Clinical safety failures, non-compliance with legal requirements, excessive use of mechanical restraints, and withholding of medication and food are some of the findings of health ombud Prof Taole Mokoena after a probe into two cases at George Mukhari Academic Hospital and Netcare Femina Hospital.
Mokoena released the findings with an assurance that the health system is committed to the improvement and prevention of tragedies such as these from recurring.
The first case involved the death of a 35-year-old mental health care patient, Lerato Mohlamme, after a fire in the psychiatric unit at George Mukhari Academic Hospital in June 2024.
Mokoena said Mohlamme’s allegations of sexual assault were not properly assessed or reported to law enforcement.
“This represented clinical and legal procedure failures. The investigation identified serious procedural, clinical, ethical, and safety failures or lapses in the care provided to Ms Mohlamme. Her admission process did not comply with legal requirements, where two medical practitioners did not independently examine and commit the patient in the prescribed form and manner, thus rendering the application technically invalid,” he said.
Mokoena added that mechanical restraints were applied in excess, inconsistent with national policy guidelines.
“Prescribed medication was deliberately withheld as punishment. However, medical records were falsified to indicate administration. The patient was denied food as punishment during the seclusion.
“Fire safety concerns raised by another patient were dismissed. The patient was not thoroughly searched before being committed to the seclusion room. The patient had a cigarette lighter on her person, which she most probably used to start the fire.”
Mokoena said the findings also point to systemic weaknesses and failures in governance and oversight, as well as insufficient staff knowledge of the Mental Health Care Act.
He described the psychiatric unit as unfit for purpose, with recommendations that it be redesigned and refurbished.
“The hospital must procure certified fireproof mattresses. They need to redesign and refurbish the psychiatric unit to comply with all legal requirements for a psychiatric unit, including security and safety requirements, as well as patient recreation and rehabilitation facilities.”
In the case of baby Moatlegi Masoka, who died at Netcare Femina Hospital, Mokoena said a clinical error occurred when adrenaline was administered intravenously instead of via nebulisation.
“This was a result of an incorrect prescription route and poor communication. There were weaknesses in the safety of medication systems and poor clinical communication among different health professionals. Poor governance and oversight in the neonatal intensive care unit. Failure by the hospital to refer unnatural death or death from a healthcare procedure or intervention for a forensic post-mortem examination as required,” he said.
Mokoena added that there were outdated medication protocols, an inadequate shift-handover process, and weaknesses in electronic medical record access controls.
He directed both facilities to implement corrective measures and strengthen clinical governance.
“The two investigations, though different in context, share a common message: namely, patient safety must be guarded and ensured at all times. It must be built into systems with appropriate leadership, appropriate staff training, and accountability at every level of care.”
Sowetan
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