Category: Media Releases

The Health Ombud Professor Taole Mokoena released the findings of the investigation into the allegations of a patient denied the provision of care at the Motherwell NU 11 Clinic in the Eastern Cape Province who later died at the Motherwell Police Station Community Service Centre (MPSCSC).

The investigation report issued is in terms of the National Health Amendment Act (NHAA), 12 of 2013, in conjunction with the Procedural Regulations pertaining to the functioning of the Office of Health Standards Compliance (OHSC) and handling of complaints by the Ombud to inform the complainant and the health establishment on his/her findings and recommendations. The Office of the Health Ombud (OHO) conducts its investigations in terms of Section 81A (1) of the National Health Amendment Act (NHAA), which gives the Ombud the powers to consider, investigate and dispose of the complaint relating to breaches of the prescribed norms and standards in a fair, economical, and expeditious manner; and in terms of Regulation 42 of the Procedural Regulations, which regulates the powers conferred upon the Ombud. 

The report communicates the findings and recommendations by the Ombud, following a complaint lodged by the Democratic Alliance’s (DA) Shadow Minister of Health, the Honourable Michéle Clarke, MP, in September 2022 against the Motherwell NU 11 Clinic. Honourable Clarke alleged that the clinic denied the provision of care, resulting in the death of the patient, Ms Zenizole Vena. The complaint was referred further by the Honourable Minister of Health, Dr Joe Phaahla, MP in October 2022. In the referral, the Minister requested the Ombud to investigate potential negligence and suboptimal care at the clinic.

Primarily, Honourable Clarke, alleged that the Motherwell NU 11 Clinic failed to assist Ms Vena, a 15-year-old who went to the clinic accompanied by an elderly woman seeking healthcare after being sexually assaulted. Ms Vena was instead turned away by healthcare workers at the clinic and later died at the Motherwell Police Station Community Service Centre (MPSCSC) where she sought assistance.

The Health Ombud deployed a team of two Investigators in terms of Section 81(3)(c) of the NHAA to investigate the complaint. Upon analysis of the complaint and allegations, the investigators identified the following issues, to form the basis of the investigation:

a)Whether Ms Vena (the patient) was denied provision of care at the clinic.
b)Whether Motherwell NU 11 Clinic failed to refer Ms Vena to the next level of care.
c)Whether the death of Ms Vena was due to negligence of the healthcare workers at the Motherwell NU 11 Clinic.

The investigation was conducted through analysis and triangulation of information and documentary evidence received from the Motherwell NU 11 Clinic, the Eastern Cape Provincial Department of Health (ECDoH), the Nelson Mandela Bay District Health (NMBDH), onsite visits, interviews with relevant personnel at the affected institutions, and the application of the relevant legislation to enable the Ombud to decide on the resolution of the complaint.

FINDINGS
The investigation sought to establish, and made the following findings:
a)Whether Ms Vena (patient) was denied provision of care at the Clinic
The allegation that Ms Z Vena was denied provision of care at Motherwell NU 11 Clinic was substantiated and confirmed based on the information gathered during the investigation.
The healthcare workers who attended to Ms Vena at the clinic did not touch nor examine her with the belief that every sexual assault case should be referred to the South African Police Services (SAPS). She was instead instructed to go to the Motherwell Police Station Community Service Centre as nurses at the clinic erroneously believed that “nurses are not allowed to touch rape victims to avoid tampering with evidence.”
Despite their belief, the two nurses did not arrange transport to take both the escort (an elderly old lady) and victim to MPSCSC nor call the police to come to Motherwell NU11 Clinic to take over the case.

One of the nurses indicated that she only took the patient’s vital health data, which was written in a personal diary but not in the approved Patient Administration Record (PAR).
b)Whether Motherwell NU 11 Clinic failed to refer Ms Vena to the next level of care The allegation that Motherwell NU 11 Clinic failed to refer Ms Vena to the next level of care was substantiated and confirmed by the investigation.
Based on the verbal and documentary evidence gathered and considered, it can be concluded that both healthcare workers concerned failed to refer Ms Vena to the next level of care needed. It was evident that she was not attended to in a manner that was consistent with the nature and severity of her health condition.
The nurses’ conduct of failing to refer Ms Z Vena to the next level of care violated the provisions of Regulation 5(1) and (2)(b) of the Norms and Standards Regulations for different categories of health establishments.
c)Whether the death of Ms Vena was due to negligence of the healthcare workers at the Motherwell NU 11 Clinic
The allegation that the death of Ms Z Vena was due to the negligence of the nurses at Motherwell NU 11 Clinic was substantiated and confirmed.
Based on the evidence obtained, it can be concluded that Ms Z Vena was not attended to in a manner that was consistent with the nature and severity of her health condition at Motherwell NU 11 Clinic.
d)The investigation further revealed additional findings, such as the failure of the Motherwell Police Station Community Service Centre to assist Ms Vena upon her arrival at the charge office. Ms Vena was told to wait, they only attended to her after she waited for 1h30 minutes. During this time, she experienced seizures and was foaming at the mouth. She was found dead laying on the floor in the charge office.
RECOMMENDATIONS
The Health Ombud made 14 recommendations detailed in the report, which amongst them include:
•The District Manager of the Nelson Mandela Bay District Health should institute a disciplinary inquiry against the two health workers who attended to Ms Vena at the Motherwell NU 11 Clinic.
•Plans should be put in place such that all SAPS employees engaged with the public are trained in First Aid, or if there is an emergency, they have easy physical access to first responders 24 hours a day. This should be implemented within 12 months of the report.
A detailed report is available on the Health Ombud’s website www.healthombud.org.za. Ends.

