The judicial inquest to determine legal grounds for prosecutions of those linked to the Life Esidimeni tragedy wrapped up witness testimonies at the end of May.

It’s one step forward towards the possibility of criminal prosecutions, which has largely been seen as the missing piece needed for justice for victims’ families since the horror scandal made headlines in 2016. 

The outcome of this inquest could open the door for criminal charges to be brought against NGO owners and managers, senior department of health officials and the political heads in Gauteng who were responsible for pushing ahead with a flawed patient transfer project or whose lack of care and incompetence led to the deaths of a known 144 mental health patients. 

Read more in Daily Maverick: Life Esidimeni — seven years of indignity and injustice

The transfer of around 1,500 mental health patients in Gauteng took place in late 2015 from Life Esidimeni facilities to27 NGOs. The Gauteng Department of Health (GDoH) had a contract with Life Esidimeni for nearly 30 years but scrapped the contract with the private service provider ostensibly as a cost-cutting measure. It then embarked on its Mental Health Marathon Project to transfer the patients.

But many of the NGOs earmarked to receive patients proved to be unfit to do the job as has been established in other inquests and official reports since 2016. The NGOs were unlicensed, lacked skilled personnel, equipment, resources, and acceptable infrastructure to care for mental health patients with severe conditions who were in need of specialised care.

Read more in Daily Maverick: Looking back on Life Esidimeni – ‘Mental health still comes last in healthcare’

Professor Lesley Robertson is an adjunct professor in the Department of Psychiatry at the University of Witwatersrand and head of the community psychiatry clinical unit at Sedibeng District Health Service in Gauteng.
(Photo: Supplied / Spotlight)

The final witness in the May inquest was Professor Lesley Robertson. Robertson is a community psychiatrist based in the Sedibeng district.  During her two days of testimony and cross-examination, she faced questions from a slew of legal teams representing the numerous parties in the matter. 

Robertson drew a timeline of the mental health landscape in the past 20-odd years of deepening crises leading to shrinking services by the early 2000s then the low point of the Life Esidimeni tragedy, exposed in 2016. 

She said that the programme in the mid-1990s to deinstitutionalise mental health patients for community-based care was in line with World Health Organization guidelines but was supposed to see a redirection of budgets. She said no additional resources were made available making it harder for people in need to get help and to be managed on treatment in the community.

Robertson also unpacked some of the findings from analyses of costs for patient care; the mismatches between plans and strategies by GDoH and the on-the-ground realities; and an analysis of excess deaths of mental health patients in the province in the first six months of the GDoH’s Life Esidimeni transfer project.

Protests during the testimony of former Gauteng Health MEC Qedani Mahlangu at the Life Esidimeni arbitration hearings in Johannesburg on 22 January 2018. (Photo: Gallo Images / Sowetan / Thulani Mbele)

Family members become emotional as Daniel Buda, an administration officer at Mamelodi Hospital Mortuary testifies during the Life Esidimeni arbitration on November 30, 2017 in Johannesburg, South Africa. (Photo: Gallo Images / The Times / Alaister Russell)

Relatives of Life Esidimeni patients who died attend the media briefing by the Health Ombudsman to announce the final report in Pretoria on 1 February 2017. (Photo by Gallo Images / Beeld / Felix Dlangamandla)

Concerns ignored by officials

Robertson’s testimony focused on the repeated efforts she made to raise concerns and cautions about the patient transfer plans with senior officials. These included Dr Barney Selebano, who was at the time head of department in the province, former director of mental health in the province Dr Makgabo Manamela and the MEC of health at the time Qedani Mahlangu. The aim was to get the senior officials to pause and consult with mental health experts and to ensure the NGOs were fit for purpose, she said. 

“Things were happening rapidly and we were just trying to get an in so that we could have further discussions,” said Robertson. Their urging was for GDoH to slow down and to re-strategise. Robertson said these attempts for engagement were done at various meetings and engagements in 2015 where the officials were present and also through written correspondence. She made these attempts in her capacity as a psychiatrist in the Sedibeng district and also through the South African Society of Psychiatrists (Sasop), of which is a member.  

From as early as 2015 civil society groups including Sasop, Section 27, the South African Depression and Anxiety Group and the South African Federation for Mental Health were pushing for GDoH to reconsider plans to relocate patients from Life Esidimeni.

