An investigation by the health ombud into the death of a state mental patient at Dr George Mukhari Academic Hospital, near Ga-Rankuwa, Tshwane, has laid bare a catalogue of abuse, finding she was starved, deprived of medicine, and confined to a seclusion room in freezing winter conditions, clad only in underwear.
She died in a fire that began in her room.
It is the third probe by the health ombud to reach damning conclusions about extensive failings in the care provided to state mental patients.
The probe follows an investigation into the 2016 Life Esidimeni scandal, in which 144 state mental patients died of starvation and neglect after the Gauteng health department ordered their transfer from private facilities to unlicensed non-governmental organisations, and a more recent investigation into the deaths of two patients at the Northern Cape Mental Health Hospital.
The investigation into Lerato Mohlamme’s death at Dr George Mukhari Academic Hospital in June 2024 uncovered systemic violations of the rights of mental healthcare patients, including the use of punitive practices, said health ombud Taole Mokoena.
“Protecting the dignity, safety and rights of mental healthcare users is not an option: it is a constitutional and legislative imperative,” Mokoena said at the release of his investigation report on Monday.
The hospital is the main teaching facility for medical students at Sefako Makgatho Health Sciences University but is overcrowded and dilapidated. It is one of three large public hospitals identified for a complete overhaul.
The investigation into Mohlamme’s death was triggered by a complaint laid by the South African Human Rights Commission (SAHRC). It found the hospital did not follow up on her claim that she had been sexually assaulted, deliberately withheld prescribed medication and food as a form of punishment, and subjected her to prolonged use of restraints in violation of national policy.
She was placed in a seclusion room far from the nurses’ station without adequate monitoring systems in place. Emergency exits were locked, keys were misplaced or hidden, and there were critical delays in accessing her room when the fire broke out, said the ombud.
Mokoena recommended that the Gauteng health department improve the hospital’s infrastructure and staff training and that the Health Professions Council of South Africa and the South African Nursing Council launch professional conduct inquiries into implicated personnel.
The South African Federation for Mental Health said the continued deaths of mental health patients in the institutions that were meant to treat them are unacceptable.
“These types of events illustrate that there is still no full commitment to human rights regarding the lives of persons with mental health conditions,” said SAFMH deputy director Leon de Beer.
Acting health director-general Nicholas Crisp said health minister Aaron Motsoaledi is deeply concerned about the state of care provided to mental patients and is taking steps to ensure their protection.
“The minister is actively pushing provinces to establish mental healthcare boards, and improve infrastructure, training and awareness,” he said.
The health ombud also released the findings of an investigation into the death of a baby admitted to neonatal ICU at private hospital group Netcare’s Femina facility in May 2023. The probe was triggered by a complaint laid by the baby’s mother.
While the investigation found no evidence of deliberate neglect or abuse, it found that a prescribing mistake and poor communication during shift handovers led to Moatlegi Masoka’s death. The baby died after he was given adrenaline intravenously instead of via a nebuliser.
The ombud recommended that Netcare strengthen its medication verification processes, update its protocols and improve the supervision of nursing staff.
Netcare’s head of health informatics, Chris Mathew, said the hospital group takes the health ombud’s findings very seriously and has already implemented some of them. A task team has been established in line with the health ombud’s directive, and the hospital is engaging in a mediation process with the baby’s family, he said.
Motsoaledi said both hospitals breached the fundamental ethical principle of “first do no harm”. Dr George Mukhari Academic Hospital has been earmarked for a big infrastructure upgrade, he said.
The government is considering a R10bn public-private partnership to rebuild the hospital and is establishing a transaction advisory team to conduct a feasibility study, according to the latest budget review.
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