By Thapelo Molefe
The Office of the Health Ombud has found that serious negligence, unethical conduct and systemic failures in both public and private healthcare contributed directly to the deaths of a psychiatric patient and a newborn baby.
“These reports concern tragic loss of life,” Health Ombud Professor Taole Mokoena said on Monday, while releasing reports into the deaths.
“There are families who continue to live with grief, seeking answers, accountability, and reassurance that our health system is committed to improvement.”
The first report focuses on the death of 35 year old psychiatric patient Lerato Mohlamme at Dr George Mukhari Academic Hospital, in Ga-Rankuwa, north of Pretoria.
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Mohlamme died on 24 June 2024 after a fire broke out in a seclusion room where she had been placed.
The ombud found that despite being in what was meant to be a “safe” ward, critical safety protocols and monitoring systems failed, resulting in her sustaining fatal burns.
Mokoena said the investigation uncovered “serious procedural, clinical, ethical, and safety failures” and pointed to “systemic violations of the rights of mental health care users.”
According to the report, the patient was unlawfully admitted and subjected to punitive treatment, including the withholding of medication and food, while medical records were falsified to conceal this. Allegations of sexual assault were also not reported to police.
The investigation further found that the patient was not properly searched and had a cigarette lighter, which was believed to have started the fire. The seclusion room lacked proper monitoring, was poorly located and emergency exits were locked, delaying rescue efforts.
A post-mortem confirmed she was alive when the fire started and died from burn injuries and smoke inhalation.
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The ombud said the findings pointed to a “lack of basic care” and systemic safety gaps, with hospital management and the Gauteng Department of Health tasked with implementing urgent corrective measures.
In a separate investigation, the ombud examined the death of a newborn at Netcare Femina Hospital following allegations that incorrect medication had been administered.
“The investigation found that a clinical error occurred when adrenaline was administered intravenously instead of by nebulisation,” Mokoena said.
“This was as a result of an incorrect prescription route and poor communication.”
He said the case revealed clinical mismanagement and failures in pharmaceutical safety protocols within the private facility, alongside broader weaknesses in oversight.
Gauteng Premier Panyaza Lesufi said the provincial government accepted responsibility for the failures at the public hospital and had already begun implementing changes.
“We deeply regret and take full responsibility for the failures that have been identified,” Lesufi said. “We have no intention to disguise our disappointment, but also we have no intention to put excuses forward.”
He said the province had already acted after receiving the draft report.
“We moved with lightning speed to ensure that we rectify what has been established,” he said.
Lesufi added that steps had been taken to improve staffing and safety at the hospital.
“When the incident happened, there were only three specialised psychiatrists. To date, we have increased that from three to eight,” he said.
He said additional nurses and security had been deployed, CCTV cameras installed and fire compliance improved.
“We have now received the certificate of fire compliance,” he said.
Lesufi said the lessons would be applied across the health system.
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“The recommendations here might be about one hospital, but we don’t want the reoccurrence. We are expanding the recommendations to all hospitals,” he said.
Health Minister Aaron Motsoaledi said the findings pointed to both ethical and systemic failures, adding that basic medical principles had been ignored.
“[A] cornerstone of medical ethics has been breached, because when we hire doctors and nurses and other professionals, we don’t pick them from the street,” Motsoaledi said.
“The principle called primum non nocere, meaning first do no harm… in this case, it means that principle was thrown out of the window.”
He also expressed frustration that similar issues persisted despite ongoing interventions.
“It’s quite disappointing that we’re still having these problems, but we’ll keep on training,” he said.
Motsoaledi raised concerns about the historical inequalities in South Africa’s health infrastructure, particularly in training hospitals.
“If you check all the medical schools that were established to train white medical students, you will find that they built a medical school and a hospital,” he said. “Only in 1953, when the first black medical school was established, the process of ignoring to build hospitals started.”
He said this legacy continues to affect institutions like Dr George Mukhari Academic Hospital.
Motsoaledi also stressed that some of the failures identified could not be blamed on infrastructure or training. “Withholding food… withholding medicine… it’s just outright inhuman,” he said.
He added that regulatory bodies would be expected to act.
“We will insist that they do something about it,” he said.
The ombud has recommended disciplinary action against implicated healthcare professionals and referred the cases to the Health Professions Council of South Africa and the South African Nursing Council for further investigation.
“Patient safety must be guarded and ensured at all times,” Mokoena said.