Robertson said she received no response to her letters that resulted in action from any of the officials. The transfer of patients did go ahead by October 2015. In August 2016 Christine Nxumalo found out her sister, Virginia Machpelah who was one of the Life Esidimeni patients, had died. When she heard that there were other deaths she sounded the alarm. 

Read more in Daily Maverick: Life Esidimeni: Mental health is still the ‘stepchild’ of health and remains underfunded, underresourced

Robertson said there was “an underestimation of the severity of the conditions of the people who were reliant on Life Esidimeni care who were not suitable for community-based care.”

The NGOs, including those in her district, were in no way ready or suitable to receive the patients. She stressed that the patients were people who needed stability, routine, access to emergency health care if the need arose and specialised mental health care. 

She also described in her testimony how in April 2015 she unwittingly signed off a clinical checklist for three NGOs. Robertson said this happened on a walkabout to the Anane care facility. Present on the walkabout were her hospital department head, other colleagues as well as Selebano and Manamela. She said it was Selebano who asked her to sign the checklist. 

“I was taken aback and caught off guard but I didn’t want to push back in that moment. I was naïve and afterwards, I felt conned and foolish when I realised what I had put my signature to,” she said.

Robertson said it was two weeks later at a project management meeting she attended that she realised that signing the clinical checklist was tantamount to vetting the three NGOs. She said her intention to set the record straight in this regard was another key motivator for the letters she wrote to her superiors.

She added: “Many of the caregivers in these NGOs were lay people who had training in home-based care for HIV patients or caring for the elderly, which is very different from caring for someone who has a severe mental health conditions.”  

Family member Maria Phehla testifying at the Life Esidimeni Hearings.
(Photo: Joyrene Kramer)

A woman is comforted during the Life Esidimeni arbitration hearing in Johannesburg on 16 October 2017. (Photo: Gallo Images/Sowetan/Alon Skuy)

Former Gauteng health MEC Qedani Mahlangu testifies during the Life Esidimeni arbitration hearings in Johannesburg on 24 January 2018. (Photo: Gallo Images / Sowetan / Alon Skuy)

Inadequate and poor conditions

Robertson recounted in her testimony the likes of an NGO approved to house 33 patients in a small house. She said such overcrowding for severely ill patients with impaired impulse control and reduced executive functioning makes the environment toxic and a trigger for aggression.  

She also described how there was an absence of a medical care plan for patients or staffing standards at these facilities. It meant that many of the NGOs simply had to make up their own decisions about how to take care of patients. There was also considerable staff burnout, she said.

“With no plan on who was getting what medicines the NGOs had to go through the medicines they were given for each patient and work out the morbidities of the patient by themselves,” she said. She added that this put patients at risk of relapse, seizures and to face other health emergencies as a result of disruptions to their treatment regimes for conditions like HIV and diabetes. She said there was potential to cause longer-term complications. 

“If there wasn’t a lack of skills and experience; a lack of preparedness, a lack of financial security; a lack or rehabilitative support and a lack of access to appropriate health care at these NGOs then we might not have had so many deaths,” she said.

Robertson has worked on analysing the post-mortem reports of 36 of the Life Esidimeni victims and also on excess death data in the first six months after the transfers took place. 

Read her research and analysis here. 

Robertson said they established that there was 70% excess deaths in the first six months of the transfer project. She also testified about the high vulnerability of mental health patients especially in the first two to six months of trying to adjust to a new environment and new routines.   

She was questioned on the number of deaths at Life Esidimeni in the period before the transfer to the NGOs. Robertson said she and her colleagues who were part of the Health Ombud’s 2016 expert panel investigating the tragedy, did not undertake a study of these deaths for comparison but she added that had there been high mortality figures at Life Esidimeni these would have been flagged and would have led to a public outcry. She also said that the Department of Health conducted annual audits of Life Esidimeni and no issue of high mortality numbers was ever noted. 

Robertson stressed on the stand that the transfer of patients in the manner it was carried out by GDoH was irrational, inhumane, unjustifiable and irresponsible. 

The inquest proceedings resume on 28 July to hear heads of arguments from the evidence leaders. DM