At least 94 people died after Gauteng Health moved 1,900 psychiatriac patients out of Life Esidimeni to 27 unlicensed facilities, says SA’s Health Ombudsman, Professor Malegapuru Makgoba, in an explosive report. Patients died of starvation and lack of water, with the number of fatalities provisional, since bodies remain unidentified in morgues.
Makgoba, has identified Gauteng MEC for Health Qedani Mahlangu as a key player in the movement of mentally ill patients from the Life Esidimeni Health Care Centre to the NGOs where they died.
An IoL report quotes Makgoba as saying at the release of his much awaited report: “Available evidence by the expert panel and the Ombud showed that a high level decision to terminate the Life Esidimeni Health Care Centre contract precipitously was taken, followed by a programme of action with disastrous outcomes/consequences including the deaths of assisted mental health care users.”
The report says the Ombud identified three key players in the project – MEC Qedani Dorothy Mahlangu, head of department Dr Tiego Selebano and director Dr Makgabo Manamela at times referred to as dramatis personae in the text [the report]. “Their fingers are peppered throughout the project. The decision was reckless, unwise and flawed, with inadequate planning and a chaotic and rushed or hurried implementation process,” Makgoba noted.
Makgoba said in contrast to the widely-reported figure of 36 patients, at least 94 psychiatric patients died between 23 March and 19 December last year in Gauteng. “I want to emphasise that this is a provisional number and the actual number could be more,” Makgoba said.
“All the 27 NGOs to which patients were transferred operated under invalid licences, therefore all patients who died in these NGOs died in unlawful circumstances.”
The report says the more than 1,000 patients were transferred from the Life Esidimeni Health Care Centre to the NGOs in 2015, and 36 of them died within three months of the transfer.
Families of the deceased blamed the department for the mishandling of the transfers and deaths of their loved ones. Some said they were not informed about the whereabouts of their relatives and were sent from pillar to post by the department. They also blamed the department for not informing them immediately about the deaths and how they had happened.
The official report was scheduled to be released three weeks ago, but was delayed after Mahlangu requested more time to study the report.
The Times reports that the 18 key findings by the Health Ombud are:
1. The Gauteng Mental Health Marathon Project must be de-established.
2. The Premier of the Gauteng Province must‚ in the light of the findings herein‚ consider the suitability of MEC Qedani Dorothy Mahlangu to continue in her current role as MEC for Health.
3. Disciplinary proceedings must be instituted against Dr Tiego Ephraim Selebano for gross misconduct and/ or incompetence in compliance with the Disciplinary Code and Procedure applicable to SMS members in the Public Service. In the light of Selebano’s conduct during the course of the investigation‚ which includes tampering with evidence‚ it is recommended that the Premier should consider suspending him pending his disciplinary hearing‚ subject to compliance with the Disciplinary Code and Procedure applicable to SMS members in the Public Service.
4. Disciplinary proceedings must be instituted against Dr Makgabo Manamela for gross misconduct and/ or incompetence in compliance with Disciplinary Code and Procedure applicable to SMS members in the public service. In the light of Dr Makgabo Manamela’s conduct during the course of the investigation‚ which includes tampering with evidence‚ it is recommended that consideration be given to suspending her pending her disciplinary hearing‚ subject to compliance with the Disciplinary Code and Procedure applicable to SMS members in the public service.
5. The findings against Drs M Manamela and TE Selebano must be reported to their respective professional bodies for appropriate remedial action with regard professional and ethical conduct.
6. Corrective disciplinary action must be taken against members of the Gauteng Department of Mental Health: S Mashile (deputy director); F Thobane (deputy director); H Jacobus (deputy director); S Sennelo (deputy director); Dr S Lenkwane‚ (deputy director); M Pitsi (chief director); D Masondo (chair MHRB)‚ M Nyatlo (CEO of CCRC)‚ M Malaza (Acting CEO of CCRC) in compliance with the Disciplinary Code and Procedures applicable to them‚ for failing to exercise their Fiduciary duties and responsibilities. They allowed fear to cloud and override their fiduciary responsibilities and thus failed to report this matter earlier to relevant authorities. Fiduciary responsibility is essential for good corporate governance;
7. All the remedial actions recommended above must be instituted within 45 days and progress be reported to the CEO of the Office of Health Standards Compliance within 90 days.
8. The Ombud fully supports the ongoing SAPS and Forensic investigations under way. The findings and outcomes of these investigations must be shared with appropriate agencies so that appropriate action where deemed justified can be taken.
9. The National Minister of Health should request the SAHRC to undertake a systematic and systemic review of human rights compliance and possible violations nationally related to Mental Health.
10. Appropriate legal proceedings should be instituted or administrative action taken against the NGOs that were found to have been operating unlawfully and where MCHUs died.
11. In light of the findings in the report‚ the NDoH must review all 27 NGOs involved in the Gauteng Marathon project; those that do not meet health care standards should be de-registered‚ closed down and their licenses revoked in compliance with the law.
