OHSC Fraud Hotline

Progress on the implementation of the report into the 'Circumstances surrounding the deaths of Mentally-ill patients: Gatueng Province'

The Health Ombud, Prof Malegapuru Makgoba has noted with great concern the recent media reports titled: ‘Doctors warn SA Mental healthcare collapsing after Esidimeni’ by the News24 and other media.

These statements/reports are not only premature but also have the potential to create an impression that nothing has been done since the release of the Ombud’s Report into the Circumstances Surrounding the Death of Mentally-ill Patients in Gauteng Province. Nothing could be further from the truth.

Prof Makgoba would like to point out that a lot has been done by the National Minister of Health, the Premier of Gauteng and the Gauteng MEC of Health since the release of the above-mentioned report.

All the 18 Recommendations have been accepted and implemented within the law, and with much progress to be proud of.

“I am happy that all mentally-ill patients have now been moved by 31 May 2017 from unlicensed NGOs to licensed facilities with qualified professional staff to render the necessary care and services for these vulnerable patients.

Since the release of the Report, the Office of the Ombud has received a total of 9 briefings on progress relating to the recommendations from the offices of Dr. Aaron Motsoaledi, the National Minister of Health. Mr. David Makhura, the Premier of Gauteng and Dr. Gwen Ramokgopa, the MEC of Health in Gauteng.

Over the past 3 years (2014, 2015, 2016), a total of 41 mentally ill patients died in the month of June i.e. 13.6 patients died every June. Although the month of June ends tomorrow, not a single mentally ill patient has died during this month this year so far!  While one swallow does not make rain, this ‘no death in June 2017’ may be an exceptional and important swallow to watch. You be the judge!

The three offices are in the process of finalizing a Report on the progress made so far in the implementation of the Recommendations of Report. One thing clear is that the Ombud has ‘stopped counting deaths’.

While the Life Esidimeni episode may have been ‘the lightening rod or tip of an iceberg’, commonsense and experience  tell us, no iceberg melts like a lightning strike.

Issued by the Office of Health Ombud

For more information, please contact: Mr Ricardo Mahlakanya: Director: Communications and Stakeholder Relations; Tel: 012 339 8631; Email: This email address is being protected from spambots. You need JavaScript enabled to view it. 

New OHSC Board Appointments

The Minister of Health, Dr Aaron Motsoaledi has recently appointed additional two (2) Ms Sheila Barsel and Ms Keitumetse Mahlangu as new Board Members of the OHSC. The additional appointments bring the total number of Board Members to nine (9). The inauguration date for the new Board members will be announced in due course.

Issued by the Office of Health Standards Compliance

For more information, please contact: Ricardo Mahlakanya: Communication & Stakeholder Relations; Tel. 012 339 8631; Email. This email address is being protected from spambots. You need JavaScript enabled to view it.

The OHSC embarks on roadshow campaigns in KwaZulu-Natal and Northern Cape provinces

The Office of Health Standards Compliance (OHSC) is currently embarking on a national road show campaigns from 13 – 17 March 2017 by visiting the various areas in KwaZulu-Natal and Northern Cape provinces. The aim of the campaign is to promote the Complaints Management Call Centre as well as other services offered by the Office. The OHSC is an independent body established by the National Health Act, 2003 (Act No. 61 of 2003) to protect and promote the health and safety of users of health services and regulate health establishments, as defined in the Act). Please see details for the roadshow campaigns below:

Roadshow schedule 20170315

Roadshow schedule 1 20170315

Roadshow schedule 2 20170315

 

Issued by the Office of Health Standards Compliance

For more information, please contact: Ricardo Mahlakanya: Director: Communications & Stakeholder Relations; Tel. 012 339 8631; or Email. This email address is being protected from spambots. You need JavaScript enabled to view it.

