An investigation into the treatment, complications and deaths of psychiatric patients at the Northern Cape Mental Health Hospital (NCMHH) and the Robert Mangaliso Sobukwe Hospital (RMSH) has uncovered alarming levels of systemic failure, gross negligence and widespread mismanagement — all of which have contributed directly to patient harm and in some cases death.
On Wednesday health ombud Prof Taole Mokoena released the findings of an investigation initiated at the request of national health minister Dr Aaron Motsoaledi. Two investigators looked into the circumstances of the deaths of two patients at the NCMHH and admission of two others to the RMSH in critical condition in July and August last year.
The investigation revealed a health-care environment plagued by infrastructure collapse, including:
- prolonged power outages;
- leaking roofs;
- blocked sewerage systems; and
- the absence of emergency equipment.
The report details how these conditions severely compromised patient care, resulting in unnecessary suffering and preventable fatalities.
Mokoena said the NCMHH exposed patients to severe cold during the absence of electricity as a result of electric cable theft and vandalism of the electricity power substation.
“It is an indictment of the mental hospital that it took a year to repair the damaged electricity infrastructure which the adjacent private hospital managed to repair within days,” he said.
The investigation found that the delay in repairing the electricity supply to the 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 system non-functional, exposing patients and staff to extreme weather 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, and other necessary equipment was unavailable for use.
The NCMHH was also found to have procured poor quality pyjamas and blankets, which were inadequate to provide warmth to patients during the severe winter’s cold, especially at night.
“One of the patients died from hypothermia and another developed multilobar pneumonia, while the third possibly developed intracranial coagulation and stroke from the extreme cold.”
Mokoena said both hospitals were confronted with severe staff shortages, where junior health-care workers were left in charge of high acuity units. Mokoena said they failed to recognise the gravity of illness or complications of their patients — with fatal results.
“Junior doctors were left unsupervised and made final decisions that were wrong or inappropriate, to the detriment of or the death of their patients. Had these shortcomings or infrastructure, especially lack of electricity, not been allowed to prevail as long as they did, the patients who died could still be alive today.”
The NCMHH lacks emergency resuscitation equipment and relevant drugs, he said.
“Some equipment had flat batteries from not having been charged due to the lack of electricity. Thus, patients could not receive necessary emergency resuscitation — with dire consequences. For instance, a patient, Tshepo Mdimbaza, who died there at the hospital, and Petrus de Bruins, who before he was transferred to the Robert Mangaliso Sobukwe Hospital, needed resuscitation, which he did not get.
- The 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.
- Leadership instability in the Northern Cape provincial department of health negatively affected service delivery, safety and the quality of patient care at the two hospitals.
- The general care provided to the four patients whose circumstances were investigated was found to be substandard, and they were not attended to in a manner consistent with the nature and severity of their health conditions.
— SUMMARY OF FINDINGS:
“The mental hospital is experiencing acute staff shortages, especially among professional nurses. As a result, the hospital is working at 53% of its commissioned capacity. The hospital operates some of the shifts without professional nurses.”
Mokoena said the hospitals both lacked written protocols and standard operating procedures or guidelines on the management of patients to guide both doctors and the medical staff.
“Both hospitals lacked professional leadership and the management was inefficient and ineffective. This, in our view, stems from the fluidity and the instability of senior management at the provincial health department level, whereby nearly all senior managers or management posts are filled by acting personnel. The result is poor management of patients.”
Citing the case of Cyprian Mohoto, the ombud said: “He was referred from the mental hospital for presumed bowel obstruction to Robert Mangaliso Sobukwe Hospital after a telephonic consultation with the surgical department at the hospital.”
On arrival at the hospital, chest and abdominal X-rays were conducted. These revealed that there was no bowel obstruction, but rather multilobar pneumonia. Despite this finding, the patient was discharged by a medical officer without receiving treatment for the pneumonia. He remained in the surgical recovery unit for three days but was not assessed by any senior doctors, nor was his condition addressed or managed.
“Had his pneumonia been treated, he might well have been alive today,” Mokoena said.
Mokoena said a lack of proper equipment and inadequate care impeded treatment for Mdimbaza.
“The resuscitation process was delayed due to the unavailability, malfunction, or unpreparedness of 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 postmortem report indicated that he died due to 'exposure to the elements' at NCMHH.”
The ombud also noted several other concerning findings, including:
- the superficial and unnecessary procurement of furniture;
- the purchase of golf carts;
- the procurement of inappropriate hospital beds;
- a delay in commissioning an ECT machine;
- no clinical audits conducted at either hospital; and
- the accident and emergency department at Robert Mangaliso Sobukwe Hospital was severely overcrowded.
Mokoena recommended that the MEC for health in the Northern Cape, and the head of the Northern Cape health department, urgently address the staff shortage by recruiting staff and be on a retention drive.
“They must appoint non-South Africans where there are no South Africans who qualify for those vacancies. Both hospitals must devise comprehensive standard operating procedures, guidelines and protocols to guide the health personnel on how to manage patients.”
The ombud recommended that the national department of health should establish a forensic investigation of the whole provincial health supply chain management to determine and appropriately censure those responsible for:
- the procurement of poor-quality linen, blankets, pyjamas, inappropriate golf carts, inappropriate specialised hospital beds and superfluous furniture; and
- failure to secure service providers for the repair of the damage to the electricity infrastructure.
Motsoaledi welcomed the release of the investigation and said it was clear the hospitals have a management problem. “I'm more alarmed to find that even clinical management is poor by doctors who are trained,” he said.
Motsoaledi said some medical staff identified for possible professional misconduct have already been selected for referral. However, he said he would prefer to refer the entire staff to the Health Professions Council and the Nursing Council.
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