They died from cold, hunger
A summary of the final report on the “Circumstances surrounding the deaths of mentally ill patients: Gauteng Province”, made available by The Office of Health Standards Compliance
A STAGGERING 55 of the 94 mentally ill patients who died after they were moved from Life Esidimeni Health Care Centre were from Tshwane.
The patients died of cold and hunger, dehydration and general lack of care.
The capital and other regions bore the brunt of the mismanagement that saw mentally ill patients moved from Life Esidimeni to NGOs across the province.
They were transferred after former MEC Qedani Mahlangu terminated the contract with Life Esidimeni Health Care Centre on March 31, 2016.
An estimated 1 371 chronically mentally ill patients were moved to NGOs from April 1 to June 30 – most of them to the city.
Close to 900 patients were moved to Cullinan Care and Rehabilitation Centre, Siyabadinga, Anchor in Cullinan, Precious Angels in Atteridgeville and Tshepong in Hammanskraal.
Precious Angels had 20 deaths, Tshepong 10 and Cullinan Care and Rehabilitation Centre, Siyabadinga and Anchor collectively recorded 25 deaths.
The sick spent three months in facilities that had no trained staff nor funds to cater for them. The homes also had inadequate facilities and many patients without medical records.
The report by the Office of Health Standards Compliance looked into the circumstances surrounding the deaths of 94 mentally ill patients, transferred to 27 NGOs across the province last year.
DA shadow MEC for Health in Gauteng, Jack Bloom, said the city’s loss of 55 patients was the worst in the province.
Bloom said his observations of the centres revealed that Tshepong, in particular, seemed like a dormitory.
It did not look completely bad, but it had been difficult to assess the NGO’s medical facilities.
“Tshepong seemed to have been improved after complaints were levelled at the department, but it only had basic facilities,” Bloom said.
“Precious Angels was a residential house and was completely unsuitable for the patients.”
Patients were reportedly sent to NGOs without medical records or medication and had poor hygiene and nutritional status.
Precious Angels – where the majority of deaths occurred – had already been under investigation by the SA Human Rights Commission.
During the commission’s investigations into the centre it found the NGO abandoned and an inquest had been under way for the deaths of 13 patients.
A look into looking possible human rights violations such as the right to life, access to healthcare, the right to dignity, the right to freedom and security of the person, access to information and proper consultation had already been initiated. Additionally, cruel and inhumane care, and allegations that patients had died of hunger and dehydration were also being looked into.
The NGO only had a licence to care for children with severe and profound intellectual disabilities, but patients with different needs and mental problems had been sent there.
The report stated that the head of department, Dr Ephraim Selebano, admitted that they should have done a proper fit-for-purpose assessment and accepted that they were unfair to Precious Angels because they had sent too many different types of patients – from intellectually disabled, demented, chronic and elderly to bedridden.
“He claimed in pursuit of what they wanted to achieve they forgot the families. That’s when he noted they are doing it the wrong way,” the report stated.
Contributory factors that could have led to the deaths of the patients at Precious Angels were hunger and cold.
“The rooms were very cold and there was no food to feed them due the department taking three months to pay them. So they were struggling to buy food. At Tshepong it was the same food situation and Dr Makgabo Manamela (department director) was informed about this.”
In the report, blame was apportioned to Mahlangu and senior officials in the department.
The release of the report and the subsequent resignation of the MEC attracted anger and disgust from different sectors of society, with families of the dead calling her a coward and others calling for criminal charges to be levelled against her.
Meanwhile, a number of the NGOs responsible for the negligent care leading to the deaths refused to speak, insisting the state answered for them over the tragedy.
The provincial government’s spokesperson Thabo Masebe said the office of Premier David Makhura would only be focusing on the relocation of patients, as per the recommendations of the report by the Health Ombudsman.
However, the licensing of NGOs as mental health facilities and the possibility that many of the organisations that housed these patients were unlicensed, would be only be dealt with once new MEC Dr Gwen Ramokgopa has been sworn in.
“We are not dealing with the licensing of the organisations; we are dealing with the recommendations of the ombudsman that said we must move the patients. The aim is that by next week she would be sworn in. Once she has been sworn in, the process of her appointment will be facilitated,” he said.
THE Health Ombud, Professor Malegapuru Makgoba, was requested by Minister of Heath Dr Aaron Motsoaledi to undertake an investigation into the “Circumstances Surrounding the Death of Mentally ill Patients in Gauteng Province, and advise on the way forward”.
The Honourable MEC of Health in Gauteng, Ms Qedani Mahlangu, was supportive that the ombud should investigate the matter as priority and urgent. The investigation was instituted when the Gauteng Department of Health terminated its contract formally with Life Esidemeni (LE) Health Care Centre on March 31, 2016 and extended the contract for further months to June 30, 2016. An estimated 1 371 chronic mentally ill patients were rapidly transferred to hospitals and 27 non-governmental organisations (NGOs) from April 1 to June 30, 2016 in Gauteng.
As part of the investigation, the ombud requested for clinical records and any relevant information or documents from the MEC of Health and Gauteng Department of Health. He constituted a team of seven independent psychiatric experts with vast clinical expertise, as well as one expert experienced in public health to assist with the investigation. The Office of Health Standards Compliance (OHSC) also constituted a team of inspectors to conduct inspections at the health establishments concerned.
The investigation was requested in terms of Sections 81A (1-11) and 81B (2) of the National Health Amendment Act, (Act No.12 of 2013). The Ministerial Advisory Committee on Mental Health, chaired by professor Solomon Rateamane, was dispatched even before the ombud was appointed. Key findings The ombud established that:
A total of 94 and not 36 mentally ill patients (as initially and commonly reported publicly in the media) died between March 23, 2016 and December 19, 2016 in Gauteng. This total number of 94 should be seen as a working and provisional number.
