Health Ombudsman releases final report on deaths of Psychiatric patients in Gauteng

The Health Ombudsman today released its final report on its inquiry into the recent deaths of Psychiatric patients in Gauteng province. Below is the Executive summary of the Ombudsman’s report


The full report is available here:

Executive Summary from the Report:

  1. 1 The Ombud established that:
  • A total of ninety-one (94+) and not thirty-six (36) mentally ill patients (as initially and commonly reported publicly in the media) died between the 23rd March 2016 and 19th December 2016 in Gauteng Province.
  • All the 27 NGOs to which patients were transferred operated under invalid licenses.
  • All patients who died in these NGOs died under unlawful circumstances.
  • On the date, 13th September 2016, when the MEC made the public announcement of 36 deaths, 77 patients had already died.
  • Between May and September 2016, 77 MCHUs died.
  • The OHSC inspectors and Ombud identified and confirmed 73 deaths, while the Ministerial Advisory Committee on Mental Health identified and confirmed 66 deaths during the course of their investigations.
  • At the time of writing the Report, 94 patients had died in 16 out of 27 Non-Governmental Organisations (NGOs) and 3 hospitals.
  • 75 (79.78%) patients died from 5 NGO complexes (Precious Angels 20, CCRC/Siyabadinga/Anchor 25, Mosego/Takalani 15, Tshepong 10 and Hephzibah 5).
  • There were 11 NGOs with no deaths, 8 NGOs with average deaths and 8 NGOs with ‘higher or excess’ death.
  • Only 4 MCHUs died in hospitals compared to 77 MCHUs deaths at NGOs; in absolute numbers for every 1 death at the hospitals there were 19 deaths at the NGOs but correcting for the total base population the ratio is 1:7. This ratio is very high. This finding is consistent with the interpretation that the problem was in the NGOs.
  • 1% Deaths occurred at the NGOs from those MCHUs directly transferred from Life Healthcare Esidimeni (LE).
  • 81 deaths were LE-associated while 13 deaths were not.
  • The Gauteng Directorate of Mental Health (GDMH) could only identify 48 deaths. These differing numbers are symptomatic and pathognomonic of an institution with poor data integrity (lack of accuracy and lack of consistency) and the lack of reliable and quality information systems found during the investigation.
  1. 2. Available evidence by the Expert Panel and the Ombud showed that a ‘high-level decision’ to terminate the LE contract precipitously was taken, followed by a ‘programme of action’ with disastrous outcomes/ consequences including the deaths of Assisted MCHUs. Evidence identified three key players in the project: MEC Qedani Dorothy Mahlangu, Head of Department (HoD) Dr. Tiego Ephraim Selebano and Director Dr. Makgabo Manamela. Their fingerprints are ‘peppered’ throughout the project.
  • The decision was unwise and flawed, with inadequate planning and a ‘chaotic’ and ‘rushed or hurried’ implementation process.
  • The decision to terminate the contract precipitously contradicted the National Mental Health Policy Framework and Strategy, the cost rationale could not be justified above the rights of the mentally ill patients to dignity and the state’s constitutional obligation to accessible health care. This precipitous approach was not supported by available research experience or legislative prescripts.
  • The project has brought ‘pain and anguish’ to many families, it has also brought national and international disrepute and embarrassment to South Africa, particularly its Health System Annexure 1a-b (UN Expert Report).
  • Several factors in the ‘programme of action’ were identified independently by Expert Panel, OHSC Inspectors, Ombud and MAC that contributed and precipitated to the accelerated deaths of mentally ill patients at NGOs. The transfer process particularly, was often described as ‘chaotic or a total shamble’.
  1. 3 The Gauteng Mental Health Marathon Project (GMMP) , as it became known was: done in a ‘hurry/ rush’; with ‘chaotic’ execution; in an environment with no developed, no tradition, no culture of primary mental health care community-based services framework and infrastructure.
  • This 2013-2020 policy framework and strategic plan were selectively interpreted, misrepresented and contravened in this project to drive the overall universally-accepted objective of deinstitutionalisation, the core of the Mental Health Care Act, (MHCA), 2002 (Act No. 17 of 2002).
  • The policy and the strategy are clear. ‘Deinstitutionalisation of patients must be done systematically and with adequate provision made for community services’. Evidence in this report did not find that this was the case in this project.