12. The National Minister of Health must with immediate effect appoint a task team to review the licensing regulations and procedures to ensure they comply with the National Health Act‚ the Mental Health Care Act 2002 and Norms and Standards. The newly established process must ensure that NGO certification is done through the OHSC. This newly established licensing process should form the first line of protection for the mentally ill. Currently‚ this does not seem to be the case.
13. All patients from LE currently placed in unlawful NGOs‚ must be urgently removed and placed in appropriate Health Establishments within the Province where competencies to take care of their specialized needs are constantly available‚ this must be done within 45 days to reduce risk and save life; simultaneously‚ a full assessment and costing must be undertaken.
14. There is an urgent need to review the NHA 2003 and the MCHA 2002 to harmonise and bring alignment to different spheres of government. Centralisation of certain functions and powers of the MHCA must revert back to the National Health Minister‚ While Schedule 4‚ Part A of the Constitution and Sections 3 subsection 2; section 21‚ subsection l ‚ section 25‚ subsection 1 and 2‚ sections 48 and 49 and section 90 of the National Health Act. No. 61‚ 2003‚ recognize and define Health as a concurrent competence between the National and Provincial government spheres the findings and lessons of this investigation merits such a review.
Furthermore‚ projects of high impact on the quality and reputation of the national health system and whose outcomes undermine human dignity‚ human well-being and human life must not be permitted nor be undertaken without the expressed permission of the National Health Minister or his/her nominee.
15. Projects such as the GMMP must not in future be undertaken without a clear policy framework‚ without guidelines and without oversight mechanisms and permission from the National Health Minister; where such policy framework exists the National Health Minister must ensure proper oversight and compliance.
16. This investigation has clearly shown that for deinstitutionalisation to be undertaken properly‚ the primary and specialist multidisciplinary teams that are community based mental health care services must be focused upon‚ must be resourced and must be developed before the process is started. It will most probably require more financial and human resource investment initially for deinstitutionalisation to take root. Sufficient budget should be allocated for the implementation.
17. The National Minister of Health must lead and facilitate a process jointly with the Premier of the Province to contact all affected individuals and families and enter into an Alternative Dispute Resolution process.
This recommendation is based on the ‘low trust’‚anger‚ frustration‚ loss of confidence’ in the current leadership of the GDoH by many stakeholders.
The National Department of Health must respond humanely and in the best interest of affected individuals‚ families‚ relatives and the nation. The process must incorporate and respect the diverse cultures nd traditions of those concerned.
The response must include an unconditional apology to families and relatives of deceased and live patients who were subjected to this avoidable trauma; and as a result of the emotional and psychological trauma the relatives have endured‚ psychological counselling and support must be provided immediately.
The outcome of such process should determine the way forward such as mechanisms of redress and compensation.
A credible prominent South African with an established track record should lead such a process.
18. The Gauteng Mental Health Review Board was found to be moribund‚ ineffective and without authority and without independence. As a structure its terms of reference must be clearly defined and strengthened in line with the National Health Act and the Mental Health Care Act 2002 and its independence and authority re-established.
Jack Bloom DA Gauteng Shadow MEC for Health said that he was shocked to the core by the revelation that 94 psychiatric patients died (and possibly more) after their transfer last year from Life Healthcare Esidimeni.
He says: “Health MEC Qedani Mahlangu lied to me in the Gauteng Legislature on 13 September last year when she said that 36 patients had died in the NGOs in which they were placed. Health Ombudsman Malegapuru Makgoba said that on that date 77 patients had already died.
“Premier Makhura has to fire Mahlangu and ensure that disciplinary action is taken against the 11 senior health department officials identified in the report. Criminal charges should also be laid against all implicated parties including those in the five NGOs where 80% of the patients died.
“Premier Makhura must also ensure that immediate steps are taken to ensure the safety and well-being of all the patients who are still with the NGOs. Makura’s image has taken a severe blow because of his failure to fire Mahlangu earlier and to replace her with a competent and caring Health MEC.
“This is a crisis for the ANC in Gauteng and all those who failed to act earlier against Mahlangu. I will study the full report and monitor the actions based on its findings.”
There’s widespread speculation around whether Mahlangu will resign in the wake of the damning findings, reports Eyewitness News. Last month, the Health Department said it was unaware of reports that 80 psychiatric patients died after being transferred from Esidimeni.
The department says that according to their records, the number of patients who died during transfers still stands at least 36. Spokesperson Steve Mabona is quoted in the report as saying they have always been consistent about the number of deaths.
“We are not aware that the report has been released but one can really put the emphasis that, as the department, we are very consistent in the number that we revealed. We revealed the number 36.”
Makgoba spent 80 hours listening to family members and inspectors during his investigation, says a Business Day report.
The NGOs were overcrowded and some did not have qualified staff with the requisite skills for the patients. This was in addition to a lack of safety and security and even proper heating in winter.
Families travelled from across the province to hear the details of why their loved ones died. One woman was sobbing as Makgoba spoke‚ shaking her head and wiping tears away.