27 January 2021
THE REPORT INTO THE CIRCUMSTANCES SURROUNDING THE CARE AND DEATH OF SHONISANI LETHOLE AT TEMBISA TERTIARY HOSPITAL
“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 6th 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 25th 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 1st 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 23rd 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 23rd June 2020 registered entry on the patient’s registry at 12h36 at COVID-19 Isolation (Patient’s Number: 3521074), until Friday, the 25th 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 23rd 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 23rd and 24th 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 27th June 2020, Mr. Shonisani Lethole never received feeding after he was sedated and intubated at 13h00 until the day of his demise on the 29th 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 2nd 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 25th 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 24th 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 29th June 2020 at 22h30, and not on the 27th June 2020 as his father firmly believed, nor on the 28th 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 28th June 2020, and the other clinical team equally declared that he died on the 29th 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 29th June 2020 at 22h30.
- Lethole, demised on the 29th 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 30th 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 23rd 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 23rd 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 24th 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 23rd June 2020 at 12h36 until Friday, the 26th 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 23rd 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 27th 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 28th June 2020 at 17h00 by Dr. Molehe until the 30th 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 23rd, 24th, 25th, 28th, 29th and 30th 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 24th and 25th 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 28th 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 23rd, 24th, 25th, 28th, 29th, and 30th 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 23rd June 2020 for A & E Isolation area.
- Sylvia Tshabalala for indicating that she ordered and provided food for Mr. Lethole on the 23rd 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
27th January 2021
Enquiries: Mr Ricardo Mahlakanya – 079 769 7955 or Mr Medupe Simasiku – 066 300 0111