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27 January 2021

“There is no more difficult art to acquire than the art of observation, and for some men, it is quite as difficult to record an observation in brief and in plain language” ~ Sir William Osler

This Report of the Health Ombud is in terms of Section 81(A) of the National Health Act, 2003 (Act No. 61 of 2003). The report communicates the findings and recommendations of the investigation that was undertaken succedent to a complaint lodged by the Minister of Health, Dr. Zwelini Mkhize for the Health Ombud to investigate the circumstances surrounding the care and death of Mr. Shonisani Lethole at Tembisa Provincial Tertiary Hospital (TPTH) in Gauteng Province. The Health Ombud commenced investigating the allegations levelled against TPTH from the 6^th July 2020. A preliminary report was prepared and forwarded to all those implicated as required by the Act following the completion of the investigation. Responses and inputs were received after six weeks. The various responses together with the preliminary report were assessed, analysed and evidence was weighed to prepare the final report.

The Minister’s complaint followed the public outcry and the media uproar sparked by a tweet purportedly posted by the late Mr. Shonisani Lethole on the 25^th of June 2020, at 20h31 while admitted at TPTH. Mr. Shonisani Lethole (Twitter handle: @Shonilethole) used the popular social media platform, Twitter, to pen the viral tweet: @DrZweliMkhize Mkhize can I respond to your tweets if the problems I have at one of your facilities continues it is becoming unbearable, and they don’t seem to care. Didn’t eat for 48 hours. 

The viral tweet subsequently triggered an online #JusticeforShoni where twitter users demanded answers and justice. This gathered momentum following the death of Mr. Shonisani Lethole at TPTH, ostensibly from denial of food for 48 hours. A petition was then formulated which at the time of the handover had attracted 21 758 signatures nationally and internationally.

Mr. Lethole’s complaint was the first to be raised with and referred to the Office of the Health Ombud (OHO) at the time the Honourable President of the Republic of South Africa, Mr. Cyril Ramaphosa, had declared a National State of Disaster and announced the National Lockdown Restrictions to curb the spread of the COVID-19 infections and Save Lives. The National Lockdown Restrictions were eased to Alert Level 3 in terms of the Disaster Management Act from the 1^st June 2020.

The Health Ombud’s investigation established that:Shonisani Lethole (Mr. S. Lethole) a 34-year-old severely ill male, athletic patient and without a history of co-morbidities was referred from Kempton Park Clinic to TPTH on Tuesday, the 23^rd June 2020, with history of chest pain, difficulty in breathing and generalised body weakness for two days. He was accompanied by his father, Mr. Albert Lethole and was subsequently admitted at the Casualty COVID-19 Isolation, a designated area, as a Patient Under Investigation (PUI). Patients were admitted and kept at Casualty COVID-19 Isolation on a short-term basis, which was common practice, while awaiting their SARS-CoV-2 (COVID-19) test results. Mr. Lethole had SARS-CoV-2 Pneumonia.

Mr. Shonisani Lethole, from all the evidence, adduced, was not offered meals during his first 43 hours, 24 minutes of admission at TPTH since the 23^rd of June 2020 registered entry on the patient’s registry at 12h36 at COVID-19 Isolation (Patient’s Number: 3521074), until Friday, the 25^th of June 2020 at 08h00 at Ward 23. The period was calculated as 43 hours, 24 minutes, from the recorded time of admission. However, if one added the 8 hours, 36 minutes since the last meal at 04h00 at his home on the 23^rd of June this period would total approximately 52 hours of involuntary fasting. More importantly, the hospital management failed to summon a single witness or a previously admitted patient to provide credible evidence to the investigation that breakfast, lunch, and supper were delivered, served and eaten by Mr. Lethole at Casualty Isolation on the 23^rd and 24^th of June 2020.

Therefore, Mr. Shonisani Lethole’s tweet to the Minister had merit and was found credible and truthful. The evidence from TPTH that meals were provided to Mr. Lethole was found to be without foundation.

Since Saturday, the 27^th of June 2020, Mr. Shonisani Lethole never received feeding after he was sedated and intubated at 13h00 until the day of his demise on the 29^th of June 22h30.  No nasogastric tube had been inserted following his intubation. Dr. Urmson verbally testified and confirmed that she only ordered this later when Mr. Lethole was reported vomiting, but her order was not followed up and acted upon. This omission was recognised by Dr. Molehe that Dr. Urmson had not inserted the nasogastric tube during intubation. Dr. Urmson’s order was not even documented in the clinical notes.

In her interview, Dr. Urmson confirmed that she ordered the nasogastric telephonically through a nurse but did not followup whether the order was acted upon or not.  However, in a statement to the Chief Executive Officer (CEO) dated the 2^nd of July 2020, Dr. Urmson claimed to have inserted the nasogastric tube. Both versions could not be true. No other witness who cared for Mr. Lethole ever saw an inserted nasogastric tube. So, for another 57 hours, 30 minutes, Mr. Shonisani Lethole was to endure not being fed at TPTH. This took place when he was most vulnerable and sedated. The health care professional team of doctors and nurses conceded to the investigation to this negligent, callous, and uncaring omission. This uncaring attitude represented gross medical negligence.

*So, for 100 hours, 54 minutes of his total stay of 153 hours, 54 minutes (65.6% of the time of his stay), at TPTH, Mr. Shonisani Lethole did not receive any meals on two separate occasions. The health establishment and its management must shoulder the accountability and responsibility for these failures.

Whether Mr. Lethole was ‘officially or unofficially admitted’ he depended entirely on the hospital for his needs, wellbeing and care. He was weak, he was on Oxygen, he was already being treated for COVID-19, he had spent the night at the hospital without supper and breakfast. The hospital had a duty of care for Mr. Lethole. He was pleading with his parents to bring him food for lunch or supper.

Shonisani Lethole tweeted on Thursday, the 25^th of June 2020 evening at 20h31 to the National Health Minister, Dr. Zwelini Mkhize that:

• ‘the problems I have at one of your facilities continues it is becoming unbearable,
• and they don’t seem to care.
• Didn’t eat for 48 hours.’ 

He had also complained to his parents on the 24^th of June 2020, around midday and to his girlfriend that he had not eaten. His Dad and Mom separately went out to buy him buns, Kentucky Fried Chicken and Nandos food respectively. These were not delivered to him as cleaners were afraid to enter Ward 23 without Personal Protective Equipment (PPE).

 *Mr. Shonisani Lethole’s tweet was accurate, credible, and truthful. The environment and conditions at TPTH were ‘unbearable’, and they did ‘not seem to care’ as outlined through the extensive evidence and findings in this report.

Two Information Technology (IT) analysis reports were commissioned by the Health Ombud to authenticate the tweet bearing Mr. Lethole’s complaint to the Minister of Health. The first report came from the Minister’s Office, and the second report was independently performed by the OHSC IT Unit. Both detailed IT analyses showed that there was no evidence that the Minister of Health, Dr. Zwelini Mkhize ever saw or received Mr. Lethole’s tweet while he was still alive. The viral tweet only gained prominence after Mr. Lethole’s passing on. Both IT analyses confirmed that the Tweeter handle accounts were authentic and active.

However, the Twitter message of Mr. Lethole did reach the Twitter account of the Minister of Health, which was run by a third-party administrator who manages the account according to the social media strategy, which entails the distribution of public information of health-related issues, rather than engaging individuals. Upon receipt of the twitter message, the Health Minister immediately acted on this by lodging a complaint with the Health Ombud, hence this investigation.

