“He was a nice, good boy,” said Elizabeth Phangela. Her younger brother Christopher Makoba went to school until Grade 12, but in Grade 9 he started to show symptoms of epilepsy. He went through a number of institutions and ended up at Life Esidimeni’s Waverley facility in Germiston. “As time goes by, he knew how in the morning he must wash himself, eat breakfast, then take his medication.” His case was severe. He didn’t know much else, but he was happy there.

“I feel like crying now,” said Phangela on Tuesday. Makoba died shortly after being moved from Life Esidimeni to an NGO called Precious Angels in Atteridgeville. The Gauteng department of health had, against all advice, moved over 1,000 patients into community facilities, neither ready nor equipped to take patients with chronic psychiatric illnesses. Phangela has been demanding answers and she finally found some on Wednesday.

In his much-anticipated report, Health Ombudsman Professor Malegapuru Makgoba on Wednesday added shocking details to what we already knew, with scathing implications for the Gauteng government. The provincial department wasn’t prepared to move 1,371 patients from Life Esidimeni to NGOs and hospitals. The department’s leaders ignored the warnings, transferred society’s most vulnerable as though they were cattle, dumped them in facilities neither equipped or prepared to handle the patients, and, essentially, left them to die.

Makgoba’s investigation has already led to the resignation of Gauteng Health MEC Qedani Mahlangu. The provincial government has promised to rectify the situation. But for the loved ones of those who died, it’s only the beginning of holding decision-makers accountable. Makgoba’s report had a chilling sub-heading to sum up the catastrophe: “No guns: 94+ deaths and still counting”.

Phangela and her brother’s story is tragically similar to those told by family members of the 94 patients who died after being moved from Life Esidimeni mid-2016. Shockingly, the department was only able to identify 48 deaths, leaving Makgoba to reveal the extent of what’s already being called a massacre.

Phangela had been involved in the families’ failed efforts to fight the move from Life Esidimeni. She was worried her brother would not receive quality care at an NGO after it was clear the department had failed to prepare to relocate patients. When Christopher Makoba was moved, neither Phangela nor any of her family members were told. Her 45-year-old brother was taken to Precious Angels and, by chance, her family found out. He died before they could visit him.

On a Saturday, an employee from the NGO called to tell Phangela her brother had passed. The caller asked when the family would take the body and if they could negotiate paying the fee for a funeral home. The body wasn’t at a funeral home. Phangela collected it outside of Precious Angels. She said her brother’s body was “tiny, tiny, tiny, dark”. She was notified days after her brother had died and even then, according to the documents, he had died a day before the NGO staff claimed he had. She wanted to know what happened. She tried to visit and inspect the conditions of the NGO but struggled to get access – what she saw she described as “horrible”.

“I want answers as I’m speaking now. I’m emotional because he was just innocent and my mother is an old lady,” she said.

After over a year-and-a-half of obfuscation from the Gauteng health department, on Wednesday family members finally got some answers.

The health ombudsman’s report began by dismissing the MEC’s statements on how many deaths had occurred. Makgoba found there were “94+” deaths between March and December 2016, more than double what Mahlangu had publicly acknowledged. In fact, the Gauteng directorate of mental mealth (GDMH) could only tell the ombudsman it identified 48 deaths, which Makgoba said was “symptomatic and pathognomonic of an institution with poor data integrity”.

“The findings of the investigation indicated that the decision taken by the GDoH [Gauteng Department of health] to terminate and relocate/transfer patients from LE [Life Esidimeni] centres precipitously was fundamentally flawed, irrational, unwise and inhumane,” said Makgoba’s report, which was prepared with the help of a panel of experts.

The department had no plan to improve community health services but only rapidly develop NGOs and transfer patients. Further, the ombudsman said the MEC’s justification for moving the Life Esidimeni patients, which was that government was paying too much to the private company, was unjustified. Government spends more on patients at its own equivalent facilities than it paid to Esidimeni. The amount it planned to spend on patients sent to NGOs was less than both; Makgoba said it was never feasible.

The ombudsman blamed three officials: Mahlangu, head of department Dr Tiego Ephraim Selebano and director Dr Makgabo Manamela. They would not listen, to anyone, and ignored the warnings. “This overwhelming revelation of frustration and disempowerment came across all the sectors of the department during oral evidence below the director’s level. This finding is most troubling and a damning indictment on the leadership of the GDMH. Staff members could not exercise their fiduciary responsibility out of ‘fear and disempowerment’,” said the report on the department’s employees who wanted to speak out. The department’s leaders wouldn’t listen to its own staff, let alone outsiders.

Makgoba said the planning for the move was poor or non-existent and carried out in a way that put patients’ care in danger, with no medical assessments done before the patient transfers, vulnerable patients being transferred between NGOs, and relatives failing to be informed of where their loved ones were going. Conditions at the NGOs were often dire. Makgoba said Gauteng’s most vulnerable citizens were moved to facilities without proper licences, that had been set up as business opportunities. Many of the NGOs “were found for professional, legal or infrastructural reasons to be so substandard that they should not be in operation”.

The NGOs didn’t have the staff, infrastructure or finances to deal with severe psychiatric cases. Overcrowding was common. Makgoba’s report called the treatment “bordering on the criminal”.

“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.”