Final report into the 'Circumstances surrounding the deaths of mentally ill patients: Gauteng Province'

A. Background

The Health Ombud, Professor Malegapuru Makgoba was requested by the Minister of Heath, Dr Aaron Motsoaledi to undertake an investigation into the ‘Circumstances Surrounding the Death of Mentally ill Patients in Gauteng Province and advice 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 terminatedits contract formally with Life Esidemeni (LE) Health Care Centre on 31 March 2016 and extended the contract for further months to 30 June 2016. An estimated 1371 chronic mentally ill patients were rapidly transferred to hospitals and 27 Non-Governmental Organisations (NGOs) from 1 April to 30 June 2016 in Gauteng Province.

As part 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 (7) independent psychiatric experts with vast clinical expertise as well as (1) 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 purpose of the inspections was to assess the veracity of the allegations as well as to determine the capability and competence of the alleged health establishments with regards to the management and care for mental health care patients.

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 to urgently visit and assess conditions in NGOs to intervene where necessary and make the necessary recommendations to save life and prevent more death or further loss of life. 

 B. Key Findings

Upon the investigation, the Ombud has established that:

  • A total of ninety-four (94+) and not thirty-six (36) mentally ill patients (as initially and commonly reported publicly in the media) died between 23 March 2016 and 19 December 2016 in Gauteng Province. 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; therefore, all patients who died in these NGOs died in unlawful circumstances.
  • 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 existent 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.
  • 75 (79.78%) patients died from 5 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, 8 NGOs with average deaths and 8 NGOs with ‘higher or excess’ death;
  • Only 4 Mental Health Care Users (MCHUs) died in hospitals compared to 77 MCHUs deaths at NGOs; in absolute numbers for every 1 death at the hospitals there were 19 deaths at the NGOs but correcting for the total base population the ratio is 1:7. This ratio is very high.
  • When the MEC of Health made announcement on 13 September 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 3 hospitals.  
  • 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 Centrecontract 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. Their fingerprints are ‘peppered’ throughout the project. The decision was reckless, unwise and flawed, with inadequate planning and a chaotic and ‘rushed or hurried’ implementation process.
  • Several factors in the ‘programme of action’ were identified by the (Expert Panel, OHSC Inspectors, Ombud and Ministerial Advisory Committee) that 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; in an environment with no developed, no tradition, no culture of primary mental health care community-based service framework and infrastructure;
  • Human Rights Violations.

 

There is prima facie evidence, that certain officials and certain 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, Right to protection from an environment that is not harmful to their health or well-being, Right to access to quality health care services, sufficient food and water and Right to an administrative action that is lawful, reasonable and procedurally fair. 

 

C. Negligent/Reckless Decisions/Actions

The Ombud established that the following decisions/actions were negligent or reckless by the Department of Health:

  1. Overcrowded NGOs which are more restrictive, is contrary to the deinstitutionalization policy of the MHCA and MH Strategy and Policy.
  2. Transfer of patients to far-away places from their communities, is contrary to the policy of deinstitutionalization.
  3. Transfer of patients to NGOs that were ‘not ready’, that were ‘not prepared properly for the task’.
  4. Transfer of patients without the provision of structured community mental health care services is contrary to the Mental Health policy.
  5. NGOs without qualified staff and skills to care for the special requirements of the patients.
  6. NGOs without appropriate infrastructure and not adequately financially resourced.
  7. NGOs without safety and security.
  8. NGOs without proper heating during winter, some were described as ‘cold’.
  9. NGOs without food and water, where patients became emaciated and some died of ‘dehydration’.
  10. Grant and sign licences without legal or delegated authority.
  11. 27 NGOs operating under invalid licences.
  12. To transfer patients without the knowledge of their families or relatives.
  13. Change the pre-selected placements of patients into NGOs, thus transporting patients to several NGOs.
  14. To transport patients particularly ‘frail and sickly’ patients in inappropriate vehicles.
  15. To transfer patients from the ‘structured environment of 24-hours non-stop professional care’ in a licensed institution to an environment of ‘overcrowded, non-structured, unpredictable substandard or no care at the NGOs with invalid licences.
  16. To transfer any patient from a place of care to one of substandard or no care runs against the fundamental philosophy and principle of health care i.e. the promotion of well-being and life; this contravenes the Constitution.
  17. To transfer ‘precipitously and chaotically’ without a well thought-out plan and against the advice of experts and professional practitioners of psychiatry and mental health.
  18. 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.
  19. The manner, the rate, the scale and the speed of transferring such large numbers of patients were reckless.
  20. These decisions/actions contravened the Constitution, NHA and the MHCA.