Issued by Professor Taole Mokoena – South Africa’s Health Ombudsman

For Media Enquiries: Mr Ricardo Mahlakanya Cell: 066 473 8666

 

The Office of Health Standards Compliance (OHSC) is a statutory regulator of the healthcare sector established through the National Health Act of 2003. The Office joins the healthcare community worldwide in observing World Patient Safety Day on 17 September, a global public health day, observed under the theme: “Engaging patients for patient safety”.

World Patient Safety Day is one of the World Health Organization’s (WHO) global public health days observed annually on 17 September. The global campaign was established in 2019 with the objectives of increasing public awareness and engagement; enhancing global understanding of the significance of patient safety; working towards global solidarity and action by Member States to enhance patient safety; and reduce patient harm. Being the health regulator mandated to ensure quality and safety in healthcare on behalf of our health users, we persist in our efforts to ensure safety through conducting compliance inspections at health establishments to assess establishments’ compliance with the national health system norms and standards. Inspection tools have been developed to assess health establishments in different levels of care to provide safe and quality health services within the health system. The development of inspection tools is an important part of the process of OHSC in ensuring health establishments are assessed comprehensively in line with the relevant regulations. In addition to the inspection tools, a compliance status framework has been developed to ensure that the OHSC and health establishments have a common understanding of the way inspection findings are processed toward the compliance decision. A certificate of compliance is issued to a compliant health establishment and a notice of compliance to a non-compliant health establishment.

As an institution, we continue to closely monitor indicators of risk to identify serious breaches of norms and standards through the Early Warning System (EWS). Information collected guides the authorities to address challenges that may result in serious harm to users. The EWS recommendations report outlines the trends in breaches of norms and standards, as they relate to patient safety and overall health system weaknesses and provides explicit recommendations to address these weaknesses.

Furthermore, the OHSC works closely with the Office of the Health Ombud (OHO) mandated to protect and promote the health and safety of healthcare users by considering, investigating, and disposing of complaints in the national health system. These complaints relate to non-compliance with prescribed norms and standards. The OHSC and OHO urge healthcare users and the public to report any poor quality of healthcare received from both public and private facilities to the Office of the Health Ombud through our Toll-Free Call Centre number at 080 911 6472 or email complaints@ohsc.org.za

Click on the links below to view messages by the Acting CEO, Professor Lilian Dudley, and the Health Ombud, Professor Taole Mokoena

Professor Lilian Dudley message

Professor Taole Mokoena message

Issued by the Office of Health Standards Compliance.

For Media Enquiries Contact: Ricardo Mahlakanya – Senior Manager: Communication Services and Spokesperson 066 473 8666 / rmahlakanya@ohsc.org.za

The Office of Health Standards Compliance (OHSC), a regulator of health services, is required in terms of the National Health Amendment Act (NHA) to monitor and enforce compliance by health establishments relating to breaches of the prescribed norms and standards regulations applicable to different categories of health establishments.

The norms and standards regulations applicable to different categories of health establishments provide a framework for the development of inspection tools that are used to inspect health establishments in different levels of care to provide safe and quality health services within the South African health system. The development of inspection tools is an important part of the process to ensure health establishments are inspected in line with the relevant regulations. In addition to the inspection tools, a compliance status framework has been developed to ensure that the OHSC and health establishments have a common understanding of the way inspection findings are determined towards the compliance decision.

The OHSC is in the process of developing an inspection tool for GP practices. The inspection tool development process requires that all relevant stakeholders be consulted. The inspection tool will be used to inspect the quality and safety of services provided by various GP practices. The OHSC adopted an incremental approach to the development of inspection tools aligned to the norms and standards regulations for inspecting and measuring compliance at various practices.