Shonisani Lethole died on the 29^th of June 2020 at 22h30, and not on the 27^th of June 2020 as his father firmly believed, nor on the 28^th of June 2020 as some staff members strongly testified. Mr. Lethole’s death necessitated a rigorous verification process inclusive of telephone records to confirm his date of death due to these incongruities and inexplicable conflicting evidence obtained from the two clinical teams, caring for the same patient, in the same ward and the same hospital and from his family. There was a clinical team that swore under oath that he died on the 28^th of June 2020, and the other clinical team equally declared that he died on the 29^th of June 2020. All these transpired due to poor record-keeping and lack of proper communication.

*The truth was finally established through telephone records between the hospital and Mr. Albert Lethole’s cell phone and confirmed by the evidence of Ms. Conny Mathibela, the Operational Manager for Ward 23, who made the call, that Mr. Shonisani Lethole died on the 29^th of June 2020 at 22h30.

Lethole, demised on the 29^th of June 2020, at 22h30 as recorded by professional Nurse Zitha. Dr. Bangala was called twice by the nursing staff to come to certify Mr. Shonisani Lethole timeously but never turned up. He failed to hand over to his colleagues. Mr. Shonisani Lethole was certified on the 30^th of June 2020, 10 hours, 15 minutes after his lifeless body remained on his hospital bed until Dr. Marole around 8 am retrospectively certified him, and the family was only then notified of his passing at 08h50 as shown by the telephone call log records.

There was no attempted effort to offer Mr. Lethole Cardiopulmonary Resuscitation (CPR) despite being young and without any co-morbidities. Also, the decision for CPR not to be attempted was not documented, discussed with the patient or the family. This was established and confirmed through the completed Morbidity and Mortality form from TPTH 41 days after his death.

*The decision made not to resuscitate Mr. Lethole was ill conceived and in contravention of the Tembisa Hospital Resuscitation Guidelines.

On admission at TPTH on the 23^rd of June 2020, X-rays and other blood tests were ordered and done. The blood tests and Chest X-ray results on admission confirmed that Mr. Lethole was severely ill with multiple systemic tissue injuries of the kidneys, liver, lungs, and skeletal muscles and with a systemic inflammatory response, all consistent with SARS-CoV-2 infection. However, these critical results were not seen, reviewed, interpreted, or repeated and acted upon timeously by the senior doctors caring for him. Mr. Lethole had Stage 4 renal failure as determined by the Glomerular Filtration Rate and high blood potassium on admission that were never attended to or reviewed throughout his stay at TPTH.

 *Had these grossly dysfunctional tests results been properly reviewed and acted upon timeously and followed up, Mr. Lethole’s management pathway would have been significantly altered. This failure of tests results, and review analysis constituted a serious error of clinical decision-making in the care of a severely ill patient, where biochemical markers already at admission already showed severe multi-system tissue injury and pathology.

Shonisani Lethole was tested for SARS-CoV-2 on the 23^rd of June 2020 at Accident and Emergency (A & E) Isolation area, also known as Casualty or COVID-19 Isolation and was transferred and received at Ward 23, on the 24^th of June 2020, at 23h50, a ward populated by SARS-CoV-2 positive and negative patients and without the knowledge of his SARS-CoV-2 results and status. Through this action, the health care professionals placed Mr. Shonisani Lethole and the other patients at great health risk of transmitting SARS-CoV-2 infection. Mr. Lethole’s condition deteriorated, and he passed away without receiving or knowing his SARS-CoV-2 test results. His family and girlfriend had to undergo testing out of fear and anxiety on their own initiative after his passing.

*The family and others who visited his parent’s home were later tracked and traced in terms of the guidelines for case-finding, diagnosis, and public health response in South Africa. Lethole’s medical care was characterised by inordinate delays of consultations, delays on following up on clinical decisions, delays on interventions, and delays in the timeous interpretation of results and the ‘appalling’ clinical record-keeping at TPTH. This was established by the investigation and supported by the independent reports of Drs, Fareed Abdullah and Portia Ngwata, Head on Internal Medicine at TPTH. The investigation by the Health Ombud and Dr. Ngwata further found that Mr. Lethole’s care was negligent. It took approximately 69 hours, 19 minutes before two registered Medical Practitioners, Dr. Bangala and later Dr. Shabangu could assess Mr. Lethole’s condition for the first time since admission at Casualty COVID-19 Isolation, also known and referred to as Accident and Emergency (A & E) Isolation on the 23^rd of June 2020 at 12h36 until Friday, the 26^th of June 2020, in Ward 23 at 09h55. This inordinate delay in attending to Mr. Lethole was unexplainable, since Drs. Bangala and Shabangu were on-call as indicated by the roster register on the day of his admission. Had all these been attended to, the outcome of Mr. Lethole’s condition would likely have been different (Health Ombud and Dr. Fareed Abdullah). Dr. Ngwata put it that Mr. Lethole’s ‘mortality was preventable and avoidable’.

*Still, the severity and deterioration of Mr. Lethole’s condition were not detected. This first medical assessment failed to review all the clinical laboratory tests and Chest X-ray already undertaken. This inordinate delay is deemed negligent.

Shonisani Lethole was not regularly evaluated and monitored as would be the norm befitting the severity of his condition, this much was conceded by those interviewed; however, he was left for prolonged periods of low Oxygen saturation, *which would no doubt have resulted in further systemic tissue injuries contributing to his deteriorating health condition.

Repeated evidence by staff revealed during the interviews, and contained in the Clinical Records and in hindsight, confirmed that the care rendered to Mr. Lethole was not only substandard, but also negligent. This was supported by the findings of the independent expert, Dr. Fareed Abdullah and Dr. Portia Ngwata, Head of Internal Medicine at TPTH. Mr. Lethole’s care contravened several basic prescribed norms and standards, rules, and regulations of health care. There was a complete mismatch between the severity of his medical condition and the level and environment of his care. The care was provided by well-meaning, but inexperienced and inadequately supervised health care practitioners in an unsuitable and not fit for purpose environment. Firstly, on arrival at Casualty on the 23^rd of June 2020 at 11h40, Mr. Lethole was triaged by an unsupervised intern; secondly, at Casualty COVID-19 Isolation, he was seen and admitted by an unsupervised Clinical Associate.

*All staff who were asked to rate Mr. Shonisani Lethole’s care rated it substandard and added they ‘would not like any of their relatives to be cared for in this way’. Others confirmed that the environment of his care did not match the severity of his condition.

While both the Health Ombud and investigator reported several findings of systems related nature, these were not sufficient to explain the degree of substandard and negligent care provided to Mr. Lethole. The health professionals involved had to shoulder direct and collective responsibility for this sub-standard and negligent care. They failed Mr. Lethole, they failed Mr. Lethole’s family, they failed each other through total lack of leadership, a lack of management plan, a lack of collaboration and communication, a lack of teamwork and team spirit and a failure to observe basic good clinical practice.

*TPTH should not have been designated a COVID-19 hospital, yes there were systemic faults; yes, the management of the establishment had not done their job, but the individual health care professionals involved in providing care also failed to discharge their responsibilities and their conduct could not be fully explained by the broader systemic issues. TPTH and its medical team of health providers must take accountability and responsibility for this substandard and negligent care provided Mr. Lethole.

In Ward 23, SARS-CoV-2 positive and negative patients were mixed, posing a serious health risk to Mr. Lethole. He was nursed in an area where he was in proximity with corpses at COVID-19 Isolation as well at Ward 23, for hours before the bodies could be moved to the Hospital Mortuary. *The mixing of SARS-CoV-2 positive and negative patients, the failure to remove deceased patients’ bodies from the Ward timeously posed another health risk for a contagious infectious agent such as SARS-CoV-2 according to World Health Organisation (WHO) Guidelines. Instead of maintaining social distancing and avoiding contact with SARS-CoV-2 individuals, the hospital plans encouraged crowding, contact and exposure. This was inconsistent with the National Coronavirus Command Council Regulations and recommendations.