The report also included a statistical comparison between the mortality rate at Life Esidimeni and the NGOs patients were moved to. It found that around double the amount of patients died at the NGOs than had died in the past at Life Esidimeni, mostly at those that provided the worst care. Makgoba drew a clear link between the decision to move patients out of Life Esidimeni, the NGOs they went to, and the increased number of deaths. In a sample of 38 people who died after being moved, Makgoba said pneumonia, followed by uncontrolled seizures, was the most common cause of death. “The former raises concern about the living conditions and infection control at the NGOs, while the latter raises concern that these patients did not receive medication for their epilepsy.”

Gauteng Premier David Makhura announced on Wednesday that MEC Qedani Mahlangu had resigned. Mahlangu claimed the ombudsman did not find her culpable, which is far from the truth. Makhura announced that former deputy minister of health Gwen Ramokgopa would take over as MEC. The premier said he had been deceived. He promised action against those implicated. Health Minister Aaron Motsoaledi said he was beyond embarrassed and “very angry”.

For the families of the patients, Wednesday brought a moment of vindication after they have attempted to engage with the department, went to court, and protested against the rushed relocation of their loved ones. But Makgoba’s report brought only a semblance of the justice they are seeking.

Andrew Pieterson, a leader of the Life Esidimeni relatives committee, said the ombudsman’s report was “very hard-hitting” and thorough. “The general feeling was, it’s fantastic,” he said, also happy with the premier’s engagement on the day. Another member of the committee representing the families, Ivan Lukhele, said while the report and engagement on Wednesday was positive, it was too little, too late. “Unfortunately with our government it seems people have to die, have to protest, before anything’s done.”

The families will meet with their legal representatives next week to decide how they can ensure the responsible are held to account and whether or how they want to proceed on issues of compensation. Each family member Daily Maverick spoke to wanted to ensure Mahlangu does not avoid further consequences. “I hope and pray that the premier will still hold her accountable for what she did,” said Nomvula Nonjabe.

President of the SA Society of Psychiatrists, Dr Mvuyiso Talatala, said it felt as if efforts to warn against the move were vindicated on Wednesday. His society raised concerns repeatedly but the provincial department failed to listen or engage, even with a special interest group of professionals. He noted the ombudsman’s findings that the move from Life Esidimeni was not cost-effective and questioned why MEC Mahlangu’s past report tallying the costs was never released. “The journey we’ve travelled, the government has not been honest with us,” said Talatala. He was hopeful after the ombudsman’s report, but raised doubts on whether Makhura’s intervention will improve the situation.

Section27, which has worked closely with patients’ families and repeatedly warned of the consequences of the ill-prepared move out of Life Esidimeni, said, “The MEC and her administration knew of the risks before embarking on this project and watched as the tragedy unfolded. They did nothing to stop it. They should be held to account to the fullest extent of the law.” It called for an extensive review of Gauteng’s mental health system.

Of the 94 deaths, at least some of them can be linked to the failures of government, drawing comparisons with the Marikana Massacre, which inevitably politicised the issue. The DA’s Jack Bloom, who has continually followed the story and first uncovered the multiple deaths at the NGOs when he asked the MEC a question in the Gauteng Legislature last year, on Wednesday said Mahlangu had lied to the legislative body. Makhura’s image was tarnished and it was a crisis for those in the ANC who had failed to act earlier on the issue, he said. He commended the ombudsman, the “public protector of health”, but noted that his recommendations are not binding.

Gauteng ANC Provincial Secretary Hope Papo said Makhura should implement the report “without fear or favour” and Mahlangu’s decision to step down “demonstrates political accountability and sensitivity to the affected families”.  The ANC Youth League in the province, however, said the Life Esidimeni saga was a “true reflection of the careless, negligent and poor leadership of not only the Gauteng provincial department of health, led by the disgraceful MEC Qedani Mahlangu, but the entire leadership of the Gauteng provincial government”. The provincial group said it will lay murder charges against Mahlangu on Thursday and called on Makhura to resign within 14 working days.

In his recommendations, Makgoba said the project of relocating Life Esidimeni patients must be scrapped and they should return to suitable institutions. He said disciplinary proceedings must be instituted against top health department officials and he supported SAPS criminal investigations into the deaths. He made wide-ranging recommendations to reform the province’s treatment of mentally disabled patients to ensure such a situation never occurs again.

“You can see our loved ones were just brutally slaughtered,” said Boitumelo Nangena.

On Wedneday, the impact of the ombudsman’s report was still sinking in. Nangema’s 66-year-old mother, Rehab Nangena, who suffered from vascular dementia and died at Takalani Home, said it felt like Makgoba had detailed how the families have been treated. She wasn’t informed of her mother’s move from Life Esidimeni, nor was she told when Takalani took her mother to Jabulani Hospital, where Rehab died.

Boitumelo’s brother went to Takalani to check on his mother’s care while she was there and found it overcrowded, with patients hungry and cold. “Especially today has just released more hurt and anger than anything else,” said Boitumelo Wednesday.

The relatives of the dead don’t talk of patients; they remember family members. Like many others, Elizabeth Phangela still wants justice for her brother Christopher. He was a “nice, good boy” with a smile, who died at the notorious Precious Angels NGO. “Gold, silver, platinum won’t bring my brother back,” she said. Yet there is hope in Makgoba’s report. “At least the battle is on. The fight has began. I see the light now.” DM

Photo by Simon and His Camera via Flickr