The Health Ombud has found that businessman Shonisani Lethole received “substandard and negligent” care at Tembisa Hospital last June and that his death could have been avoided.
The report found that Lethole was not fed for more than 100 hours and that he was put in a room near corpses and patients who had tested positive and negative for Covid-19.
“Yes, there were systematic faults. Yes, the management of the establishment had not done their job. Still, the individual healthcare professionals involved in providing care also failed to discharge their responsibilities, and their conduct could not be fully explained by the broader systemic issues,” he said.
The 35-year-old Lethole was referred from the Kempton Park Clinic to Tembisa Hospital on 23 June 2020 suffering from chest pain, difficulty breathing and general body weakness.
Two days after being admitted to the hospital, Lethole tweeted to the Minister of Health Dr Zweli Mkhize that conditions at the facility were becoming “unbearable” and “the[y] do not seem to care”, adding that he had not eaten in 48 hours.
He died a week after admission, prompting Mkhize to ask the Health Ombud to investigate the circumstances surrounding his death urgently.
Soon after his death, the hospital said that it had records and evidence to show that he was fed regularly since his admission to the facility and was well treated.
But the Health Ombud’s report proves otherwise.
The report found that Sithole was not adequately fed at the hospital. Lethole only received food on 25 June 2020, when he was moved to ward 23.
“Whether Mr Lethole was ‘officially or unofficially admitted’, he depended entirely on the hospital for his needs, wellbeing and care,” said Makgoba.
Professor Makgoba added that Lethole’s tweet to the minister had “merit and was found credible and truthful”.
The report revealed that when Lethole arrived at the hospital, Covid-19 and other blood tests were ordered and done. However, these tests had not been seen nor acted upon by senior doctors by the time he died.
Later, the tests showed that he had Covid-19, that he had severe pneumonia and stage four renal failure.
The report further unearthed that in ward 23, to which Lethole was moved, Covid-19-positive and -negative patients were mixed, and there were corpses in the isolation room, which was in close proximity.
Makgoba said there were also “significant” general findings related to poor record-keeping and reporting the general care of a patient. In addition, the hospital failed to follow up on Lethole’s status and implement good healthcare practices and decisions.
“Medical records were defective, inaccurate in many places and some parts falsified,” said Makgoba, adding that doctors’ notes were illegible and missing on some days.
Makgoba also confirmed that Lethole died on 29 June and not two days before, as his father believed. The report found that the hospital staff had declared Lethole had died on 28 June. The Ombud said the hospital’s medical team must take accountability and responsibility for this substandard and negligent care provided to Lethole.
He recommended that the Gauteng health MEC, Dr Nomathemba Mokgethi, should institute disciplinary enquiry against the chief executive of the hospital, Dr Lekopane Mogaladi, for “presiding over such a state of affairs”. He said Mogaladi signed inaccurate and misleading reports to the former MEC of health in Gauteng, Dr Bandile Masuku, and the Health Ombud.
“He failed to report missing clinical notes to the SAPS as is required by law. He side-lined quality assurance in exercising their due responsibility in addressing complaints and safeguarding records of Mr Lethole”, said the health ombudsman.
He also said the Gauteng department of health and the hospital should institute a disciplinary inquiry into 19 senior medical doctors and nurses at the hospital for failing in their duty of care.