A report by Health Ombudsman Professor Malekgapuru Makgoba has found that the death of Shonisani Lethole at Tembisa Hospital was avoidable and preventable.
Lethole was admitted to the facility in July last year with breathing difficulties and died before receiving his results, which showed that he had tested positive for COVID-19.
He used Twitter just days before his death to reach out to Health Minister Zweli Mkhize.
Makgoba has also called on the new Gauteng Health MEC Dr Nomathemba Mokgethi to urgently appoint an independent forensic firm to determine if the hospital’s leadership was fit for purpose.
The audit would also review the hospital’s admissions policy, review the hospital’s corporate governance principles and also conduct a survey to determine the relationship between patients and staff in relation to patient care at the hospital.
In a scathing report, Makgoba said the Tembisa Hospital should never have been designated as a Covid-19 hospital as it had systemic faults, management had been poor and individual health workers also failed to discharge their responsibilities and the medical teams had to take accountability and responsibility for the substandard and negligent care provided to Lethole.
Makgoba has called on Mokgethi to take disciplinary action against the hospital’s chief executive Mogaladi for “presiding over such a state of affairs”.
“He signed inaccurate and misleading reports to the former Health MEC Dr. Bandile Masuku and the Health Ombud. He failed to report missing clinical notes to the SAPS as is required by law.
“He sidelined quality assurance in exercising their due responsibility in addressing complaints and safeguarding records of Lethole.
“He failed to report the missing doctors’ notes of the 23rd, 24th, 25th, 28th, 29th, and 30th June 2020 to the SAPS for ‘loss or theft’,” said Makgoba.
Makgoba found that teamwork and communication among healthworkers was weak and that doctors and nurses did not work as a team, failing Lethole and his family.
“The outcomes of this forensic and audit analysis should form the basis to rebuild and improve the norms and standards and quality of care at the hospital into the future,” said Makgoba in his report.
Makgoba said a panel constituting a senior medical doctor, a senior legal counsel with experience in medico-legal matters, should form part of the panel that would take action against at least 10 doctors, nurses and workers who have been flagged as failing to provide duty of care to Lethole.
“Mr Lethole’s medical care was characterised by inordinate delays of consultations, delays on following up on clinical decisions, delays on interventions, and delays in the timeous interpretation of results and the appalling clinical record-keeping at Tembisa Hospital.
“This was established by the investigation and supported by the independent reports of Drs Fareed Abdullah and Portia Ngwata, head of Internal Medicine at Tembisa Hospital.
“The investigation by the Health Ombud and Dr Ngwata further found that Mr Lethole’s care was negligent. It took approximately 69 hours, 19 minutes before two registered medical practitioners, Dr Bangala and later Dr Shabangu, could assess Mr Lethole’s condition for the first time since admission at casualty Covid-19 Isolation on June 23 at 12:36pm until Friday, June 26, in Ward 23 at 9.55am.
“This inordinate delay in attending to Mr Lethole was unexplainable, since Drs Bangala and Shabangu were on-call as indicated by the roster register on the day of his admission. Had all these been attended to, the outcome of Mr Lethole’s condition would likely have been different. Dr Ngwata put it that Mr Lethole’s ‘mortality was preventable and avoidable’,” said Makgoba.
– Dr Shabangu, for failure of duty of care
– Dr Bangala, for failure of duty of care
– Dr Urmson,for failed in the duty of care
– Dr Sunnyraj, for failure of duty of care.
– Dr Ncha, for claiming on Health-eNews that Tembisa Hospital was “ready for the Covid-19” and providing the CEO with inaccurate information by drafting reports that were factually incorrect and misleading to MEC Masuku, the OHSC Complaints Centre and to the Health Ombud.
– Dr Ngobese, for failure to ensure that critical care equipment at Ward 23 was available and functioning properly and for failure to complete the required morbidity and mortality template form timeously.
– Dr Marole, for falsifying the death certification process and for failure to examine Mr Lethole fully before to ensure that the death certification is properly done.
– Dr Pawson, for unbecoming and rude conduct and for denying his actions under oath. The ombud notes he has since apologised.
– Clinical associate Tshali, who used a doctor’s credentials, resulting in confusion over Lethole’s Covid-19 test results.
– Dr Modika, who allowed his professional credentials to be used in the Sars-CoV-2 test by a clinical associate, leading to Lethole’s results being viewed through his credentials, but not acting. He has since apologised for his conduct.
– Sikelela Mavuma, for taking Lethole’s body to the mortuary and signing for it and still denying he did so.
– Nurse Phahlane, for lying in her statements and for not being a credible witness.
– Infection Prevention and Control nurse Hilda Mapunya, for failure to report notifiable medical conditions (NMC) within 24 hours of the clinical diagnosis results had become available.
– The kitchen staff leadership of Ms Mtwesi and Ms Ngoasheng for suspending the standard operating procedure for ordering meals without authority and rationale and creating an unreliable system of “pieces of scrap papers”.
– Ms Mamsie Matshaba for encouraging Mtwesi and Ngoasheng to retrospectively update figures to reflect that food was ordered on the June 24 2020 for the A&E isolation area.
– MsSylvia Tshabalala, for lying that she ordered and provided food for Lethole on June 23.
– Mr Sono, for giving instructions on terminating the standard operating procedure on the ordering of meals without authority, rationale and without providing a reliable alternative system.
– Professional Nurse Conny Mathibela, for mixing up the dates of Lethole’s death. She has since apologised for her conduct.
– Professional Nurse Zitha, for continuing to record nurses’ notes even after Lethole’s death.
“The recommendations made in this final report are meant to encourage and foster a culture of high-quality health care at TPTH. A culture that respects the dignity of patients, a culture that complies with the prescribed norms and standards of the National Health System and a culture that is consistent with the ethics and codes of good clinical practice.
“‘There is only one version of the truth. The truth has no different versions or shades’,” said Makgoba.