On Saturday, the 27^th June 2020, at 11h05, Mr. Lethole’s condition deteriorated and necessitated him to be intubated and be put on mechanical ventilation. The decision to intubate followed the Consultant’s recommendation. The intubation was delayed by 1 hour, 55 minutes. *A postintubation chest X-ray (CXR) was not ordered or done to confirm endotracheal tube (ET) placement as is recommended and is standard practice. A nasogastric tube for feeding was not inserted. The delay in intubation, the failure to do a postintubation X-ray and the failure to insert a nasogastric feeding tube are all serious clinical failures with consequences.

Lethole’s condition was inadequately monitored by the clinicians, notwithstanding the fluctuation in the Oxygen saturation levels while ventilated. The last documented doctor’s review was on Sunday, the 28^th of June 2020 at 17h00 by Dr. Molehe until the 30^th of June 2020 when he was certified dead in a rigor-mortis stage.

 *This for a patient sedated, intubated, and not being fed who needed intensive monitoring, evaluation and interventions, was grossly negligent.

Analysis of the evidence suggested that had there been a system of health care practitioners collaboration; a proper monitoring and hand over-communication processes of changes in clinical risks of patients before the next shift, a detailed review and analysis of all the tests done on admission, a clearly articulated management strategy, *the severity and change in Mr. Shonisani Lethole’s condition could have been detected earlier and would have resulted in a different management process and pathway with probably a different outcome.

Inadequate communication and collaboration among health care professionals in the hand over process impeded the continuity of care and resulted in delays in diagnosis and treatment of Mr. Shonisani Lethole. *The diagnostic investigations that were ordered were not followed through.

There was a severe shortage of staff with requisite experience and competencies to the detriment of patient safety. *Several of the staff that took care of Mr. Lethole were newly appointed, inadequately inducted, and poorly supervised.

Several significant general findings relate to poor record-keeping; reporting the general care of a patient; the contradicting statements by staff and the failure to follow up and implement good health care intentions and decisions.

*The investigation found that there were missing doctor’s notes for the dates of the 23^rd, 24^th, 25^th, 28^th, 29^th and 30^th of June 2020. This finding was corroborated and confirmed by Ms. Chilwane, the Assistant Manager Quality Assurance, the Investigator, the Health Ombud and by Dr. Fareed Abdullah, the independent expert. Dr. Ngobese, former Head of the COVID-19 Unit confirmed there were no clinical notes for the dates of the 24^th and 25^th of June 2020. The Quality Assurance audit of Mr. Lethole’s Clinical Record yielded a score of 19/37, which is equivalent to 51% indicating a very poor score for compliance with the Clinical record-keeping standards. Except for the 28^th of June 2020, none of the other missing doctor’s notes has been found in the Clinical Records. One possibility was that these notes were never recorded and were never there or that these notes were lost. In either scenario, to have missing patient’s notes in a health establishment represented gross negligence in Mr. Lethole’s care. TPTH and its management must take responsibility and accountability for this appalling record-keeping.

It is quite clear from the evidence gathered in this Report on the inconsistencies and inaccuracies; from the records and record-keeping with missing clinical notes to bypassing legitimate structures such as the Quality Assurance Unit for auditing and in safeguarding Mr. Lethole’s records and presenting incomplete Clinical Records to the Health Ombud and the OHSC Complaints Centre and Assessment and distorting and falsifying obvious facts in the Clinical Records presented as reports to the Health MEC and the Health Ombud, that the management of TPTH was only keen to obfuscate and mislead the investigation as to what transpired to Mr. Lethole and to create an unsustainable fictitious and false reality that unfolded around the care of Mr. Lethole. These missing notes were never reported to the South African Police Service (SAPS) as is required by law. This represented the worst administrative bungles in record safekeeping and handling in the health system.

The Health Ombud made the following recommendations:

The Gauteng MEC for Health, Dr. Nomathemba Mokgethi, must urgently appoint an independent forensic and audit firm to:  i) conduct a competency, ‘fit for purpose’ assessment of the leadership and management staff at TPTH; ii) review and revise hospital’s admission policy and processes to bring these in line with the universally acceptable caring mission of a hospital and universally practised norms and standards of hospital admissions; and iii) to review corporate governance at the hospital in line with appropriate and applicable King IV corporate governance principles; and iv) conduct an appropriate climate survey assessment of staff and patients at the hospital to assess ‘attitudes’ towards patient care.

In this report, communication and collaboration between the health providers were found to be weak, there were no esprit de corps, doctors did not work as a team, nurses did not work as a team, doctors and nurses did not work as a team, together they failed Mr. Lethole and his family, they failed each other and were failed by the system. The outcomes of this forensic and audit analysis should form the basis to rebuild and improve the norms and standards and quality of care at the hospital into the future.

 

In light of the wide-ranging findings in this Report, the Health MEC, Dr. Nomathemba Mokgethi should institute disciplinary enquiry against Dr. Mogaladi, the CEO and Accounting Officer of TPTH for presiding over such a state of affairs. He signed inaccurate and misleading reports to the former MEC of Health in Gauteng, Dr. Bandile Masuku and the Health Ombud. He failed to report missing clinical notes to the SAPS as is required by law. He side-lined Quality Assurance in exercising their due responsibility in addressing Complaints and safeguarding records of Mr. Lethole. He failed to report the missing doctors’ notes of the 23^rd, 24^th, 25^th, 28^th, 29^th, and 30^th of June 2020, to the SAPS for ‘loss or theft’.

The Gauteng Department of Health and TPTH should institute disciplinary inquiry under the prevailing policy and compatible with the Labour Relations Act; constituted of a senior medical doctor and a senior nurse, jointly chaired, supported by a senior legal Counsel with experience in medico-legal matters and with experience in disciplinary enquiries against the following staff members:

• Shabangu: Failure of duty of care as articulated in this report.
• Bangala: Failure of duty of care
• Urmson: Failed in the duty of care
• Sunnyraj: For failure of duty of care.
• Ncha: For advising Health-eNews that TPTH was ‘ready for the COVID-19’, when the facts could never have supported any such conclusion. She provided the CEO with inaccurate information by drafting reports that were factually incorrect and misleading to the former MEC Dr. Bandile Masuku, the OHSC Complaints Centre and to the Health Ombud.
• Dr Ngobese: For failure to ensure that critical care equipment at Ward 23 was available and functioning properly; for failure to complete the required Morbidity and Mortality Template form timeously.
• Marole: For falsifying the death certification process and for failure to examine Mr. Lethole fully before to ensure that the Death certification is properly done.
• Pawson: For unbecoming and rude conduct; for denying his actions under Oath. He has apologised for his conduct.
• Tshali: She used Dr. Modika’s credentials without his express authorisation. This action resulted in confusion in the access of Mr. Lethole’s SARS-CoV-2 test results.
• Modika: He allowed his professional credentials to be used in the SARS-CoV-2 test by ClinAs. This led to Mr. Lethole’s results being viewed through his credentials, but not acted upon. He has apologised for his conduct.
• Sikelela Mavuma: He took Mr. Lethole’s body to the mortuary and signed for it and still denied he did so.
• Enrolled Nurse Phahlane for being untruthful in her statements. She was not a credible witness.
• Infection Prevention and Control Nurse, Hilda Mapunya for failure to report Notifiable Medical Conditions (NMC) within 24 hours of the clinical diagnosis results had become available.
• The Kitchen staff leadership of Ms. Mtwesi and Ms. Ngoasheng for unilaterally suspending the SOP for ordering meals without authority and rationale and creating an unreliable system of ‘pieces of scrap papers.’
• Mamsie Matshaba for encouraging Ms. Mtwesi and Ms. Ngoasheng to retrospectively update figures to reflect that food was ordered on the 23^rdof June 2020 for A & E Isolation area.
• Sylvia Tshabalala for indicating that she ordered and provided food for Mr. Lethole on the 23^rdof June 2020 while knowing that this was false.
• Sono: For giving instructions on terminating the SOP on the ordering of meals without authority, rationale and without providing a reliable alternative system.
• Professional Nurse Conny Mathibela (Operational Manager) for mixing up the dates of Mr. Lethole’s death. She has apologised for her conduct.
• Professional Nurse Zitha for continuing to record nurses’ notes even after Mr. Lethole’s demise.

