Health ombud probe finds patients ‘froze to death’ in Northern Cape Mental Health Hospital

Two mental healthcare patients at the Northern Cape Mental Health Hospital (NCMHH) died from significant exposure to extremely cold winter conditions and substandard care at the facility between July and August 2024, according to the health ombud’s investigative report on the deaths.

Another two patients at the hospital suffered health complications resulting from failing infrastructure that was “not attended to in a manner consistent with the… severity of their health condition”.

“During the time when these patients were being being treated there, the Northern Cape Mental Health Hospital was experiencing a lot of trouble with electricity supply as a result of electricity cable theft and vandalism of the electricity substation that supplies the hospital, together with the adjacent properties,” said Professor Taole Mokoena, health ombud, at the release of the investigative report on Wednesday, 30 July.

“We found that during this time when there was no electricity, patients were freezing to death, literally.”

There had been problems with the electricity supply at the mental health facility since October 2022. The hospital was relying for power on a generator that was “inadequate” for its needs, necessitating “power distribution rationing” for certain hours daily to prevent the generator from overloading, according to the investigative report.

The health ombud’s investigation found that three of the patients received substandard care at Robert Mangaliso Sobukwe Hospital (RMSH) in Kimberley, after being referred there from the Northern Cape Mental Health Hospital.

Needless loss of life

Tshepo Mdimbaza, one of the patients, died at the Northern Cape Mental Health Hospital on 3 August 2024. He was discovered unresponsive with cold skin due to “extremely cold conditions in the ward”. His resuscitation was delayed as the required equipment was not functional. The postmortem report revealed that he died due to “exposure to the elements” at the facility.

Another mental health patient, Cyprian Mohoto, died on 16 July 2024 after being transported to Robert Mangaliso Sobukwe Hospital with a suspected abdominal or bowel obstruction that turned out to be multi-lobar pneumonia. The investigation found “gross mismanagement” of Mohoto in the emergency centre and the surgical recovery unit at RMSH.

“A medical officer… reviewed Mr Mohoto and discharged him back to NCMHH on Lactulose without treating the lobar pneumonia with intravenous antibiotics or referring him to the Internal Medicine Department for further management,” stated the investigative report.

“Mr Mohoto spent three days in a Surgical Recovery Unit waiting to be transported back to NCMHH without being reviewed by doctors from the General Surgery Department… His condition was deteriorating, and no appropriate action was taken.

“According to the senior clinical manager and the head of surgery of RMSH, if Mr Mohoto’s lobar pneumonia had been actively managed when he presented on 13 July 2024, his death could have been avoided.”

Two other patients, Petrus de Bruin and John Louw, were transported from the Northern Cape Mental Health Hospital to Robert Mangaliso Sobukwe Hospital for treatment in July 2024, and were later discharged back to the mental health facility.

“The general care provided at NCMHH and RMSH to all patients was substandard, and patients were not attended to in a manner consistent with the nature and severity of their health condition,” stated the report.

‘Multi-system organ failure’

The health ombud’s investigation was conducted jointly with the members of the South African Human Rights Commission in the Northern Cape, after Minister of Health Dr Aaron Motsoaledi lodged a complaint against the Northern Cape Mental Health Hospital in October 2024.

Among the findings of the health ombud was that the lack of electricity at the mental health facility meant nurses were forced to work in the dark, using their cellphone torches for light. The electromagnetic locks at the hospital were non-functional, resulting in doors being propped open using heavy objects.

“Patients were washing/bathing with cold water; the blankets used were thin, of poor quality, and insufficient for the number of patients. Patients also did not have shoes, proper clothing or pyjamas to keep warm. The wards were extremely cold even during the day, and patients would sit out in the sun to stay warm. The exposure to extreme cold resulted in deaths from hypothermia or lobar pneumonia in some patients,” stated the investigative report.

The Northern Cape Mental Health Hospital lacked emergency resuscitation equipment and relevant medications, said Mokoena. Acute staff shortages meant the facility was working at “53% of its commissioned capacity” and operated some shifts without professional nurses.

“Without electricity, the telephone system was not working, and the hospital did not have effective communication means, such that the staff had to use their own mobile phones to effect official communication. The mental health hospital has a blockage of the sewage system, leaking roofs and sagging ceilings and walls, and there’s also evidence of original poor workmanship during the construction of the then new hospital,” said Mokoena.

Neither the mental health hospital nor the Robert Mangaliso Sobukwe Hospital had written protocols and standard operating procedures, or guidelines on the management of patients for doctors and medical staff.

“Both hospitals lack professional leadership, and the management was inefficient and ineffective. This, in our view, stems from the fluidity and the instability of senior management at the provincial health department level, whereby nearly all senior managers or management posts are filled by acting personnel. And this has been going on for some time in the province,” said Mokoena.

On receiving the health ombud’s report, Motsoaledi said, “I was a physician in practice and if I was to make a diagnosis of these two hospitals, I’d diagnose them as having multi-system organ failure.”

Chronic system failure

The health ombud made several recommendations following the findings of the investigation, including:

• Urgent recruitment and retainment of healthcare providers for NCMHH and RMSH;
• The identification of skills shortages and gaps at the facilities, with a plan to address these;
• The appointment of non-South Africans to fill in vacancies where no South African applicants are available;
• The development of comprehensive Standard Operating Procedures, protocols and guidelines to guide healthcare personnel in providing healthcare services; and
• The appointment of a task team by the head of the health department in the Northern Cape to monitor the implementation of the health ombud’s recommendations.

The health ombud has given Northern Cape MEC for Health Maruping Lekwene and head of the health department Mxolisi Mlatha nine months to provide a plan, including strategies and timelines, for addressing shortcomings at the health facilities.

The health ombud recommended that disciplinary measures be taken against the assistant director of the accident and emergency department at Robert Mangaliso Sobukwe Hospital, for his unilateral decision to stop the “matron’s report” policy that served as a reporting system between shifts.

It also recommended disciplinary action against the CEO of the Northern Cape Mental Health Hospital for a failure to advocate for patients. The report said the CEO failed to hold a service provider accountable for the “poor workmanship” of patients’ pyjamas.

“A forensic investigation should be initiated by the National Department of Health on the procurement processes for the NCMHH relating to buying linen, blankets and pyjamas, buying golf carts, specialised beds and furniture, [and] the delay in securing service providers for the repair of damage to the electricity infrastructure,” said the health ombud’s report.

The Northern Cape Department of Health acknowledged receipt of the health ombud’s investigative report, adding that it took the findings “very seriously” and was “committed to ensuring the highest standards of patient care and safety” across all its healthcare facilities.

“The department recognises the critical importance of mental health services and the vulnerability of psychiatric patients. We are dedicated to implementing necessary improvements to prevent similar incidents from occurring in future,” said the department.

Read more: Behind the scenes at Kimberley’s shiny new, half-empty mental health hospital

It’s not the first time the poor condition of health facilities in the Northern Cape have been in the public eye. In 2019, Spotlight ran a series of articles on the “virtual collapse” of health services in large parts of the province, caused in no small part by severe shortages of qualified doctors, specialists and nurses.

The Northern Cape Mental Health Hospital itself has a tainted history. While its construction was originally budgeted at R290-million, costs ballooned to R2-billion over 13 years, according to a Spotlight report. In 2020, it was running at less than half its capacity due to a lack of funding for staff or medical supplies.

A Hawks investigation was conducted into allegations of corruption related to the construction of the hospital. Nine suspects appeared in the