The Gauteng provincial government is addressing operational inefficiencies identified at the psychiatric unit at Dr George Mukhari Academic Hospital, following the death of a patient in a fire.
The inefficiencies at the hospital are being addressed through increasing capacity, strengthening security, enhancing staff training, installing additional CCTV cameras, and implementing fire remedial projects.
“When the draft report on the matter was presented to us, we immediately undertook an overhaul to rectify the situation and to ensure that this kind of incident does not occur within our institution again,” Gauteng Premier Panyaza Lesufi said on Monday, during a media briefing in Pretoria.
He was responding to a report by Health Ombud, Professor Taole Mokoena, on the findings from two investigations into patient safety incidents in Gauteng.
The briefing addressed the death of a mental health care user at Dr George Mukhari Academic Hospital and the neonatal death at Netcare Femina Hospital (NFH).
Ms L Mohlamme, a 35-year-old mental health care user, died following a fire incident while admitted at the public hospital. She had been brought to the hospital on 19 June 2024 by her brother-in-law.
The Health Ombud’s investigation sought to determine whether the care provided complied with the Mental Health Care Act, which requires that all mental health care users receive humane, dignified, and least restrictive care.
Following the conclusion of the investigation into the death of Mohlamme, professional bodies, the Health Professions Council of South Africa (HPCSA) and the South African Nursing Council (SANC), will be requested to consider the findings and to initiate appropriate professional conduct enquiries on the implicated health professionals.
“More broadly, the investigation uncovered systemic violations of the rights of mental health care users, including the use of punitive practices, inadequate infrastructure, inadequate staffing, and insufficient staff knowledge of the Mental Health Care Act. The findings also point to systemic weaknesses and failures in governance and oversight overall,” Mokoena said.
Since receiving the preliminary report, the Gauteng government has added 12 nurses, bringing the total to 105 nurses.
The Health Ombud recommended the redesign and refurbishment of the psychiatric unit at Dr George Mukhari Academic Hospital to comply with all legal requirements of the psychiatric unit, including security and safety requirements.
“As reflected in the reports, the reporting processes and security structures were non-existent. We have now strengthened these by assigning nine permanent security personnel who are stationed on-site so that in incidents of this nature, they are the first to respond.
“We are strengthening supervision to ensure that those tasked with this work are properly trained and capacitated. To date, we have trained 21 nurses and two social workers, enabling them to better understand the responsibilities outlined in the report. We have also installed additional CCTV cameras to allow security personnel to monitor situations in real time,” the Premier said.
The government has also implemented fire remedial projects - some are still in progress, while those completed resulted in the issuing of a certificate of fire compliance on 19 February.
“This means that the hospital is now fire compliant, although there are still outstanding matters requiring urgent attention. We need to procure items such as certified fireproof mattresses and other issues identified in the report, which we believe are critical to achieving full compliance,” Panyaza added.
The report also recommended upgrades to include the patient recreation and rehabilitation facilities.
“Protecting the dignity, safety, and rights of mental health care users is not optional; it’s a constitutional and legislative imperative. The Health Ombud will continue to monitor the implementation of the recommendations and will work with all stakeholders to ensure that such a tragedy does not occur again.”
Key findings in the Mohlamme case include the following:
- Her admission process did not comply with legal requirements, where two medical practitioners did not independently examine and commit the patient in the prescribed form and manner, thus rendering the application technically invalid.
- Mechanical restraint was applied in excess, inconsistent with national policy guidelines.
- A history of alleged sexual assault that she gave was not appropriately assessed, documented, or reported to the South African Police Services as required, thus representing both clinical and legal procedure failures.
- Prescribed medication was deliberately withheld as punishment. However, medical records were falsified to indicate administration.
- The patient was denied food as punishment during the seclusion.
- The required safety procedures were not followed during the seclusion process.
- The seclusion room was poorly located, being very far from the nurses' station, and lacked adequate monitoring devices.
- Safety fire concerns raised by another patient were dismissed.
- The patient was not thoroughly searched before being committed to the seclusion room. The patient had a cigarette lighter on her person, which she most probably used to start the fire.
- Emergency exits were locked and keys were misplaced or hidden.
- Disaster-preparedness systems were inadequate.
- Mattresses in the psychiatric unit were not fireproof or fire-retardant and thus readily allowed ignition and spread of fire.
- A postmortem confirmed that Mohlamme was alive during the fire and died from severe burn injuries. -SAnews.gov.za