TPTH should not have been designated a COVID-19 hospital, yes there were systemic faults; yes, the management of the establishment had not done their job, but the individual health care professionals involved in providing care also failed to discharge their responsibilities and their conduct could not be fully explained by the broader systemic issues. TPTH and its medical team of health providers must take accountability and responsibility for this substandard and negligent care provided Mr. Lethole.

The recommendations made in this final report are meant to encourage and foster a culture of high-quality health care at TPTH. A culture that respects the dignity of patients, a culture that complies with the prescribed Norms and Standards of the National Health System and a culture that is consistent with the ethics and codes of good clinical practice.

‘There is only one version of the truth. The truth has no different versions or shades.’

Issued by Professor Malegapuru W Makgoba

MB., ChB., (Natal); D.Phil., (Oxon); FRCP (Lond); FRS (SA); OMS. Foreign Associate Member of the National Academy of Medicine (USA)

Health Ombud: Republic of South Africa

 For more information contact: Ricardo Mahlakanya: Mobile. 066 473 8666, and Email. rmahlakanya@ohsc.org.za.

25 January 2021

The Health Ombud, Professor Malegapuru Makgoba on 27 January 2021 hosts a virtual media briefing to release the findings of the investigations into the circumstances surrounding the care and death of Mr Shonisani Lethole at Tembisa Tertiary Hospital.

Date:     Wednesday, 27 January 2021

Time:    10h00 – 13h00

Venue:  Ronnie Mamoepa Press Room (GCIS Tshedimosetso House, 1035 Francis Baard Street, Hatfield, Pretoria)

Media Participation: Journalists may view the media briefing via live streaming on the links below.

Facebook:     http://facebook.com/GovernmentZA

Facebook:     https://www.facebook.com/ohscsocialmedia

Twitter:          http://twitter.com/GovernmentZA

Twitter:          https://twitter.com/OhscSocialmedia

YouTube:      https://www.youtube.com/user/GovernmentZA

 For more information contact: Ricardo Mahlakanya: Mobile. 066 473 8666, and Email. rmahlakanya@ohsc.org.za.

6 July 2020

The Health Ombud, Professor Malegapuru Makgoba is ‘honoured and inspired’ to be invited by the United States of America Government to serve on the 12-Member expert panel of the Data and Safety Monitoring Board for the first COVID-19 vaccine clinical trials.

The Data and Safety Monitoring Board is responsible to ensure the safety of participants, the efficacy and the immunogenicity of the candidate vaccine being tested or on trial and it is the final structure to pronounce on the vaccine approval.

The 12-member expert panel currently consists of nine USA scientists, physicians, ethicists, and biostatisticians, with three non-USA experts from South Africa, Brazil, and the United Kingdom (UK). Members are selected based on their expertise and experience.

The committee is independent of investigators, organisations, and institutions conducting the vaccine clinical trials. The Data and Safety Monitoring Boards has the authority to recommend that a trial be stopped early should there be concerns of participant safety.

The race to develop a safe and efficacious vaccine is on globally. Finding a safe and efficacious vaccine is the goal that has become a global emergency, to significantly impact to change the course of the COVID-19 pandemic, that has caused so much damage and misery to the whole of humankind and the future of the world.

The recommendations of the Data and Safety Monitoring Board will have an enormous impact on the overall global response to the COVID-19 pandemic.

“I feel greatly honoured and inspired to be a member of this Data and Safety Monitoring Board. I shall do my best to make a meaningful input and contribution to the task,” said Prof Makgoba.

For more information contact: Ricardo Mahlakanya: Mobile. 066 473 8666, and Email. rmahlakanya@ohsc.org.za.

2 June 2020

South Africa and many countries have taken a wide range of steps to curb the spread of the Coronavirus (COVID-19) pandemic. In our country, led by the National Coronavirus Command Council (NCCC) following the declaration of a National State of Disaster joined hands with various sector institutions and experts to manage the COVID-19 public health emergency. The Office of Health Standards Compliance (OHSC) is grateful to all health workers and frontline personnel involved in the battle against COVID-19. Health workers have demonstrated dedication and commitment in the delivery of health care services, despite the daily challenges faced and the constant threat of exposure to COVID-19.

The OHSC acknowledges the immense strain put by COVID-19 on the entire health system and its resources, particularly health workers and personnel who have contracted COVID-19 infection and further note with grief the ultimate sacrifice of those health workers and frontline personnel who succumbed to COVID-19 infection.

The OHSC, as the regulator in the health care sector, has a responsibility to protect and promote the health and safety of users of health services in the country. The OHSC wishes to express concern in instances where the provision of services, quality and safety in health establishments is compromised. The quality of health services and the safety of all the users of health services remains paramount even during these trying times.

All health workers are urged to continue to provide the much-needed health care delivery required by South Africans during these challenging times. The OHSC further wishes to emphasise that the protection of health workers and all personnel through adequate availability and provision of personal protective equipment must be a priority. Management teams in all health establishments have a responsibility to ensure the protection of health workers.

As the country enters level three of the lockdown, the South African public is encouraged to always observe the COVID-19 preventive measures in all public spaces to protect themselves and those around them.

The OHSC Board wishes to express support for the response and leadership of the Honourable President Cyril Ramaphosa, the National Coronavirus Command Council (NCCC), the Minister of Health, Dr. Zweli Mkhize, South African Government Departments and all role players during these difficult times.

For more information contact: Ricardo Mahlakanya: Mobile. 066 473 8666, and Email. rmahlakanya@ohsc.org.za.

14 May 2020

The Office of Health Standards Compliance (OHSC) learnt with great shock and deeply saddened by the passing of the Chairperson of the Council of Medical Schemes (CMS), Dr Clarence Mini.

Dr Mini was a great servant of the nation in the medical fraternity, steadfast, and always shared the utmost insight in the field with anyone he would strike a conversation with. He will forever be celebrated for having served the medical industry with great distinction and humility in many roles and various capacities over the years. Dr Mini’s contribution to the liberation struggle during the darkest hour in our country is loaded.

Dr Mini demonstrated a deep knowledge of the medical field and abundantly supported the growth of South Africa’s health system despite its challenges. His role as the Chairperson of the CMS was critical, particularly in the dawn of South Africa’s universal health coverage.
His passing comes at a time when the country and the world are fighting Covid-19 pandemic that is ravaging the world.

The OHSC wishes to convey sincere, heartfelt condolences to Dr Mini’s family, his friends, colleagues and the entire medical fraternity across the country and internationally, as well as all staff of the Council for Medical Schemes.

May all who served with him always hold fond memories of his life and legacy.

For more information contact: Ricardo Mahlakanya: Mobile. 066 473 8666, and Email. rmahlakanya@ohsc.org.za.

28 March 2020

The last few weeks have been unparalleled with a worldwide public health emergency due to the outbreak of the Coronavirus (Covid-19) affecting people in South Africa and thousands across the globe in various countries.

The Office of Health Standards Compliance (OHSC) noted with appreciation the announcement by the Honourable President, Mr Cyril Ramaphosa that South Africa should observe a nationwide lockdown for 21-days with effect from midnight on Thursday, 26 March 2020 as part of efforts to curb the rapid transmission of the Coronavirus (Covid-19) and flatten the curve in the country.