  • Mentally ill patients were transferred ‘rapidly and in large numbers with a short timeframe’ from the ‘structured and non-stop caring environment’ of LE into an ‘unstructured, unpredictable, sub-standard caring environment’ of the NGOs; this decision was not only negligent and a violation of the rights of the mentally ill patients but also goes totally against the principle of health, i.e. the preservation of life and not the opposite.
  • The transfer project occurred against widespread professional, expert and civil society stakeholders’ warnings and advice; these advice and warnings have sadly come true.
  • Newly-established NGOs were mysteriously and poorly selected, poorly prepared, ‘not ready’, their staff was not trained, not qualified and was unable to distinguish between the highly specialized non-stop professional care requirements of ‘assisted’ Mental Health Care User (MCHU) from LE and a business opportunity; there were often mismatches between MCHU functionality with NGO fitness for purpose.
  • Patients were transferred to far away places from their homes and their communities, at times without the knowledge of the families, often bringing additional financial burden and stress on the family.
  • Some patients were transferred into overcrowded facilities which are more restrictive and contrary to the policy of the deinstitutionalisation.
  • Transferring mentally ill patients to unfamiliar unstructured environments and to too far away, NGOs defeated and rendered the concept and purpose of mental health community services null and void.
  • Some MCHUs ended up in NGOs not originally selected, others were transported to several NGOs; these further exacerbated anxieties and added instability on the mentally ill patience.
  1. 4.The NGOs where the majority of patients died had neither the basic competence and experience, the leadership/managerial capacity nor ‘fitness for purpose’ and were often poorly resourced. The existent unsuitable conditions and competence in some of these NGOs precipitated and are closely linked to the observed ‘higher or excess’ deaths of the mentally ill patients. These NGOS were not only unsuitable to care for the high specialised non-stop needs of the ‘assisted’ MCHUs they received but were also not adequately prepared for the task.
  • This project demonstrated clearly that basic professional care skills for community mental health care, cannot be acquired through seminars or workshops but through professional education, training and qualifications.
  1. 5 Human Rights Violations There is prima facie evidence, that certain officials and certain NGOs and some activities within the Gauteng Marathon Project violated the Constitution and contravened, the National Health Act (NHA), (Act No. 61 of 2003) and the Mental Health Care Act (MHC), (Act No. 17 of 2002). Some executions and implementation of the project have shown a total disregard of the rights of the patients and their families, including but not limited to the Right to Human dignity; Right to life; Right to freedom and security of person; Right to privacy, Right to protection from an environment that is not harmful to their health or well-being, Right to access to quality health care services, sufficient food and water and Right to an administrative action that is lawful, reasonable and procedurally fair. Some patients were transferred directly from ‘sick bays’ to NGOs; others were transferred with co-morbid medical conditions that required highly specialized medical care (‘bedsores and puss oozing out of sores’ or medical conditions such as epilepsy and hypertension) into NGOs where such care was not available, and yet other frail, disabled and incapacitated patients were transported in inappropriate and inhumane modes of transport, some ‘without wheel chairs but tied with bed sheets’ to support them; some NGOs rocked up at LE in open ‘bakkies’ to fetch MCHUs while others chose MCHUs like an ‘auction cattle market’ despite pre-selection by the GDMH staff; some MCHUs were shuttled around several NGOs; during transfer and after deaths several relatives of patients were still not notified or communicated to timeously; some are still looking for relatives; these conducts were most negligent and reckless and showed a total lack of respect for human dignity, care and human life.
  1. 6 A combination of 1.2, 1.3, 1.4, 1.5 above contributed to the different pattern of deaths and to more deaths experienced in some NGOs.
  • The Premier of the Gauteng Province must, in the light of the findings in this Report, consider the suitability of MEC Qedani Dorothy Mahlangu to continue in her current role as MEC for Health.
  • The GMMP must cease to exist.