Health Ombudsman report: Motherwell NU 11 Clinic found negligent in Zenizole Vena case

Health ombud Professor Taole Mokoena. Picture: GCIS / Ntswe Mokoena

Health ombud Professor Taole Mokoena. Picture: GCIS / Ntswe Mokoena

Published Dec 12, 2023


An investigation by the Health Ombudsman has found negligence after a 15-year-old rape victim was turned away from a clinic in the Eastern Cape before she died.

Health ombudsman Professor Taole Mokoena released the findings of the investigation in Pretoria on Tuesday.

Health Minister Dr Joe Phaahla said he wants action taken against those whose “appalling service and grievous neglect” led to the teenager’s death.

Mokoena said the Deputy Director of Public Prosecutions in Gqeberha permitted the report to be released, as it would not compromise the criminal investigation.

His probe into the incident was to find out if Zenizole Vena died as a result of neglect, whether she was denied care at the clinic as alleged, and whether the clinic staff failed to refer her to the next level of care.

The teenager was kidnapped and gang-raped in September 2022 in Motherwell.

She sought assistance at the Motherwell NU 11 Clinic at 7am after the incident on September 21, 2022, but was told by nurses they “do not touch the rape victims to avoid tampering with evidence,” and she was referred to the police.

Without any money for transport, Vena and her friend walked two kilometres to the police station. En route, Vena collapsed, wet her pants, and started having seizures. The driver of a local taxi (also known as ‘jikeleza’) gave them a lift to the Motherwell police station, as Vena could no longer walk or talk.

At the police station at about 8am, the friend alleged that as she sought assistance for Vena, she was told by an officer in the Motherwell Police Station Community Service Centre (MPS CSC) to sit down.

A police sergeant said she went to check on Vena at 9.30am, who had been at the laying on the charge office floor and she was no longer crying. The sergeant realised she had died.

In September 2022, Democratic Alliance (DA) shadow minister of health, Michéle Clarke, requested an investigation be launched into Vena’s death.

Clarke said Vena was failed by both the clinic and the police.

The report further found that Vena had waited an hour and 30 minutes to get assistance at the charge office.

In terms of Section 27(1) of the Constitution of the Republic of South Africa, everyone has the right to access health care services, including reproductive health care; no one may be refused emergency medical treatment.

Interviews were conducted with 13 witnesses between February 28, 2023, and March 27, 2023. The other 10 interviews were conducted by the Ombud and the investigation team from May 15 to 19, 2023. Eight witnesses were re-interviewed from May 15 to 19, 2023, and did not contradict themselves. Statements from three witnesses were also received from the MPS CSC and analysed.

“According to information gathered during the investigation, the two professional nurses believed that the patient had to go to Thuthuzela Centre in Dora Nginza Hospital via the police station; thus, the patient was directed as such. The patient’s social, psychological, and physical state were not considered.

“Despite their belief, the two nurses did not arrange transport to take the escort and victim to MPS CSC or call the police to come to Motherwell NU 11 Clinic to take over the case. One of the nurses indicated she only took the patient’s vital health data, which was written in a personal diary, but not in the approved Patient Administration Record,” the report read.

“According to the District Manager of Nelson Mandela Bay District (NMBDH), Ms Sonia Lupondwana, there was no doctor at Motherwell NU 11 Clinic on the day Vena came.

“This explanation is not accepted because the absence of doctors does not absolve the nurses from providing the necessary care to the patients,” the report stated.

It further read that Emergency Medical Services (EMS) were called at 9.11am, but arrived at 9.38am and declared Vena dead at 9.45am. However, the date of the incident was recorded as September 22, 2022, whereas the incident occurred on September 21, 2022.

The Operational Manager: EMS, Ashwell Botha, described this as a typing error.

“Based on the information gathered, it was confirmed that Ms Vena was denied the provision of care at Motherwell NU 11 Clinic. Dr R Wagner also indicated that the clinical manager, Dr Machi had an apology letter, but the apology letter was never given to the family of Ms Vena,” the ombudsman report found.

Mokoena said Vena’s death certificate indicated that her cause of death was still under investigation and the post-mortem, dated October 6, 2022, could not determine the cause of death as toxicology results were pending.

He said a physical examination of the teenager’s body revealed she had abrasions on her toes and on the back of one thigh. The fact that there were no visible injuries on the genital area does not exclude sexual assault.

“According to Dr LJ Mostert, the toxicology report uncovered a white substance in the stomach that looked like tablets. There were no severe injuries that might have caused the death, and the suspected cause of death could be in keeping with a high level of Trimethoprim drug also known as Co-trimoxazole, in the stomach content, the blood, eye fluids, and bile. These levels were much higher than the normal levels in people taking this medication. It appeared that Vena ingested a lot of Trimethoprim tablets. According to Dr LJ Mostert, ‘the toxicology results, the cause of death will be consistent with Trimethoprim overdosage’,” the report read.

“There was no alcohol or other intoxicant substance in her bloodstream. Based on the evidence obtained, it can be concluded that Ms Vena was not attended to in a manner that is consistent with the nature and severity of her health condition at Motherwell NU 11 Clinic,” Mokoena’s report stated.

It also revealed that while the clinic conducted an internal investigation into the incident, no action was taken against the two nurses.

While a number of challenges faced by the clinic were highlighted, Mokoena also gave a lengthy list of recommendations following his report, which include disciplinary hearings against the nurses and for them to be referred to the South African Nursing Council for an investigation into their sheer misconduct.

Health Minister Dr Joe Phaahla said he and the Eastern Cape Health Department welcomed the report and recommendations made by the ombudsman.

“The Office of the Health Ombud is a statutory body, which means its work and recommendations reflect a bearing on the policy, regulations, and work we do as the health sector in delivering quality healthcare in the country. It is obligatory on us to reflect and consider its findings and recommendations, as it will assist to improve our services.

“I have noted from the Ombud’s report a number of acts of negligence pertaining to how Ms Zenizole Vena was treated. Ms Vena received an appalling service, which is described as the cause of death and could have been avoided if the nursing staff on duty had acted professionally as required by both professional ethics conduct and the employer's workforce guidelines.

“These acts constitute the grievous neglect of duty and responsibilities in this health facility and deserve nothing but the strongest condemnation,” Phaahla said.

He said the provincial health department has already been requested to institute a departmental disciplinary process to ensure those responsible receive appropriate sanctions.

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