The OHSC noted with great sadness the passing of a patient who succumbed to Covid-19 in the Western Cape. The constant increase in Covid-19 cases, confirmed by the Minister of Health in South Africa is of great concern. The OHSC acknowledges efforts by the National Department of Health (NDoH), the various South African Government Departments, the National Institute for Communicable Diseases (NICD) and many other role players in the public and private health sector to provide measures to prevent the spread of the virus in South Africa.

The World Health Organization (WHO) called on Governments to increase the manufacturing of personal protective equipment such as protective surgical gear ,masks and N95 respirators to curb the spread of Covid-19 in South Africa and other countries.

The OHSC as the regulator in health has a responsibility to protect and promote the health and safety of users of health services, both in the public and private health establishments in South Africa.

Whilst Covid-19 is recognised as a public health emergency, the OHSC calls on the public and private health establishments to employ all measures to minimise at all cost the risk of spread of Covid-19 to those in the coalface of managing the virus by providing all healthcare workers, laboratory personnel, support personnel and identified patients with personal protective equipment in all health establishments in South Africa. The country cannot afford to lose any healthcare workers, laboratory personnel or any other personnel involved in the management of the disease. These selfless members of society should be protected from contracting the disease.

The OHSC extends support and gratitude to healthcare workers and all personnel currently engaged in efforts to fight Covid-19.

The South African public is urged to observe the call to stay at home to protect themselves and those around during the lockdown period and adhere to preventive measures.

For more information contact: Ricardo Mahlakanya: Mobile. 066 473 8666, and Email. rmahlakanya@ohsc.org.za

8 February 2020

The OHSC together with the Office of Military Ombud (OMO) and Health Professions Council of South Africa (HPCSA) embark on a series of community outreach events in Lephalale Local Municipality. The purpose of engagements is to educate members of the community about the services of the OHSC, OMO and HPCSA:

Venue	Date	Time
Marapong Community Hall	11 February 2020	10:00-12:00
Ga-Seleka Community Hall	11 February 2020	14:00-16:00
Witpoort Community Hall	12 February 2020	10:00-12:00
Lamplaas Community Hall	12 February 2020	14:00-16:00
Abbotspoort Community Hall	13 February 2020	10:00-12:00
Ga-Monyeki Community Hall	13 February 2020	14:00 – 16:00

For more information contact: Ricardo Mahlakanya: Mobile. 066 473 8666, and Email. rmahlakanya@ohsc.org.za

12 July 2019

The Health Ombud, Prof Malegapuru Makgoba welcomes the implementation of the National Health Insurance (NHI) Bill as this important step is long overdue.

‘The provision of universal quality healthcare is a ground-breaking step in the delivery of the National Health System in South Africa. We should all learn from the implementation process to improve the NHI Bill,’ said Prof Makgoba.

The Health Ombud will work together with all role players for successful realisation of the NHI.

For more information contact: Ricardo Mahlakanya: Mobile. 066 473 8666, and Email. rmahlakanya@ohsc.org.za

23 August 2018

Minister of Health, Dr. Aaron Motsoaledi

Deputy Minister of Health, Dr. Joe Phaahla

Director-General of the Department of Health, Ms. Malebona Matsoso

Hon MA Dunjwa, Chairperson of the Portfolio Committee on Health

Members of the Ministerial Advisory Committee on Mental Health

OHSC Board Members

OHSC Chief Executive Officer, Dr. Siphiwe Mndaweni

Senior managers

Members of the media

Distinguished Guests, Ladies and gentlemen

INTRODUCTION:

1. William Osler- When Osler made this statement below, the importance of the art of medicine was high; the biological revolution of monoclonal antibodies, DNA and the internet were not yet games in town, and the importance and rising influence of science on the understanding of disease and practice of medicine has since grown in leaps and bounds.

There are only two sorts of doctors: those that practice with their brains, and those that practice with their tongues.

2. Medicine and science are interdependent and both are anchored and governed by the search for the truth and the practice of ethics to advance and improve humankind and the human condition.

3. Modern medicine and science are very important in the wellbeing of nations; they are the cornerstones for economic development; they are necessary for vibrant and successful democracies; they are important for national reputation and the comparisons of nations globally. The integrity and quality of any National Health System in an internet-connected world is thus critical for the life of a nation particularly its education. That is partly why society places such trust, high prize and pride in health professionals and scientists. We are the trusted seekers of the truth, the brains trust of the nation.

4. The integrated integrity of the practice of science with the art of the practice of medicine, the ethics underlying both and the truth have guided my report. Embedded in every finding runs the blood of science and its ethics.

5.  In preparing the report on an investigation into allegations of patient mismanagement and patient rights violations at the Tower Psychiatric Hospital and Psychosocial Rehabilitation Centre, I tried very hard to ensure that every word has a place and meaning but that reading the report would be enjoyable. I was acutely aware of the complex, diverse and active compatriots for whom this Report was addressed to (Active Citizenry in National Development Plan speak). So, I went over 40 drafts of the Report before this final one. If I did not succeed fully, it is not for lack of trying.

6.  The interim draft Report was circulated and shared with those concerned at the Eastern Cape Department of Health (ECDoH), Tower Psychiatric Hospital and Psychosocial Rehabilitation Centre (TPHPRC), Eastern Cape Technical Task Team (EC TTT), Dr Kiran Sukeri and the OHSC investigators for their inputs, comments, corrections and critique. I am grateful for these inputs. Some statements were revisited with witnesses for verification and confirmation and these were incorporated following their comments to produce the final Report. This important process has strengthened the Report.

7.  Since Suzanne Venter of the Rapport newspaper broke the TPHPRC story on 4th March 2018, there has been a lot of noise almost of orchestra proportion. The nation has been baffled or bewildered, at times shocked and many innocent people left in pain and with shattered reputations, particularly so soon after the Life Esidimeni tragedy.

8. For those who listen to or follow Jazz, the legendary Miles Davis once remarked: In playing with an orchestra, it may be simpler or better still to play above rather than against the orchestra. You are likely to be heard playing above rather than against as the orchestra noise will simply drown you. This is my paraphrase and interpretation of the legendary trumpeter. A lot of noise has been playing since the 4th March 2018 in the media with articles and documentaries.

9.  Hopefully trough this Report one can play above the noise of the orchestra and be heard without disappearing into the clouds or without being drowned.

10. Hopefully, the Report provides a balance and a melody to the noise you have all heard so far.

THEMES THAT EMERGED:

There are four themes that emerged out of the investigation, evidence, analysis and consolidation.

1.  The Complaint itself

a)  The complaint was very important and unique for the ECDoH;

b)  This was the first complaint lodged by a senior health professional consultant psychiatrist against his employer, TPHPRC and ECDoH;

c)  The complaint was described as coy and complex. Coy meaning subtle and at times evasive.

d)  Dr Sukeri made the following telling statements:

• He had been fighting for 12 years, this is certainly much longer than his 2-years employment at TPHPRC;
• His recommendations for a solution forwarded during the interview with the Ombud were directed to the system and the ECDoH rather than at TPHPRC;
• He admitted he lost his cool, went to the media and exaggerated his complaint;
• He did not care; quite inimical to a profession of caring;
• He was aware he violated his professional and contractual obligations but no longer cared;
• Dr Sukeri’s complaint was supported by Dr Mo Nagdee’s email to Mr B Nzima (Annexure 1c), which pointed out to deeper, chronic and systemic failures of Mental Health Services within the ECDoH and widespread unhappiness amongst professional staff within the ECDoH;
• Dr Sukeri’s complaint was also supported by evidence from Mr Wilson of the Public Servants Association of South Africa (PSA) and others which points to prolonged failures by the ECDoH to attend to complaints raised by staff since 2007; and
• There was very little evidence of systemic institutionalised human rights violations as compared to a few isolated incidents of professional misconduct.