The OHSC is currently engaging GPs with the aim of communicating the norms and standards regulations and requirements for their inspection tool. The workshops will further create a common understanding of the way inspection tools are developed, as well as solicit General Practitioners’ inputs on the tool.

In that regard, consultation workshops with GPs were conducted in Gauteng in January, Limpopo in February, and Mpumalanga in March 2023 respectively.

Scope of norms and standards regulations
The regulated norms and standards for different categories of health establishments apply to public and private hospitals, public sector clinics and community health centres, private health clinics, and GP practices. Since the scale and range of services offered differ among these different healthcare sectors, different inspection tools are developed and used to measure compliance. The main categories of standards are:
User rights – User information; access to care; and waiting times.
Clinical governance and clinical care – User health records and management; clinical management; infection prevention and control; waste management; and responses to adverse events
Clinical support services – Medicines and medical supplies; diagnostic services; blood services; medical equipment
Facilities and Infrastructure – Management of buildings and grounds; engineering services; transport management; security services

Engagement dates with GPs in other provinces will be held as follows :

Date Province Area/City
26 August 2023 KwaZulu Natal Umhlanga
09 September 2023 Western Cape Durbanville
30 September 2023 Limpopo Tzaneen
07 October 2023 Mpumalanga Witbank
21 October 2023 Gauteng Ekurhuleni
28 October 2023 Eastern Cape East London
04 November 2023 Free State Bloemfontein
18 November 2023 Northern Cape Kimberley
02 December 2023 Northwest Mafikeng

For further information on the exact details of the scheduled workshops, please contact Dr T. Makola at (012) 942 7821 and/
or tmakola@ohsc.org.za, Ms. I. Loots at (012) 942 7848 and/or iloots@ohsc.org.za, and Mr. J Nkambule at (012) 942 7742
and/or jnkambule@ohsc.org.za.

The Office of Health Standards Compliance (OHSC) Board is deeply concerned about the current outbreak of cholera disease in South Africa, particularly in the provinces of Gauteng, Free State, North West and Mpumalanga. The OHSC noted with great sadness that the disease claimed the lives of patients at some of the health establishments.

We are urging the National and Provincial health departments to put measures in place across all healthcare establishments in order to contain the outbreak and further spread of the disease. Whilst the OHSC acknowledges the enormous strain put by the outbreak of cholera on the health system, and its resources, it is expected that the provision of quality health remains of the highest standard.

As a regulator of health services, the OHSC has a responsibility to promote and protect the health and safety of users of health services by ensuring that health establishments meet the expected health standards of care.

The OHSC will continue to monitor the situation in ensuring that the quality and safety of users of health services are not compromised in health establishments. The entity wishes to send its deepest condolences to all families who have lost their loved ones due to the disease.

Issued by the Office of Health Standards Compliance

For more information contact:

Ricardo Mahlakanya
Senior Manager: Communication Services and Spokesperson
066 473 8666
rmahlakanya@ohsc.org.za

The Office of Health Standards Compliance (OHSC) Board is deeply concerned about the current outbreak of cholera disease in South Africa, particularly in the provinces of Gauteng, Free State, North West and Mpumalanga. The OHSC noted with great sadness that the disease claimed the lives of patients at some of the health establishments.

We are urging the National and Provincial health departments to put measures in place across all healthcare establishments in order to contain the outbreak and further spread of the disease. Whilst the OHSC acknowledges the enormous strain put by the outbreak of cholera on the health system, and its resources, it is expected that the provision of quality health remains of the highest standard.

As a regulator of health services, the OHSC has a responsibility to promote and protect the health and safety of users of health services by ensuring that health establishments meet the expected health standards of care.

The OHSC will continue to monitor the situation in ensuring that the quality and safety of users of health services are not compromised in health establishments. The entity wishes to send its deepest condolences to all families who have lost their loved ones due to the disease.

Issued by the Office of Health Standards Compliance

For more information contact:

Ricardo Mahlakanya
Senior Manager: Communication Services and Spokesperson
066 473 8666
rmahlakanya@ohsc.org.za

Minister of Health, Dr Joe Phaahla would like to announce that Professor Malegapuru W. Makgoba’s term of office as the Health Ombud has come to an end as of the 31st May 2023. He was appointed Health Ombud by former Health Minister, now Minister of Home Affairs Dr Aaron Motsoaledi on the 1st of June 2016 for a non-renewable term of seven years.

The Health Ombud is an independent body established in terms of the National Health Amendment Act of 2013, with responsibility to protect and promote the health and safety of users of health services by considering, investigating, and disposing of complaints in the national health system relating to non-compliance with prescribed norms and standards.

The Health Ombud is located within the Office of Health Standards Compliance (OHSC), a schedule 3A public entity in terms of the PFMA. The mandate of the OHSC include, amongst others the responsibility to monitor the implementation of the recommendations made by the Health Ombud.

