the healthcare professionals,” he said.
He noted additional systemic weaknesses, including outdated protocols, inadequate shift handovers, and weaknesses in electronic medical record controls, with staff sharing passwords that made tracing errors difficult.
He said the hospital group has been directed to strengthen medication verification processes, update protocols, enhance supervision and training, and enforce proper electronic system controls.
“The relevant health professionals will also be referred to the professional regulatory councils such as the Health Professions Council and the Nursing Council,” Professor Mokoena added.
He said the hospital must also undertake further mediation with the Masoka family.
“Patient safety must be guarded and ensured at all times. It must be built into systems with appropriate leadership, appropriate staff training, and accountability at every level of care.”
He extended condolences to both families, He said the death of Mohlamme ''is not only a personal tragedy, but it is also a profound reminder of there responsibility we carry to protect the most vulnerable among us.
Mokoena said the Health Ombud, through the Office of Health Standards Compliance, would closely monitor the implementation of all recommendations to ensure that the relevant health establishments take meaningful corrective actions.
Meanwhile, Gauteng Premier Panyaza Lesufi acknowledged the Ombud’s findings, saying the province had acted “with lightning speed to ensure that we rectify what has been established.”
He said specialist psychiatrists had been increased from three to eight, 12 additional nurses had been added to the psychiatric unit, 21 nurses and two social workers had been trained, and nine permanent security staff were now stationed in the unit.
CCTV systems had been upgraded and the hospital had achieved fire compliance, though additional improvements such as fireproof mattresses were still underway.
“We take full responsibility for the failures that have been identified by the Office of the Ombudsman,” Lesufi said, adding that the province was committed to ensuring such incidents do not recur.
Health Minister Dr Aaron Motsoaledi also addressed the findings, emphasising the Ombud’s role in protecting the health system. “
The Health Ombud is the public protector of health,” he said, noting that the fundamental principle of medical ethics, primam non nocere - “first do no harm” , had been breached in both cases.
Motsoaledi stressed the need for ongoing training and oversight, adding that professional bodies “exist to remind health professionals that you are under oath and you must protect your patient at all costs.”
He also acknowledged infrastructure shortcomings, particularly at George Mukhari Academic Hospital, and highlighted national plans to upgrade hospitals through the Budget Facility Infrastructure (BFI) program.
hope.ntanzi@iol.co.za
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