2. The Eastern Cape Health Department

a.  Almost every witness conceded that Mental Health and its services were not a high priority within the ECDoH.

b.  The ECDoH was the cause of all the woes with Mental Health Care Services.

c.  The ECDoH failed to guide and support TPHPRC.

d.  It has a long history of failing to implement or action plans supported by well-researched studies.

3.  TPHPRC and the Ms NE Ngcume

a.  The management was in total disarray and engaged in power struggles.

4.  The Complainant Dr Kiran Sukeri | MBChB, FCPsych (SA), PhD | ResearchGate. (https://www.researchgate.net/profile/Kiran_Sukeri)

a.  Nothing was recorded for his h-index;

b.  He released unverified, false, exaggerated and damaging death statistics into the public;

c.  He violated his professional oaths and his employer’s confidentiality contractual clauses;

d. No amount of anger or frustration could be an excuse for a senior professional to behave this way and violate his professional and contractual oaths, ethics and codes of practice;

e.  Everybody disagreed totally with the manner and ways in which Dr Sukeri raised the complaint; and

f.  He irretrievably broke trust and the confidence of his colleagues.

A.  SUMMARY OF MAJOR FINDINGS, DETAILS p15-57:

1.  No prima facie evidence of institutionalised, systematic or deliberate violations of Human Rights by staff at Tower Psychiatric Hospital and Psychosocial Rehabilitation Centre was found.

a. As South Africans, we are not a nation of Human Rights violators. In a 124-year-old, 400-bedded chronic mental health institution and Rehabilitation Centre (TPHPRC), at Fort Beaufort, the Health Ombud could only identify and confirm one unquestionable instance of Human Rights violation, following a detailed and systematic evidence-based analysis of Dr. Sukeri’s complaint.

b. This violation was agreed by all stakeholders and all witnesses interviewed. There was thus no prima facie evidence of systematic, deliberate or systemic Human Rights violations found nor was there evidence found of a culture or intent to violate Human Rights by staff at TPHPRC.

c.  There were no other degrading and inhumane treatments observed or found as alleged by Dr Sukeri. This finding was corroborated by evidence from the Office of Health Standards Compliance (OHSC) investigators, the Mental Health Review Board (MHRB) Central Region, the Eastern Cape Technical Task Team (EC TTT) and evidence from research and the 34 witnesses interviewed by the Ombud.

d. Dr Sukeri’s coy complaint was primarily about chronic systemic failures and neglect of the ECDoH on Mental Health Care Services (MHCS) with pernicious systemic effects and the power struggles for change. It was not about Human Rights violations primarily as initially alleged and peddled in the media.

2.  Scientific Misconduct Committed

a.  Dr Sukeri failed to conduct credible studies, research or audits with rigorous verification of the information, data or figures available before making false and damaging pronouncements to the public through the media. This was a grave error.

b. Over an 8-year period, 68 MCHUs had died at TPHPRC and not the falsified and exaggerated total of 90 deaths as reported in the media with Dr Sukeri’s collaboration.

c. These total deaths translated into approximately 8.5 deaths/year or 0.71 deaths/month in a 400-bedded hospital. Therefore, the notion by Dr Sukeri that an alarming number of patient deaths at the hospital in recent years had gone unrecorded and without proper research and evidence must be regarded as false, untrue and must be eschewed.

d.  For Dr Sukeri to release such shoddy, poorly-researched, falsified and exaggerated patient’s vital statistical information into the public via the media, amounted to scientific misconduct or fraud a cardinal sin in science.

e. He had told Dr Snombo he was conducting research and had found a goldmine while discussing the Death Register.

f.  He was in Violation of Generally Accepted Research Practices that included an improper reporting of results to present a misleading outcome and the Falsification of Data, rather than manipulate the experiments or the data to generate preferred results, this transgression simply fabricates the data entirely (https://www.enago.com/academy/10-types-of-scientific-misconduct/).

g.  From this low averaged total death estimate of 0.71 deaths/month and an overall performance score of 89% in the National Core Standards assessment, it must be safe to conclude that TPHPRC would rank and compare favourably with the best health establishments of its kind (Weskoppies and Sterkfontein in the country) in the world and must be regarded as such (Khamker N et al 2010 and Walker et al 2013).

3. The False Life Esidimeni copy-cat phenomenon comparison

a.  Dr Sukeri’s complaint was depicted and portrayed in the media as another Life Esidimeni saga, even by Dr Sukeri as alleged in certain sections of the media such the Rapport, City Press and the eNCA TV programme, Checkpoint. The reported death of 90 MHCUs became etched in the public’s mind, reinforced by the reported statement by Dr. Sukeri saying the government did not seem to have learnt any lessons from Esidimeni and another documentary flighted as The next Life Esidimeni to air on eNCA by Health-e-News and Grocott Mail, 11th June 2018, all taken together, created this copy-cat phenomenon comparison. Dr Sukeri would have been fully aware at this time of the final total of 144 deaths recorded at Life Esidimeni over a period of one year during the Marathon Project(Robertson & Makgoba 2018).

b.  This Life Esidimeni comparison has had the effect of:

• Creating a national mass hysteria and shame so soon after the harrowing experience suffered through the Life Esidimeni tragedy. The media hype and Life Esidimeni copy-cat phenomenon or bandwagon comparison have blown the complaint out of proportion to reality. This media hype created a mountain out of a molehill. However, this comparison has no factual basis (see below).
• Another effect of this misrepresentation was to create an expectation in the local public that this complaint will lead to financial rewards just like what happened in Life Esidimeni, with some even dubbing Dr Sukeri’s complaint as Life Esidimeni R1.2m, (Adv Maxakato 2018). One point two million (R1.2m) was in reference to the average award given to each relative/family member of the Life Esidimeni tragedy, by former Deputy Justice Dikgang Moseneke premier/Pages/Life-Esidimeni.aspx).
• It was established and confirmed by all concerned (Dr. Sukeri, the complainant, the OHSC investigators (Ms. HM Phetoane and Ms. JT Monyela), Ms. NE Ngcume, the Chief Executive Officer (CEO), TPHPRC, Prof. Z Zingela, Chairperson of the EC Technical Task Team and confirmed by the Health Ombud) that a total of 68 patients died at TPHPRC over an 8-year period.
• This must be compared with a final total of 144 deaths recorded at Life Esidimeni over a period of one year during the Marathon Project Robertson & Makgoba 2018).
• It was this total death figure of 90 that led to the false comparison conferatur 94+ Life Esidimeni Deaths on 1st February 2017.

c. There was thus a 17x fold increase of deaths at Life Esidimeni compared to deaths at TPHPRC (12/0.71).

d.  There was no link between the 68 deaths with the alleged Human Rights violations, unlike the 144 deaths in Life Esidimeni.

e.  The Life Esidimeni tragedy was a once-in-lifetime event with no precedent recorded in the history of medicine and has thus become a landmark case study for quality healthcare, health professionals, politicians, lawyers, ethicists, actuaries and constitutional lawyers and the TPHPRC story is hardly ever likely to reach this status.

f. The scale/extend and degree of Human Rights violations at TPHPRC were very few, isolated and secondary and not comparable to the litany of Human Rights violations found and catalogued for Life Esidimeni (supported by medical, forensic and post mortem evidence), which were primary as detailed in the Ombud’s Report (Makgoba MW, 2018, www.ohsc.org.za), elaborated and aired during the Alternative Dispute Resolution (ADR) testimonies (published in full in Timeslive 20th March 2018) and  (http://www.gauteng.gov.za/government/departments/office-of-the-premier/Pages/Life-Esidimeni.aspx).

g.  Therefore, to compare and label Dr Sukeri’s complaint at TPHPRC as another Life Esidimeni in scale/magnitude or any dimension was both misleading and false.