 

 D. Recommendations

The Ombud recommend the following:

  1. Gauteng Mental Health Marathon Project must be de-established
  2. The Premier of the Gauteng Province 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.
  3. Disciplinary proceedings must be instituted against Dr Tiego Ephraim Selebano for gross misconduct and/or incompetence in compliance with the Disciplinary Code and Procedure applicable to Senior Management Services (SMS) members in the Public Service. 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, subject to compliance with the Disciplinary Code and Procedure applicable to SMS members in the Public Service.
  4. Disciplinary Procedures must be instituted against Dr Makgabo Manamela for gross misconduct and/ or incompetent in compliance with Disciplinary Code and Procedure applicable to SMS members in the Public Service. 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, subject to compliance with the Disciplinary Code and Procedure applicable to SMS members in the Public Service.
  5. The findings against Dr Manamela and Dr Selebano must be reported to their respective professional bodies for appropriate remedial action with regard to professional and ethical conduct.
  6. Corrective disciplinary action must be taken against members of the Gauteng Department of Health 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 (CEO of CCRC); Ms M Malaza (Acting CEO of CCRC); in compliance with the Disciplinary Code and Procedure applicable to them, for failing to exercise their fiduciary duties and responsibilities.
  7. All the remedial actions recommended above must be instituted within 45 days and progress be reported to the CEO of the OHSC within 90 days.
  8. The Ombud fully supports the ongoing South African Police Service (SAPS) and Forensic Investigations underway. The findings and outcomes of these investigations must be shared with appropriate agencies so that action where it is deemed justified can be taken.
  9. The National Minister of Health should request the South African Human Rights Commission (SAHRC) to undertake a systematic and systemic review of human rights compliance and possible violations nationally related to mental health.
  10. Appropriate legal proceedings should be instituted or administrative action taken against the NGOs that were found to have been operating unlawfully and where MCHUs died.
  11. In light of the findings in the Report, 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 de-registered, closed down and their licenses revoked in compliance with the law.

To download the full report click on the below links:

Report into the 'Circumstances surrounding the deaths of mentally ill patients: Gauteng Province'Download

Report into the 'Circumstances surrounding the deaths of mentally ill patients: Gauteng Province' - AnnexuresDownload

 

 Issued by the Office of Health Standards Compliance

 For more information, please contact: Ricardo Mahlakanya: Communication & Stakeholder Relations; Tel. 012 339 8631; Email. This email address is being protected from spambots. You need JavaScript enabled to view it.This email address is being protected from spambots. You need JavaScript enabled to view it.">

Call the OHSC Complaints Call Centre: 080 911 6475 or OHSC Fraud Hotline: 0800 003 231

Release of the Final Report into the 'Circumstances surrounding the deaths of mentally ill patients: Gauteng Province' - Updated Time

Please note that the media briefing relating to the final Report into the 'Circumstances Surrounding the Deaths of Mentally ill Patients: Gauteng Province' for logistical reasons has been moved from 14:30 - 15:30 to 10:00 - 12:00 to allow other processes to unfold.

The media briefing will be held as follows:

  • Venue:    MRC Building, 1 Soutpansberg Road, Prinshoff, Pretoria
  • Date:       Wednesday, 1st February 2017
  • Time:      10:00 - 12:00

 

The reports are now publically available.  To download the reports click on the below links or visit the following URL: http://ohsc.org.za/index.php/publications/ohsc-documents

Report into the 'Circumstances surrounding the deaths of mentally ill patients: Gauteng Province': Download

Report into the 'Circumstances surrounding the deaths of mentally ill patients: Gauteng Province' - AnnexuresDownload

 

Issued by the Office of Health Standards Compliance

 For more information, please contact: Ricardo Mahlakanya: Communication & Stakeholder Relations; Tel. 012 339 8631; Email. This email address is being protected from spambots. You need JavaScript enabled to view it.

