By Lehlohonolo Lehana.
South Africa’s Health Ombudsman, Professor Taole Mokoena, has released the findings of two critical investigations into patient safety incidents within the Gauteng province.
The probe examined the death of a psychiatric patient at George Mukhari Academic Hospital and a neonatal death at Netcare Femina Hospital, where incorrect medication has been implicated.
The George Mukhari investigation follows a complaint to the South African Human Rights Commission (SAHRC) after a patient died from burn injuries in 2024.
The family of the deceased said they have waited nearly two years for answers after their loved one died in a fire in the hospital’s psychiatric unit.
The first report focused on the death of 35 year-old psychiatric patient Lerato Mohlamme at Dr George Mukhari Academic Hospital, in Ga-Rankuwa, north of Pretoria.
Mohlamme died on 24 June 2024 after a fire broke out in a seclusion room where she had been placed.
The ombuds found critical safety protocols and monitoring systems failed, resulting in her sustaining fatal burns.
Mokoena said the investigation uncovered “serious procedural, clinical, ethical, and safety failures” and pointed to “systemic violations of the rights of mental health care users.”
According to the report, the patient was unlawfully admitted and subjected to punitive treatment, including the withholding of medication and food, while medical records were falsified to conceal this. Allegations of sexual assault were also not reported to police.
The investigation further found that the patient was not properly searched and had a cigarette lighter, which was believed to have started the fire. The seclusion room lacked proper monitoring, was poorly located and emergency exits were locked, delaying rescue efforts.
A post-mortem confirmed she was alive when the fire started and died from burn injuries and smoke inhalation.
The Health Ombuds recommended the redesign and refurbishment of the psychiatric unit at Dr George Mukhari Academic Hospital to comply with all legal requirements of the psychiatric unit, including security and safety requirements.
In a separate investigation, the ombud examined the death of a newborn at Netcare Femina Hospital following allegations that incorrect medication had been administered.
“The investigation found that a clinical error occurred when adrenaline was administered intravenously instead of by nebulisation,” Mokoena said.
“This was as a result of an incorrect prescription route and poor communication.”
He said the case revealed clinical mismanagement and failures in pharmaceutical safety protocols within the private facility, alongside broader weaknesses in oversight.
Gauteng Premier Panyaza Lesufi said the provincial government accepted responsibility for the failures at the public hospital and had already begun implementing changes.
“When the draft report on the matter was presented to us, we immediately undertook an overhaul to rectify the situation and to ensure that this kind of incident does not occur within our institution again,” Lesufi said, in response to a report by Mokoena, on the findings from two investigations into patient safety incidents in Gauteng.
“We are strengthening supervision to ensure that those tasked with this work are properly trained and capacitated. To date, we have trained 21 nurses and two social workers, enabling them to better understand the responsibilities outlined in the report. We have also installed additional CCTV cameras to allow security personnel to monitor situations in real time,” the Premier said.
The government has also implemented fire remedial projects – some are still in progress, while those completed resulted in the issuing of a certificate of fire compliance on 19 February.
“This means that the hospital is now fire compliant, although there are still outstanding matters requiring urgent attention. We need to procure items such as certified fireproof mattresses and other issues identified in the report, which we believe are critical to achieving full compliance, “Lesufi added.
Health Minister Aaron Motsoaledi said the findings pointed to both ethical and systemic failures, adding that basic medical principles had been ignored.
“[A] cornerstone of medical ethics has been breached, because when we hire doctors and nurses and other professionals, we don’t pick them from the street, “Motsoaledi said.
“The principle called primum non nocere, meaning first do no harm… in this case, it means that principle was thrown out of the window.”
Motsoaledi raised concerns about the historical inequalities in South Africa’s health infrastructure, particularly in training hospitals.
“If you check all the medical schools that were established to train white medical students, you will find that they built a medical school and a hospital,” he said. “Only in 1953, when the first black medical school was established, the process of ignoring to build hospitals started.”
These findings from the Ombud are expected to highlight systemic gaps in patient monitoring and facility safety protocols within both the public and private healthcare sectors.