Professor Makgoba, since assuming office has displayed his patriotism and commitment to the creation of an improved healthcare service in the country, by impartially and with no favour or prejudice, investigating complaints brought to his office and made recommendations that are invaluable to the health system in the country. He was expectedly assisted by his long service and experience in the clinical care work, knowledge of the public service and the requisite needs of a better and durable healthcare system.

He was bestowed with a daunting task of establishing this office since he was the first South African Health Ombud, allowing the country to follow the good examples and practices of other countries in ensuring that our people receive an improved quality healthcare in a modernized health infrastructure.

Some of the major investigations conducted under his leadership include Life Esidimeni involving mental health patients, Tembisa Hospital and the recent Rahima Moosa Mother & Child Hospital, which bear testimony to the intent to want to assist the government and the public to build the durable health system. Professor Makgoba did not only attend to high profile complaints but also spent huge amount of his term following on the complaints of ordinary people who visit our healthcare facilities.

South Africa and the healthcare system is greatly indebted to him, and his departure is a loss to the system that still require a huge overhaul and deep reform. Although, we are glad that he managed to set up systems which we believe his successor will be able to continue with good work he left behind.

The Ministry and Department hope that as he departs, he would not be completely lost from the healthcare system as it will continuously seek his advice and counsel as we proceed with the necessary reforms to build an affordable, accessible, and durable healthcare system.

It is my pleasure to announce that Professor Makgoba will be succeeded by Emeritus Professor Taole Resetselemang Mokoena with effect from the 1st of June 2023.

Professor Mokoena is one of the most outstanding South African medical scholars who has transcended the globe to show the quality the South Africans academic prowess. He is a medical graduate of the University of Natal, D.Phil graduate of University of Oxford and a fellow of Royal College of Physicians and Surgeons of Glasgow. He recently retired as a Professor and Academic Head of Department of Surgery, Chief Surgeon of Department of General Surgery at University of Pretoria and Steve Biko Academic Hospital. But he continues his work on part-time or sessional basis to teach, train and supervise undergraduate and post-graduate medical students and research.

Prof Mokoena’s clinical and research interests encompass immunology, oncology and endocrinology, and having previously been part of renal transplant unit in Universities of Natal and Witwatersrand. He is active in academic and professional leadership, having served at different times on a number of national and professional bodies like South African Medical Association, Health Professions Council of South Africa, Colleges of Medicine of South Africa, College of Surgeons of South Africa.

He was also appointed to chair a Panel for Investigation of Surgical Deaths at the Chris Hani Baragwanath Hospital in 1996/7 and the Panel of Inquiry into Discrimination within the Cardiology Department at Chris Hani Baragwanath Hospital.

This track record gives credence to his appointment as the new Health Ombud, armed with experience in investigations and inquiries in wrongdoing and injustices in the healthcare sector. We are confident that Professor Mokoena will execute his work with diligence and absolute sense of justice, eschewing impartiality and no prejudice to all.

The Minister of Health, Dr Joe Phaahla and the Department of Health wish him success in his new responsibility and assure him of unparalleled support at all material times.

The Office of Health Standards Compliance (OHSC) welcomes the appointment of Professor Taole Mokoena as the second South Africa’s Health Ombud for the seven years with effect from 1 June 2023.

Professor Mokoena, appointed by the Minister of Health, Dr Joe Phaahla succeeds the outgoing Health Ombud, Professor Malegapuru Makgoba.

Having spent extended study and working periods in the United Kingdom and Canada, Professor Mokoena comes with a wealth of experience in academic and research within the health sector. He is a medical graduate of the University of Natal, a Doctor of Philosophy graduate of the University of Oxford and a Fellow from the Royal College of Physicians and Surgeons of Glasgow. He retired as a Professor and Academic Head of Department of Surgery Chief Surgeon from the Department of General Surgery at University of Pretoria and Steve Biko Academic Hospital. He continues on a part-time sessional basis to teach, train, and supervise undergraduate and postgraduate medical students, and research.

The Office of the Health Ombud is located within the Office of Health Standards Compliance, a regulator in healthcare. The office has the responsibility to consider, investigate complaints from the public on non-compliance by health establishments.

The OHSC would like to thank the outgoing Health Ombud, Professor Malegapuru Makgoba for his excellent service and contribution in South Africa’s healthcare sector.

The OHSC Board and Staff wishes the newly appointed Health Ombud, Professor Mokoena well in his new journey and looks forward to working with him and providing the necessary support.

Issued by the Office of Health Standards Compliance

For media enquiries contact:

Ricardo Mahlakanya

Senior Manager: Communication Services and Spokesperson

066 473 8666

rmahlakanya@ohsc.org.za