By Lehlohonolo Lehana.
The health ombud, Prof Taole Mokoena, found that two psychiatric patients died from exposure to extremely cold winter conditions and substandard care at the Northern Cape Mental Health Hospital (NCMHH) and the Robert Mangaliso Sobukwe Hospital (RMSH).
This follows an investigation involving the death of two patients and another two patients who suffered health complications resulting from failing infrastructure.
The investigation was initiated following a complaint lodged by the minister of health, Dr Aaron Motsoaledi, against the Northern Cape Mental Health Hospital in Kimberley in October 2024.
“During the time when these patients were being being treated there, the Northern Cape Mental Health Hospital was experiencing a lot of trouble with electricity supply as a result of electricity cable theft and vandalism of the electricity substation that supplies the hospital, together with the adjacent properties, “said Professor Taole Mokoena, health ombud, at the release of the investigative report on Wednesday, 30 July.
“We found that during this time when there was no electricity, patients were freezing to death, literally.”
There had been problems with the electricity supply at the mental health facility since October 2022. The hospital was relying for power on a generator that was “inadequate” for its needs, necessitating “power distribution rationing” for certain hours daily to prevent the generator from overloading, according to the investigative report.
The health ombud’s investigation found that three of the patients received substandard care at Robert Mangaliso Sobukwe Hospital in Kimberley, after being referred there from the Northern Cape Mental Health Hospital.
Tshepo Mdimbaza, one of the patients, died at the Northern Cape Mental Health Hospital on 3 August 2024. He was discovered unresponsive with cold skin due to “extremely cold conditions in the ward”. His resuscitation was delayed as the required equipment was not functional. The postmortem report revealed that he died due to “exposure to the elements” at the facility.
Another mental health patient, Cyprian Mohoto, died on 16 July 2024 after being transported to Robert Mangaliso Sobukwe Hospital with a suspected abdominal or bowel obstruction that turned out to be multi-lobar pneumonia.The investigation found “gross mismanagement” of Mohoto in the emergency centre and the surgical recovery unit at RMSH.
A medical officer… reviewed Mohoto and discharged him back to NCMHH on Lactulose without treating the lobar pneumonia with intravenous antibiotics or referring him to the Internal Medicine Department for further management,” stated the investigative report.
“Mohoto spent three days in a Surgical Recovery Unit waiting to be transported back to NCMHH without being reviewed by doctors from the General Surgery Department… His condition was deteriorating, and no appropriate action was taken.
Two other patients, Petrus de Bruin and John Louw, were transported from the Northern Cape Mental Health Hospital to Robert Mangaliso Sobukwe Hospital for treatment in July 2024, and were later discharged back to the mental health facility.
“The general care provided at NCMHH and RMSH to all patients was substandard, and patients were not attended to in a manner consistent with the nature and severity of their health condition,” stated the report.
Among the findings of the health ombud was that the lack of electricity at the mental health facility meant nurses were forced to work in the dark, using their cellphone torches for light. The electromagnetic locks at the hospital were non-functional, resulting in doors being propped open using heavy objects.
The health ombud has given Northern Cape MEC for Health Maruping Lekwene and head of the health department Mxolisi Mlatha nine months to provide a plan, including strategies and timelines, for addressing shortcomings at the health facilities.
The health ombud recommended that disciplinary measures be taken against the assistant director of the accident and emergency department at Robert Mangaliso Sobukwe Hospital, for his unilateral decision to stop the “matron’s report” policy that served as a reporting system between shifts.
It also recommended disciplinary action against the CEO of the Northern Cape Mental Health Hospital for a failure to advocate for patients. The report said the CEO failed to hold a service provider accountable for the “poor workmanship” of patients’ pyjamas.
The Northern Cape Department of Health acknowledged receipt of the health ombud’s investigative report, adding that it took the findings “very seriously” and was “committed to ensuring the highest standards of patient care and safety “across all its healthcare facilities.