 

h.  Despite Dr. Sukeri admitting under oath that he was wrong in this comparison and having made the corrections and admission of statistical miscalculations to the Ombud, followed by a written apology to the National Health Minister, Dr. Aaron Motsoaledi and copied to the Health Ombud on this grave error, the reputational damage to the country was done; he has yet to succeed in correcting these in the media and the public mind.

i.  This Life Esidimeni comparison was not only factually inaccurate and far from the truth, but also ill-informed, poorly researched, unscientific, false, exaggerated and based on inaccurate statistics. This incidence at TPHPRC was no Life Esidimeni.

j.  Dr Sukeri has conceded under oath the following:

• He conceded to miscalculating his death statistics, he called this a serious mistake;
• His death statistics were wrong; to this end, he has apologised in writing to the National Health Minister and the Health Ombud;
• Dr Sukeri acknowledged he should not have gone to the press;
• Some of his statements in the letter of complaints were based on opinions with no substantiation, credible research or proper scientific basis;
• He misrepresented the dates of informing the Health Ombud and has since apologised for this also in writing;
• Dr Sukeri was the primary source of and at times a collaborator of the articles and the documentaries on this matter; and
• Now that he has admitted under oath and apologised in writing and all the evidence proved that the basis of this comparison was false and untrue, logically all articles and documentaries based on this must be declared wrong, null and void.

k.  It is, therefore, my appeal that the media that participated in peddling these falsities (The Rapport, City Press, The Daily Dispatch, Grocott’s Mail, eNCA Checkpoint and others) should consider withdrawing these articles and documentaries and joining Dr.’s Sukeri in tendering a public apology. It cannot be accepted and be ethical in a Constitutional Democracy and a knowledge society that the public is informed and educated on proven and acknowledged wrong scientific facts. We cannot create a successful non-racial, non-sexist and equitable society on the basis of lies and untruths.

4. Patient’s Confidentiality and Dignity: A Violation of the Cardinal Rule of Medical Practice

a)Trust is an essential part of the doctor-patient relationship and confidentiality is central to this. Patients may avoid seeking medical help, or may under-report symptoms, if they think their personal information will be disclosed by doctors without consent, or without the chance to have some control over the timing or amount of information shared.

b) Doctors are under both ethical and legal duties to protect the patient’s personal information from improper disclosure. But appropriate information sharing is an essential part of the provision of safe and effective care. Patients may be put at risk if those who are providing their care do not have access to relevant, accurate and up-to-date information about them (https://www.gmcuk.org/Confidentiality_good_practice_in_handling_patient_informatio…).

c) Dr Sukeri violated his professional codes of practice and ethics and breached his confidentiality contractual obligations with his employer, TPHPRC and the ECDoH. By sharing the death register (with personal patient’s information) with the Rapport newspaper and subsequently on public national television (TV) with eNCA’s Checkpoint reporters, Dr Sukeri violated one of the cardinal rules of the health professions practice, which is confidentiality. This violation was in breach of the National Health Act.

d)  By violating the patient’s confidentiality, he violated the patient’s dignity. Dr Sukeri acted in the most unprofessional way for a senior health professional, in a noble profession steeped in centuries of values, traditions, ethics and codes of conduct to advance and improve human life, protect and do no harm to humankind; he simply and consciously ignored all these. He has so far shown very little remorse for his actions, and he lied under oath.

5. Discharge of MHCUs without authorisation

a.  In the progress report provided by Dr TD Mbengashe, the SG on 21st August 2018 to the Health Ombud, following the recommendations of the EC TTT and the findings of the OHSC investigators showed that Dr Sukeri had indeed discharged patients without proper authorisation and ensuring social circumstances of the users. This item in the original Report is item 4.15.1 on page 48. This version represented an update.

b.  Follow up of the users discharged revealed the following:

• Out of a total of 142 discharges, Dr Sukeri had discharged 51 or 35.92%;
• 141 of the discharges have been traced and found;
• All 51 discharges of Dr Sukeri have been traced and found;
• A process is underway to locate in collaboration with the community to locate the 1 outstanding MHCU;
• Dr Sukeri’s 11 discharged users were not coping well in the community, some with relapses and re-admissions; 1 user was reported missing; 2 users passed away;
• One (1) user committed suicide and 1 user committed murder and was imprisoned;
• That some MHCUs have been re-admitted, 1 committed suicide, 1 committed murder and others are not coping well in the community as so far found, questioned the quality of assessment undertaken, the clinical judgements/decisions made and the competence of Dr Sukeri; and
• This was a gross violation of the MHCA, the HPCSA Codes of Practice and in defiance of the CEO and the ECDoH policy. It is also inimical to the concept of caring.

6.  Irretrievable breakdown and loss of trust and confidence

a.  Dr Sukeri has irretrievably lost the trust and confidence of the TPHPRC Board, the Mental Health Review Board (Central Region), Dr. TD Mbengashe, the Superintendent-General, Dr. PP Dyantyi the former Health MEC, the Management team at TPHPRC (Ms. NE Ngcume, Dr. Snombo and Mr. Baart) and other colleagues at TPHPRC and other officials within the ECDoH; his complaint has had the effect of dividing the psychiatric professionals in the South African Society of Psychiatrists (SASOP) National versus the SASOP EC and between members of SASOP within the EC. Ka Sepedi Ba re O nyetÅ¡e sediba meaning he pooed into his water well and in Japanese, he committed a Hara-kiri, Seppuku or Kamikaze. He has irretrievably destroyed trust and confidence across a range of stakeholders by the manner in which he went about his complaint. He disregarded all possible and available processes to him.

b.  Dr Sukeri claimed in some of his media quotes in City Press newspaper (04-03-2018) that: I know what I’m going to tell you will jeopardise my safety, as well as that of my family, but I don’t care. Those patients urgently need to be helped. He was aware that he had not followed due processes; He did not care anymore as he could no longer keep quiet or remain silent about these inhumane conditions; He showed Rapport newspaper copies of the lost register indicating at least 90 patients at the institution since 2010 and four patients died in January alone. We’ve been struggling with the same kind of problems in the Eastern Cape for years. I’ve been fighting for the rights of psychiatric patients for 12 years, said a tearful Dr Sukeri to the Rapport newspaper.

7. Brought professional and national disrepute

a. Dr Sukeri’s complaint whilst important for Mental Health Care Services in the EC, it is equally injurious to the health professions reputation, integrity and the quality of the health system and its professionals.

b.  Consequently, Dr. Sukeri has single-handedly brought disrepute to our country, its health system and its health profession and professionals at enormous human and financial costs by the manner of his actions; the processes he chose to articulate his complaint; surely this conduct and consequences thereof calls for something at the highest level to be done i.e. when a nation or society can no longer or loses trust its brain trust, something profoundly faulty has taken place.

8. ECDoH: A department with a track record of successful failures

a. Available evidence gathered and corroborated by several independent research reports showed that ECDoH:

• failed to prioritise mental health services over a long period;
• has a long history of failures to implement policies as documented in the Treatment Action Campaign (TAC) & Section 27 2013 investigation Report, Dr. Sukeri 2014 (3 articles referenced), the Ministerial Task Team Report (MTTR) following the Life Esidimeni tragedy (May 2017), Dr. Mo Nagdee’s email February 2018 & OHSC investigators 2018 Report);
• the above long history demonstrated the ECDoH was incapable of recovering or correcting by itself and without the assistance of an external tough taskmaster or administrator;
• failed to provide the necessary leadership and governance of mental health services;
• failed to treat specialists with respect and not simply as subordinates/employees (Dr Mo Nagdee);
• Not only failed to implement its plans on mental health services but also seemed incapable of action or implementation over long periods;
• failed to develop community-based mental health services, the sine qua non of de-institutionalisation;
• failed to guide and provide support to TPHPRC;
• failed to maintain adequate infrastructure standards at TPHPRC;
• as a result, infrastructure has degenerated over time as detailed in the Report;
• failed to instil Consequence Management to hold senior staff accountable;
• the work ethic has severely deteriorated;
• the leadership and governance are in disarray; and
• there are severe shortages of staff in general and at critical areas.

b.  The TPHPRC outburst was just the needed lightening rod and representative of a broader systemic and prolonged poor-quality service delivery for Mental Health Care Users (MCHUs) in the EC.