All the 27 NGOs, to which patients were transferred, operated under invalid licences.
The NGOs where the majority of patients died had neither the basic competence and experience, the leadership/managerial capacity, nor "fitness for purpose", and were often poorly resourced. The existence of unsuitable conditions and competence in some of these NGOs precipitated, and are closely linked to the observed "higher or excess" deaths of the mentally ill patients.
Seventy-five (79.78%) patients died from five NGO/hospital complexes (Precious Angels, 20, Cullinan Care and Rehabilitation Centre (CCRC)/ Siyabadinga/Anchor, 25, Mosego/Takalani, 15, Tshepong, 10, and Hephzibah, 5).
There were 11 NGOs with no deaths, eight NGOs with average deaths and eight NGOs with "higher or excess" deaths.
Only four Mental Health Care Users (MCHUs) died in hospitals, compared to 77 at NGOs.
When the MEC of Health made announcement on September 13, 2016, 77 patients had already lost their lives. At the time of writing the report, 94 patients had died in 16 out of 27 NGOs and three hospitals. A total of 95.1% deaths occurred in the NGOs from those directly transferred from LE Health Care Centre.
Available evidence by the expert panel and the ombud showed that a “high-level decision” to terminate the LE Health Care Centre contract precipitously was taken, followed by a “programme of action” with disastrous outcomes/consequences, including the deaths of assisted MCHUs. The ombud identified three key players in the project: MEC Qedani Dorothy Mahlangu, Head of Department (HoD) Dr Tiego Ephraim Selebano and Director Dr Makgabo Manamela, at times referred to as “dramatis personae” in the text.
Several factors in the “programme of action” were identified (by the expert panel, OHSC Inspectors, ombud and Ministerial Advisory Committee), which contributed and precipitated to the accelerated deaths of mentally ill patients at the NGOs.
The transfer process, particularly, was often described as “chaotic or a total shamble”;
The Gauteng Mental Health Marathon Project, as it became known, was: done in a “hurry/ rush”; with “chaotic” execution.
Human Rights Violations There is prima facie evidence that certain officials, NGOs and some activities within the Gauteng Marathon Project violated the constitution and contravened the National Health Act and the Mental Health Care Act (2002). Some executions and implementation of the project have shown a total disregard of the rights of the patients and their families, including but not limited to the right to human dignity, right to life, right to freedom and security of person, right to privacy, among others.
Negligent/reckless decisions/ actions. These include:
Overcrowded NGOs which are more restrictive, run contrary to the deinstitutionalisation policy of the MHCA and MH Strategy and Policy.
Transfer of patients to faraway places is contrary to the policy of deinstitutionalisation.
Transfer of patients to NGOs that were "not ready", that were "not prepared properly for the task".
Transfer of patients without structured community mental health care services is contrary to the Mental Health policy.
NGOs without qualified staff and skills to care for the special requirements of the patients.
NGOs without food and water, where patients became emaciated and some died of "dehydration".
Grant and sign licences without legal or delegated authority.
To transfer patients without the knowledge of their families or relatives.
To transfer "precipitously and chaotically" without a well thoughtout plan and against the advice of experts and professional practitioners of psychiatry and mental health.
To have made promises to families and the court that were not borne out by evidence, i.e. that patients’ care will not be compromised and patients will be transferred to places that are equivalent to LE Health Care Centre.
The manner, the rate, the scale and the speed of transferring such large numbers of patients were reckless. Recommendations
Gauteng Mental Health Marathon Project must be de-established.
The premier of Gauteng must, in the light of the findings herein, consider the suitability of MEC for Health, Ms Qedani Mahlangu to continue in her current role as MEC for Health.
Disciplinary proceedings must be instituted against Dr Tiego Ephraim Selebano for gross misconduct and/or incompetence. In the light of Dr 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.
Disciplinary procedures must be instituted against Dr Makgabo Manamela for gross misconduct and/ or incompetentence. In the light of Dr Manamela’s conduct during the course of the investigation, which includes tampering with evidence, it is recommended that the consideration be given to suspending her pending her disciplinary hearing.
The findings against Dr Manamela and Dr Selebano must be reported to their respective professional bodies for appropriate remedial action with regards to professional and ethical conduct.
Corrective disciplinary action must be taken against members of the Gauteng Department of Health's Ms S Mashile (deputy director); Mr F Thobane (deputy director); Ms H Jacobus (deputy director); Ms S Sennelo (deputy director); Mr M Pitsi (deputy director); Dr S Lenkwane (deputy director); Ms D Masondo (chairperson: MHRB); Ms M Nyatlo (chief executive of CCRC); Ms M Malaza (Acting chief executive of CCRC); in compliance with the Disciplinary Code and Procedure applicable to them, for failing to exercise their fiduciary duties and responsibilities.
All the remedial actions recommended above must be instituted within 45 days and progress be reported to the chief executive of the OHSC within 90 days.
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 action, where it is deemed justified, can be taken.
The national minister of Health should request the South African Human Rights Commission to undertake a systematic and systemic review of human rights compliance and possible violations nationally related to mental health.
Appropriate legal proceedings should be instituted, or administrative action taken against the NGOs found to have been operating unlawfully, and where MCHUs died.
The national Department of Health must review all 27 NGOs involved in the Gauteng Marathon Project; those that do not meet health care standards should be deregistered, closed down, and their licences revoked in compliance with the law.
To read the full report, visit www.ohsc.gov.za