Release of the Final Report into the 'Circumstances surrounding the deaths of mentally ill patients: Gauteng Province'

The Health Ombud, Professor Malegapuru Makgoba would like to inform members of the media and affected stakeholders that the Honourable MEC of Health in Gauteng, Ms Qedani Mahlangu provided feedback relating to the above-mentioned Report within the set timeframe.  The feedback consisted of two documents: (the first 10 pages were received on the 13th January 2017 and the second 12 pages were received on the 24th January 2017).

The Health Ombud has studied, analysed and researched the inputs received and finalised the Report.

The finalised Report will be provided to the Acting Chief Executive Officer (CEO) of the Office of Health Standards (OHSC), Mr Bafana Msibi on Monday 30th January 2017 as required by law for action.

In accordance with Section 82 A (11) of the National Health Amendment Act No. 12 of 2013, the Health Ombud with convene a meeting with some of the complainants and respondents to inform them about the findings and recommendations of the Report on 1 February 2017 from 13:30, an hour before the media briefing.

The Acting CEO of the OHSC will host a media briefing where the findings of the Report shall be presented to the members of the media and other affected stakeholders.

Members of the media are invited to attend the media briefing which will be held as follows:

  • Venue:    MRC Building, 1 Soutpansberg Road, Prinshoff, Pretoria
  • Date:       Wednesday, 1st February 2017
  • Time:      14:30 - 15:30

 

The reports are now publically available.  To download the reports click on the below links or visit the following URL: http://ohsc.org.za/index.php/publications/ohsc-documents

Report into the 'Circumstances surrounding the deaths of mentally ill patients: Gauteng Province'Download

Report into the 'Circumstances surrounding the deaths of mentally ill patients: Gauteng Province' - AnnexuresDownload

  

Issued by the Office of Health Standards Compliance

 For more information, please contact: Ricardo Mahlakanya: Communication & Stakeholder Relations; Tel. 012 339 8631; Email. This email address is being protected from spambots. You need JavaScript enabled to view it.

Delay in the release of the report into the circumstances surrounding the deaths of mentally ill patients: Gauteng Province

The Health Ombud, Professor Malegapuru Makgoba would like to inform members of the media and affected stakeholders that the media briefing that was scheduled to take place on the 18th January 2017 has been postponed until further notice.

Prof Makgoba provided the MEC of Health in Gauteng Province, Ms. Qedani D Mahlangu, with a 'Draft Interim Report into the Circumstances Surrounding the Deaths of Mentally ill Patients: Gauteng Province' on the 6th January 2017 to study the content of the Report and respond as required by law.

Upon receipt of the Report, the MEC Mahlangu agreed to provide Prof Makgoba with feedback by the 13th January 2017.

Prof Makgoba received a signed letter from MEC Mahlangu early Friday evening (13th January 2017), requesting for a further extension.

As a result of the request from the MEC, the Health Ombud granted her further extension up until close of business on Tuesday, 24th January 2017.

Therefore, given the above-mentioned explanation, the Health Ombud cannot release the Report on the 18th January 2017 as it was planned until further notice.

The Health Ombud would like to sincerely apologise for this delay.  However, the new date for the release of the Report will be communicated.

Issued by Prof MW Makgoba

Health Ombud

The Office of Health Ombud

 For more information, please contact: Ricardo Mahlakanya: Communication & Stakeholder Relations; Tel. 012 339 8631; Email. This email address is being protected from spambots. You need JavaScript enabled to view it.

The OHSC embarks on roadshow campaigns in Mpumalanga and North West provinces

 The Office of Health Standards Compliance (OHSC) has launched and opened the Complaints Management Call Centre on 28 November 2016 at the Medical Research Council (MRC) Building in Pretoria. The Call Centre provide an opportunity to members of the public and healthcare users to lodge unresolved complaints by health establishments. The OHSC is mandated by the National Health Act, 2003 (Act No. 61 of 2003) to protect and promote the health and safety of users of health services and regulate health establishments, as defined in the Act).

