The government has expressed regret over the preventable deaths that occurred at various health-care facilities in Gauteng and stated that measures are already underway to improve services, ensure patient safety, and prevent future fatalities.
On Monday, a high-profile government delegation received a report from the Health Ombud, Professor Taole Mokoena, which concluded that several deaths—including those of a mental health patient and an infant—were avoidable. The Ombud found that a combination of non-adherence to established protocols and inadequate facilities contributed to these deaths.
The following are some of the key findings presented by the Ombud during a media briefing attended by Health Minister Aaron Motsoaledi, Deputy Minister Joe Phaahla, Gauteng Premier Panyaza Lesufi, and Health MEC Nomantu Nkomo-Ralehoko:
The investigation identified serious procedural, clinical, ethical, and safety lapses in the care provided to Ms. Mohlamme:
- Her admission process did not comply with legal requirements, as two medical practitioners failed to independently examine and commit the patient in the prescribed manner, rendering the application technically invalid.
- Mechanical restraint was applied excessively, contrary to national policy guidelines.
- Allegations of sexual assault disclosed by the patient were not properly assessed, documented, or reported to the South African Police Service, representing both clinical and legal procedural failures.
- Prescribed medication was deliberately withheld as punishment, while medical records were falsified to indicate it had been administered.
- The patient was denied food as a form of punishment during seclusion.
“In conclusion, although the two investigations differ in context, they share a common message: patient safety must be protected at all times. It must be embedded within health-care systems, supported by effective leadership, staff training, and accountability at every level of care,” said Mokoena.
“Even one death is one too many, and we deeply regret these tragic losses. Upon receiving the preliminary report from the Ombud, we immediately began addressing some of the areas identified,” added Lesufi.
The Ombud also recommended additional training for health-care workers. While agreeing to facilitate this, Minister Motsoaledi emphasized that the fatalities were less about a lack of knowledge and more about negligence. He noted that ethical standards are already included in the basic training of health-care professionals.
“A cornerstone of medical ethics has been violated,” said Motsoaledi. “Doctors, nurses, and other health professionals are not selected from the street—they come with qualifications and training. The principle of primum non nocere, meaning ‘first, do no harm,’ was universally breached by both George Mukhari Academic Hospital and NETCARE for Femina. This principle is taught in every medical school and nursing college worldwide and precedes the Hippocratic oath. When treating a patient, if an intervention could cause more harm than good, it is better to do nothing. In this case, that principle was completely ignored.”
The minister also criticised what he described as chronic underinvestment in health-care facilities serving Black communities, a matter he has repeatedly raised with the President and Finance Minister.
“I won’t delve deeply into politics, but the facts speak for themselves. Historically, medical schools and teaching hospitals for white students were fully resourced, while black medical schools, starting with the Natal Medical School in 1953, were established with minimal infrastructure. This pattern repeated at subsequent institutions like Medunsa and Tassi Sulu University in Mthatha, and almost again in Limpopo. In a democratic South Africa, this cannot continue,” said Motsoaledi.