A damning health ombud report prompted by complaints from families of two patients who died at Gauteng and Limpopo hospitals has revealed substandard care that led to one of the deaths and a medical procedure that caused a stroke in the other patient who later died.
Pitsi Eliphuz Ramphele died at Pietersburg Provincial Hospital in Limpopo last year, while Dr Edward Mabubula, 64, died at Wits Donald Gordon Medical Centre in 2021.
Ramphele’s death was the result of substandard care and failures of the public healthcare system.
— Prof Taole Mokoena, health ombudsman
Following investigations that were launched after the families of the two men complained, the health ombudsman Prof Taole Mokoena released his finding on Wednesday.
According to Mokoena, Ramphele had sought help at Rethabile Community Health Centre (RCHC) in Polokwane on November 26 2024. Nursing staff referred him to a doctor, but the doctor reportedly left the facility before seeing him.
Later that day, Ramphele deteriorated and was rushed to Pietersburg Provincial Hospital, where he was diagnosed with acute small bowel obstruction and admitted. He died two days later while still waiting for surgical assessment.
According to Mokoena, Ramphele’s death was the result of “substandard care and failures of the public healthcare system.”
Furthermore, he said, investigators established that staff falsified Ramphele’s medical records with the intent to conceal patient negligence.
Meanwhile, investigators working the case uncovered serious misconduct, including hospital staff allegedly attempting to falsify medical records to hide their failure to transfer Ramphele promptly for specialist care, said Mokoena.
“When investigators requested the hospital’s standard procedures for managing outpatients department, chronic and child health patients on April 7, staff allegedly backdated the document to August 2024, one month before the incident, to conceal procedural loopholes.
“The investigation also found a lack of clinical supervision at the hospital, with medical interns consulting patients and making final clinical decisions without oversight.”
Regarding Mabubula’s case, Mokoena said he had been battling colon cancer since 2018 and had been receiving ongoing treatment at Wits Donald Gordon Medical Centre.
“On March 25 2021, a medical oncologist connected him to a chemotherapy pump for a 48-hour continuous infusion at home. The infusion ended on March 27 2021.”
According to Mokoena, Mabubula returned to the hospital to remove the pump and suffered cerebral air embolism, a very rare but severe complication.
He also had complications that included a stroke and died two months later.
However, while Mabulula’s aggrieved family believed that their relative was a victim of medical negligence, Mokoena said there had not been evidence of that.
“Mrs Mabubula raised concerns regarding alleged medical negligence by Wits Donald Gordon Medical Centre; however, this allegation could not be substantiated.
However, he said allegations that the allegation that Mabubula’s cerebral air embolism, stroke, and disability resulted from a medical procedure at Wits Donald Gordon Medical Centre is substantiated".
Mokoena also said an independent expert opinion obtained from a registered medical specialist in radiation oncology established that suffered cerebral air embolism is a rare event and is undocumented during port flush and removal.
“If appropriate precautions were taken, the risk could have been minimised.”
Mokoena said the two cases highlight deep systemic problems in both public and private healthcare sectors.
“Every day we release investigation findings. In the current financial year alone, we received about 1,000 complaints and managed to investigate 68. These two investigations carry important lessons,” Mokoena said.
Following the release of the findings, the health ombud formally handed the reports to the CEOs of Pietersburg Provincial Hospital and the Wits Donald Gordon Medical Centre to implement the recommendations and address the failures identified.
The report instructs the Limpopo department of health to overhaul accountability, staffing and clinical systems at Rethabile Community Health Centre and Pietersburg Provincial Hospital.
It also orders improvements in administration, including the hiring of permanent staff, clear patient-waiting-time displays, and a fully equipped triage unit with properly trained nurses.
At Wits Donald Gordon Medical Centre, Mokoena said the hospital management must develop a policy or standard operating procedure to formalise the oncology unit’s longstanding practice of performing port removals without charge.
The hospital was also ordered to provide psychological support to Mrs Mabubula and affected family members to assist them to find closure.
Sowetan
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