In an effort to make the general public aware of the existence of the Complaints Call Centre and services offered by the OHSC, the Office will be embarking on a national road show campaigns from 12-14 December 2016 by visiting the following areas in Mpumalanga and North West provinces:

MPUMALANGA PROVINCE ROAD SHOW CAMPAIGNS

TEAM A
DAY 1: 12/12/16

Ehlanzeni District, Bushbuckridge LM- Bushbuckridge- (Acornhoek), Tintswalo Hospital-Madras Clinic, Thulamahashe CHC, Shopping complex, Taxi rank

DAY 2: 13/12/16

Ehlanzeni District, Bushbuckridge LM- Bosborand- Mapulaneng - Mapulaneng Hospital, Majivan Agincourt CHC, Shopping Complex, Taxi Rank

DAY 3: 14/12/16

Ehlanzeni District, Bushbuckridge LM - Mkhuhlu Matikwane Hospital, Mkhuhlu Clinic, Marite Clinic, Shopping Complex, Taxi Rank

DAY 4: 15/12/16

 Ehlanzeni District Mbombela LM-Nelspruit, Rob Ferreira Hospital, MP Nelspruit CHC, MP Valencia Park Clinic, Shopping Complex, Taxi Rank

TEAM B
DAY 1:  12/12/16

Gert Sibande District, Albert Luthuli LM-Carolina, Carolina Hospital, Carolina Clinic, Silobela Clinic, Shopping Complex, Taxi Rank

DAY 2:  13/12/16

Gert Sibande District-Msukaligwa LM-Ermelo -Ermelo Hospital, MP Emthonjeni Clinic (Msukaligwa), Ermelo Clinic, Shopping Complex, Taxi Rank

DAY 3 14/12/16

Nkangala District, Steve Tshwete LM, Middleburg-Middleburg Hospital, Middleburg Ext 8 Clinic, Middleburg Ext 6 Clinic, Shopping Complex, Taxi Rank

DAY: 4 15/12/16

Nkangala District, Emalahleni LM- Witbank-Witbank Hospital, MP Siphosesimbi CHC, MP Beatty Clinic, Shopping Complex, Taxi Rank

NORTH WEST PROVINCE ROAD SHOW CAMPAIGNS

TEAM A
DAY 1: 12/12/16

Ngaka Modiri Molema District, Ditsobotla LM Lichtenburg- NW General de la Rey Hospital, Blydeville 2 Clinic, nw Boikhutso Clinic

DAY 2:  13/12/16

Dr Kenneth Kaunda District, Ventersdorp LM –Ventersdorp-Ventersdorp Hospital, JB Marks CHC, NW Ventersdorp Gateway Clinic, Shopping Complex, Taxi Rank

DAY 3: 14/12/16

Dr Kenneth Kaunda District, Matlosana LM-Klerksdorp -NW Klerksdorp Hospital / nw Tshepong Hospital, Alabama Clinic, Jouberton CHC, Shopping Complex, Taxi Rank

DAY 4: 15/12/16

Dr Kenneth Kaunda District, Tlokwe LM -Potchefstroom -NW Potchefstroom Hospital, Potchefstroom Clinic, Boiki Thlapi CHC, Shopping Complex, Taxi Rank

TEAM B
DAY 1: 12/12/16

Bojanala District, Kgetleng Rivier LM- Koster nw Koster Hospital, NW Reagile Clinic,nw Tlhabane CHC, Shopping Complex, Taxi Rank

DAY 2 13/12/16

Bojanala District, Rustenburg LM - Rustenberg- Job Shimankana Tabane Hospital, Bafokeng CHC, Boitekong Clinic, Shopping Complex, Taxi Rank,

DAY 3: 14/12/16

Bojanala District, Rustenburg LM -Marikana -NW Marikana Clinic, Shopping Complex, Taxi Rank, Mine?

DAY 4: 15/12/16

Bojanala District- Madibeng LM-Brits -Brits Hospital, Madibeng Clinic, NW Letlhabile CHC

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