Patient starved and denied medicine as punishment – Gauteng hospitals’ failures exposed
· Citizen
Health Ombud Professor Taole Mokoena on Monday delivered a scathing briefing exposing systemic failures at two Gauteng hospitals.
Staff at Dr George Mukhari Academic Hospital withheld medication and food from a psychiatric patient as punishment, falsified her medical records to hide it, and failed to reach her in time when she burned to death in a locked seclusion room.
Visit h-doctor.club for more information.
At Netcare Femina Hospital, a newborn died after the incorrect administration of adrenaline.
Minister of Health Dr Aaron Motsoaledi said both institutions violated medicine’s most foundational principle, and one tried to cover it up.
Hospitals ignored ‘first do no harm’ principle
When healthcare workers qualify in South Africa, they are taught a principle that predates the Hippocratic oath: primum non nocere, first, do no harm.
“When you interfere, the first thing you must put into mind is that I must not do harm to this particular patient. That’s the principle which is taught around the whole world in every medical school and every nursing college. But in this case, it means that principle was thrown out of the window,” said Motsoaledi.
He was speaking about two institutions, one public, one private, that the ombud found had caused harm to patients in their care.
At Dr George Mukhari Academic Hospital, psychiatric patient Ms L. Mohlamme, 35, was punished by staff who withheld her medication and denied her food while she was held in seclusion.
She later died in a fire in that seclusion room.
ALSO READ: Health dept promises to do better after woman hangs herself at George Mukhari Hospital
Meanwhile, at Netcare Femina Hospital, baby Moatlegi Masoka died after adrenaline was administered intravenously instead of by nebulisation.
Records falsified to hide punishment
What makes the incident at George Mukhari Hospital worse is that staff falsified the medical records, claiming the medicine had been administered.
“Prescribed medicines were deliberately withheld as a form of punishment. However, the medical records were falsified to indicate that the treatment was administered,” Mokoena told the briefing.
The same punitive logic extended to food. Mohlamme was denied meals while held in seclusion, not because of any clinical reason, but as punishment.
Motsoaledi was direct about what this represents.
“Withholding food from somebody has nothing to do with infrastructure. It’s got nothing to do with a lack of training. It’s just outright inhumane,” he said.
“Punishing somebody by withholding medicine is also a cardinal sin. What problem are you resolving by withholding medicine from somebody who came there to receive medicine?”
The investigation further found that Mohlamme’s admission was legally invalid.
It was revealed that her disclosed history of alleged sexual assault was never reported to police as required, mechanical restraints were applied beyond policy limits, and when another patient raised fire safety concerns, nursing staff dismissed them.
Patient with lighter, locked doors and no one to help
Mohlamme was placed in a seclusion room far from the nurses’ station with inadequate monitoring.
Mokoena revealed that she had not been thoroughly searched. “The patient had a cigarette lighter on her person, which she most probably used to start the fire,” said Mokoena.
When the fire broke out, emergency exits were locked, with the keys misplaced or hidden. Non-fire-resistant mattresses allowed the blaze to spread rapidly.
“The post-mortem demonstrated that she was alive when the fire broke out,” Mokoena confirmed, noting evidence of upper respiratory burn injuries and elevated blood carbon monoxide levels.
The ombud found that disaster preparedness systems were inadequate and that the unit lacked the most basic safety infrastructure.
“The psychiatric unit is currently not fit for purpose,” Mokoena said, adding it faces licence revocation and must be fully redesigned.
Netcare Femina’s different failure, yet same broken principle
The death of baby Masoka was not deliberate, but the patient was still harmed when they should have been healed.
Investigators found adrenaline was given intravenously instead of by nebulisation due to an incorrect prescription and communication breakdown.
Mokoena revealed that there was “poor communication between and among different health professionals”.
Medication protocols were outdated and shift handovers were inadequate.
“The staff swapped passwords among themselves, which means they could enter entries under somebody else’s name, and therefore it was difficult to trace who actually did whatever was inconsistent with practice,” Mokoena added.
He said the hospital also failed to refer the death for a legally required forensic post-mortem.
ALSO READ: ‘Please cut off my hand!’: Patient blames hospital neglect for eight months of pain
Accountability to follow, but families want answers now
Both the Health Professions Council of South Africa and the South African Nursing Council have been asked to initiate professional conduct inquiries against implicated staff from both institutions.
Netcare Femina has been told to overhaul its medication verification, update protocols, ban password sharing and undertake mediation with the Masoka family.
Gauteng Premier Panyaza Lesufi said the province had already acted since receiving the draft report.
He said the province increased psychiatrists from three to eight, deploying additional nurses and security, installing CCTV, and obtaining fire compliance certification in February.
“We deeply regret and take full responsibility for the failures identified by the Office of the Ombud,” he said.
Motsoaledi confirmed that the health professionals may apply for a review, but this will not pause accountability processes.
“The fact that they were found guilty doesn’t mean we’ll stop doing what we have to do.”
The Health Ombud committed to monitoring implementation of all recommendations through the Office of Health Standards Compliance.
READ NEXT: Limpopo family sues health MEC over psychiatric patient’s death