So bad was the mismanagement of patients at Robert Mangaliso Sobukwe Hospital in Northern Cape that Cyprian Mohoto, a mentally ill patient, was left unattended for three days before he died of pneumonia.
This was revealed by the health ombudsman Prof Taole Mokoena on Wednesday when he was tabling a report into the treatment and deaths of psychiatric patients at two provincial hospitals, Northern Cape Mental Health Hospital and Robert Mangaliso Sobukwe Hospital.
Mokoena said the two hospitals have severe systemic failures, acute staff shortages, and mismanagement which contributed to the deaths of two patients and poor care of another last year.
The report revealed that the mental hospital is operating at only 53% of its commissioned capacity, largely due to a dire shortage of professional nurses.
The report highlighted alarming lapses in basic patient care. Vital signs were not monitored regularly, record-keeping was poor, and both facilities lacked written protocols or standard operating procedures to guide staff in clinical decision-making. This has led to what Prof Mokoena describes as “a breakdown in the proper management of patients.”
One of the deceased patients, Mohoto, was referred to Robert Sobukwe Hospital with suspected bowel obstruction. An X-ray revealed multi-lobar pneumonia, yet no treatment was given.
“The pneumonia was never treated during the three days that the patient stayed in the surgical recovery unit until his death. His deteriorating clinical status was never attended to by either the nursing personnel nor the doctors.
“He was discharged but left in a surgical recovery unit for three days without senior medical review. If his pneumonia had been treated, he might still be alive today,” said Mokoena.
He was discharged but left in a surgical recovery unit for three days without senior medical review. If his pneumonia had been treated, he might still be alive today
— The health ombudsman Prof Taole Mokoena
In another case, Tshepo Mdimbaza was found unresponsive, hypothermic, and hypoglycaemic at the mental hospital. His resuscitation was hampered by a lack of basic equipment. A post-mortem found he had died from exposure to the elements.
Mokoena said there was also a lack of monitoring of the patient's vital signs before and during resuscitation by medical or nursing personnel. Mdimbaza did not survive the resuscitation attempt. “The post-mortem report indicated that he died due to “exposure to the elements” at NCMHH.”
Mokoena attributed these failures to weak leadership and chronic instability in senior management roles within the provincial health department. Most senior posts remain filled by acting personnel, creating a culture of poor accountability and oversight.
He added that in some cases, high-acuity units are staffed solely by enrolled nurses or nursing assistants, without the supervision of qualified professionals.
The report recommended the establishment of an international clinical governance committee to oversee decision-making and clinical audits, and calls for proper supervision of junior doctors, ensuring they are not left to make critical decisions unsupervised.
The findings paint a grim picture of mental healthcare in the province, where patients’ lives are being lost due to avoidable neglect, said Mokoena.
SowetanLIVE
Would you like to comment on this article?
Sign up (it's quick and free) or sign in now.
Please read our Comment Policy before commenting.