The Health Ombud reveals patient safety lapses, citing procedural errors, poor training, and inadequate infrastructure that contributed to the death of a psychiatric patient.
Image: GCIS
Gauteng Premier Panyaza Lesufi has apologised to the family of a psychiatric patient who died at the Dr George Mukhari Academic Hospital in 2024.
This comes as the Health Ombud, Professor Taole Mokoena, during a media briefing on Monday, pointed out a series of irregularities that led to the death of a psychiatric patient, 35-year-old Lerato Mohlamme, who succumbed to severe burns at the hospital in 2024.
Mohlamme died in a fire at the hospital, while 17 other patients were evacuated from the ward.
These failures included clinical safety failures, non-compliance with legal requirements, excessive use of mechanical restraints, and withholding of medication and food, which are some of the findings made by the Health Ombud on the circumstances that led to Mohlamme's death.
Mokoena said serious procedural, clinical, and ethical failures were identified in the care of Mohlamme, adding that the patient’s admission process did not follow the prescribed requirements.
"The patient was not properly searched before she was committed to the seclusion room. The required safety procedures were not followed during her seclusion process. The seclusion room was poorly located and far from the nurses’ rooms and lacked adequate monitoring systems or devices," he stated.
The Health Ombudsman has released two reports into deaths at George Mukhari Academic Hospital and a Netcare Femina Hospital.
Image: Picture: Oupa Mokoena/African News Agency(ANA)
Furthermore, Mokoena indicated that the patient's medical treatment was, at one stage, withheld from her as a form of punishment, adding that even though the patient had alluded to sexual assault, this was not taken into consideration by the hospital staff.
“She gave a history of alleged sexual assault, but the hospital did not report this incident to the police as required by law. Her medication was deliberately withheld as a form of punishment. The patient was denied food while in seclusion, and the required safety procedures were not followed during this process. Two doctors should have independently examined the patient and committed her to psychiatric in-hospital treatment. Thus, this lapse rendered the admission invalid," he stated.
Mokeoena also accused the hospital of negligence and failing to observe fire safety protocols, which complicated matters after the fire broke out in the seclusion room, in which the patient was committed.
"Safety fire concerns were raised by the unit, but they were dismissed by the staff. The patient was not thoroughly searched. The patient had a fire lighter that started the fire. There were critical delays in accessing the room when the fire broke out. The fire exits were locked, and the keys were misplaced. Disaster systems were inadequate, and mattresses were not flame-resistant, thus allowing fire to ignite and spread. The postmortem records revealed that she was alive when the fire broke out," he added.
Responding to the George Mukhari probe, Lesufi apologised to Mohlamme's family, saying the province has already begun the process of rectifying and attending to some of the challenges that contributed to the death.
"We come here deeply hurt and disappointed with the outcome that has been released by the office of the Health Ombudsman. There are a lot of things that still need to be improved in our health system. However, since the draft report, we have moved with speed to rectify what has transpired," he stated.
Lesufi further stated that the provincial government will continue to improve its health systems, stating:" We want to put aside excuses and concentrate on the task at hand. We regret and take full responsibility for the failures pointed out by the Ombud, especially the rights of mental care patients, the punitive practices, inadequate infrastructure, and inadequate staff training," he added.