B.  RECOMMENDATIONS, DETAILS p59:

a.  The National Health Minister must evoke the appropriate and relevant Sections of the Constitution to appoint an Administrator with respect to Mental Health Services in the ECDoH. This must be done within 90 working days through the appointment of an Administrator.

b.  This Complaint has re-emphasised the urgent need to review the National Health Act (NHA) 2003 and MHCA 2002 that took away the powers of the President, the National Minister of Health and Magistrates in addressing issues of Mental Health nationally. Locating Mental Health Services at the Provincial sphere of government in the so-called concurrent competence has created difficulties rather than solutions to Mental Health Care Service. This competency must revert back to the National Health Minister (Health Ombud Report page 54-55 item 14).

c.  Dr Sukeri should be reported to the Health Professions Council of South Africa (HPCSA) as a matter of urgency for serious professional misconduct and violations of codes of health practice identified in the report. The rationale for the recommendation is:

• Dr. Sukeri released unverified, false and damaging death statistical information to the public, in so doing committing scientific fraud;
• Dr. Sukeri violated the confidentiality of patients and by so doing their dignity;
• He violated his confidentiality clause signed in his contracts with ECDoH and TPHPRC;
• He failed in his duty of care as a professional;
• He violated the MHCA;
• He discharged patients without proper authorisation and without following the MHCA;
• Dr Sukeri denied Ms Ngcume, the CEO, the right to exercise her duty fully by discharging MHCUs without her knowledge;
• Dr Sukeri was found to be untruthful, evasive and duplicitous in his evidence;
• He created an irretrievable loss of trust and confidence with colleagues at TPHPRC and ECDoH;
• He was jointly responsible for creating a toxic working environment in which to care for vulnerable MCHUs;
• It is the Ombud’s role to protect the integrity of the health system and of users against abuse;
• Dr Sukeri caused unnecessary reputational damage to the National Health System and its integrity;
• He caused unnecessary pain and unwarranted reputational damage to innocent staff members, MHCUs and to TPHPRC as an institution and the ECDoH; and
• That some MHCUs discharged have been re-admitted, one has committed a crime and others are not coping well, as so far as found, questioned the quality of assessments undertaken, the clinical judgements/decisions and competence of the practitioner.

d.  The HPCSA should consider the immediate suspension of Dr Sukeri from any practice pending a process to assess his fitness for office as proposed out below, to safeguard the wellbeing of patients, protect him and the integrity of the profession.

e.  Disciplinary proceedings must be instituted against Dr Sukeri in compliance with the Disciplinary Code and Procedure applicable to Senior Management Services (SMS) members in the Public Service. This should follow a fair, transparent and due process.

f.  Dr Sukeri should be charged for gross misconduct and incompetence based on the findings in this report especially the violation of patients confidentiality and for committing what amounted to scientific misconduct.

• Consideration must be given that he may need assistance with psychological counselling.
• Currently and from all the evidence gathered he is like a round peg in a square hole within TPHPRC and the ECDoH.
• He has irretrievably broken trust within the TPHPRC and the ECDoH.

g.  The HPCSA must consider the appointment of a panel of 3 independent members, Chaired, by a senior psychiatrist to speedily resolve and finalise Dr Sukeri’s fitness to hold office, for his professional and ethical violations, broken relationships, misconducts and incompetence. Alternatively, the Minister should set up a special ad hoc panel to address the fitness to hold the office of Dr Sukeri.

h.  Dr Sukeri must, in addition to making an apology to the National Health Minister and copied to the Health Ombud (page 61 dated 12th July 2018) and sending a correction to the Rapport Ombudsman, should make a public and unconditional apology in writing to the nation, to his peers in psychiatry, to the medical profession, to the staff at TPHPRC and the ECDoH and to the many patients and families whose lives he compromised through peddling false and exaggerated information.

i. He must acknowledge the pain inflicted to many persons and the reputational damage caused. This apology must be widely publicised and accorded the same weight by the media as they have done with the complaint. SASOP must as a professional body take appropriate actions with regards to Dr. Sukeri.

j. The Management at TPHPRC was so dysfunctional and riddled with dead-end power struggles, it must be overhauled with new blood. This must be done through the SG’s Office and the proposed Administrator.

k.  All the recommended internal disciplinary decisions already identified were upheld and must be completed speedily following due processes and in accordance with fair labour practices.

C. CONCLUSION:

In one of his progress report forwarded to the Health Ombud on 15th August 2018, Dr TD Mbengashe highlighted a number of activities taking place at TPHPRC starting to address some of the concerns raised by various witnesses. He also provided an update on the disciplinary processes already underway.

In his input, Dr Sukeri indicated that following our visit, positive progress was already taking place at TPHPRC. All these bodes well. Advocacy for patients is a well-recognised phenomenon within the Health System and is supported fully.

However, the health professional must observe and practice the highest ethical standards, must respect the truth and be truthful at all times an advocate with integrity.

There is no place for advocacy through unethical conduct, or through lying or peddling untruths or through the disrespect for tried and tested professional complaints processes.

There is equally no advocacy through bringing disrepute to a profession, to a health system, to a nation and fellow professionals and other innocent human beings.

I hope through the findings and recommendations in this Report, the ECDoH and the Mental

Health Professionals in the EC can work together to create an attractive working environment and services, which are in the best interest of the MHCUs.

Thank you!

Issued by the Health Ombud: Prof. Malegapuru W. Makgoba

MB.; ChB.; (Natal); DPhil.; (Oxon); FRCP (Lond); FRS (SA); MAS(SA); FCP (SA) addendum;

OMP (Silver)

Foreign Associate Member of the National Academy of Medicine (USA)

Fellow of Imperial College (Lond) (Health Sciences Faculty)

Health Ombud: Republic of South Africa

For more information contact: Ricardo Mahlakanya: Mobile. 066 473 8666, and Email. rmahlakanya@ohsc.org.za

The Health Ombud, Professor Malegapuru Makgoba will brief members of the media about the “Report on an Investigation into Allegations of Patient Mismanagement and Patient Rights Violations at the Tower Psychiatric Hospital and Psychosocial Rehabilitation Centre (TPHPRC). The briefing will be attended by the Minister of Health, Dr. Aaron Motsoaledi; Deputy Minister of Health, Dr. Joe Phaahla; the Director-General of the Department of Health, Ms. Malebona Matsoso and OHSC Chief Executive Officer, Dr. Siphiwe Mndaweni.

The Health Ombud, Professor Malegapuru Makgoba to brief members of the media about the Report on an Investigation into Allegations of Patient Mismanagement and Patient Rights Violations at the Tower Psychiatric Hospital and Psychosocial Rehabilitation Centre (TPHPRC). The briefing to be attended by the Minister of Health, Dr. Aaron Motsoaledi; Deputy Minister of Health, Dr. Joe Phaahla; the Director-General of the Department of Health, Ms. Malebona Matsoso and OHSC Chief Executive Officer, Dr. Siphiwe Mndaweni.

The media briefing will be held as follows:

Date: Thursday, 23 August 2018

Venue: MRC Building, 1 Soutpansberg Road, Prinshoff, Pretoria

Time: 10:00

For more information contact: Ricardo Mahlakanya: Mobile. 066 473 8666, and Email. rmahlakanya@ohsc.org.za