After protracted investigations into the treatment and subsequent deaths of psychiatric patients in Northern Cape hospitals, the Health Ombudsman, Prof Taole Mokoena, has released findings on the probe.
The investigations were conducted at the Northern Cape Mental Health Hospital (NCMHH) and the Robert Mangaliso Sobukwe Hospital (RMSH).
It has been revealed that two patients died, while another underwent a craniotomy (skull and brain surgery) and remains bedridden.
The probe was triggered by the complaint filed by the Minister of Health, Dr Aaron Motsoaledi, who raised serious concerns about psychiatric hospitals in the province. These were over incidents that had taken place in July and August 2024, during which it was alleged that two patients died at NCMHH, and two others were admitted to RMSH in critical condition.
Response to the Minister
Responding to Motsoaledi’s request to look into the matters, Mokoena deployed a team of two investigators to look into the issues raised.
Sunday World was reliably informed that the investigation was meticulous. It was supported by documentary evidence obtained from both hospitals. On-site visits were also undertaken.
It was discovered that one patient, Cyprian Mohoto, who was admitted at NCMHH, died at RMSH. He was previously transferred from one psychiatric hospital to another in the province.
Another patient, Tshepo Mndimbaza, died while in the care of NCMHH.
At the time of the incidents, it was found that NCMHH and several nearby health facilities were facing challenges with their electricity supply due to cable theft and vandalism at their power substation.
It is understood that the power loss impacted the communication infrastructure, leaving the hospital without telephone lines.
“Electricity supply was restored within days at two of the neighbouring hospitals; however, it took an entire year for the electricity to be restored at NCMHH. The investigation found that the delay in restoring the electricity supply to NCMHH was due to dysfunctional Supply Chain Management processes within the provincial department of health.
“This delay rendered the hospital’s Heating, Ventilation, and Air Conditioning (HVAC) system nonfunctional, exposing patients and staff to extreme weather conditions during the summer and winter.
“Additionally, because of the lack of electricity, the available resuscitation equipment was not operational, as it could not be charged. Other necessary equipment was unavailable for use. NCMHH procured poor quality pyjamas and blankets which were inadequate to provide warmth to patients during the severe winter’s cold, especially at night,” read the report by Mokoena.
Early warning clearly not heeded
It was also established that the clinical manager at NCMHH had written a letter complaining to the acting head of the provincial department of health, detailing the adverse conditions which patients at NCMHH were being subjected to. These circumstances negatively impacted their health and violated their human rights, the letter alleged.
In the findings, the Health Ombudsman stated that circumstances surrounding Mohoto’s care and admission to RMSH revealed gross mismanagement regarding his care. This ultimately led to his death.
Mohoto was admitted at RMSH on 13 July 2024, with a suspected abdominal or bowel obstruction following complications at NCMHH on 12 July 2024.
“Admission abdominal X-rays ruled out bowel obstruction while the chest X-ray revealed multi-lobar pneumonia. The pneumonia was never treated during the three days that the patient stayed in the Surgical Recovery Unit until his death. His deteriorating clinical status was never attended to by either the nursing personnel or the doctors. Mr. Mohoto died on 16 July 2024 in the Emergency Centre at the Surgical Recovery Unit at RMSH,” said Mokoena in his report.
Mdimbaza was discovered unresponsive in his bed on 3 August 2024 at NCMHH.
“The resuscitation process was delayed due to the unavailability, malfunction, or unpreparedness of the resuscitation equipment. There was also a lack of monitoring of the patient’s vital signs before and during resuscitation by medical or nursing personnel. Mr. Mdimbaza did not survive the resuscitation attempt. The post-mortem report indicated that he died due to “exposure to the elements” at NCMHH,” said Mokoena.
Other patients affected
Apart from Mohoto and Mdimbaza, two other patients, Petrus De Bruin and John Louw who were at the care of the two hospitals, also had challenges with their health.
According to Mokoena’s findings, there was leadership instability in the Northern Cape provincial department of health, which negatively affected service delivery, safety, and the quality of patient care at NCMHH and RMSH.
“Northern Cape Mental Health Hospital was found to have poor governance and systemic lack of leadership and poor management at all levels, unpreparedness for emergency cases, crumbling infrastructure, poor pharmacy and medicine control management, shortage of staff, poor quality assurance management, non-compliance with patient record keeping, and poor laundry services.
“Robert Mangaliso Sobukwe Hospital was found to be experiencing critical staff shortages across the board, lack of oversight with nursing supervision, communication breakdown of reporting systems, non-compliance with guidelines on principles of good record keeping, and overcrowding at the hospital emergency centre, aggravated by the absence of a district or regional hospital.
Substandard general care
“The investigation concluded that the general care provided at the Northern Cape Mental Health Hospital and the Robert Mangaliso Sobukwe Hospital to the patients was substandard, and patients were not attended to in a manner consistent with the nature and severity of their health condition, as required by Regulation 5 (1) of the Norms and Standards Regulations Applicable to Different Categories of Health Establishments, 2018.
In his recommendations, Mokoena made clear, actionable recommendations to address the systemic failures observed at both health establishments to improve the overall safety and quality of patient care.
Key recommendations included that the provincial head of department of health must immediately appoint a task team to monitor the implementation of the recommendations as outlined in the report and to hold accountable officials found to be in breach through formal disciplinary processes.
Mokoena also said that the national department of health should initiate a forensic investigation into the procurement processes for the NCMHH.
