Why did Life Esidimeni happen?

Section 27 advocate Adila Hassim read out the names of 55 of the 118 people who died when forcibly removed from Life Esidimeni homes and sent to ill-equipped unlicensed NGOs last year.

She was speaking at the official arbitration hearing that is set down for three weeks in Johannesburg if order to find restitution for families who lost loved ones.

In June last year‚ the Gauteng department of health moved more than 1‚400 patients from Life Esidimeni psychiatric homes to NGOs and 108 died‚ it emerged on Monday. Another ten died as they were moved from Cullinan Care Centre‚ where they had lived for years‚ and placed in unlicensed NGOs to make space for Life Esidimeni patients. So at least 118 died‚ but it could be more.

It was initially reported 94 had died.

The state has agreed that it is responsible for the tragedy and it needs to be part of the processes to help families find closure.

In his opening address state advocate Tebogo Hutamo said: "The state will demonstrate its explanation. It will give an account in the events in full. This is part of a responsible government that takes responsibility."

He called the deaths "regrettable". However‚ he also denied it was as a result of purposeful government actions saying the tragedy did not "happen by design".

But he said the state was committed to helping families find "closure".

"It is our intention to make every step or effort ...so that these incidents do not repeat themselves in this country."

In her opening statement Hassim questioned why the Life Esidimeni saga had occurred.

The two reasons given by government for the move were to save money and to deinstitutionalise patients into the community as is government policy.

Neither reason held up. The removal of people led to many patients landing up in hospital‚ which was about five times more costly per patient per day. The Gauteng department of health was warned by the national department and psychiatrists that that deinstitutionalisation could only take place with appropriate preparation. Hassim said: "So the burning question is‚ if the project was not cost-saving and it was not demanded by the policy of deinstitutionalisation given the conditions that had to first be created‚ then why was this necessary? What was the motivation that drove this course of action? The burden of answering this lies with the government." In her opening address Hassim also pointed out that it is still not known exactly how many people had died.

"Lamentably‚ as we gather here‚ we are unable to state with certainty what the actual number of deaths is. Either this simple act of data gathering has eluded the Department‚ or the families‚ and this process‚ have not been taken seriously."

But the health ombudsman Malegapuru Makgoba later testified he believed 118 died as a result of the tragedy. Section 27 said his list excluded 11 dead patients they represented‚ which suggested as many as 129 died.

Retired deputy Chief Justice Dikgang Moseneke said working out who died was the "single" most difficult thing in preparing for the arbitration hearing.

It also emerged as the arbitration hearings started that the MEC Qedani Mahlangu who was in charge of the move is not on the state witness list. None of the state witnesses include people involved in the decisions to end the Life Esidimeni contracts.

State advocate Hutamo said if Section 27 and others wanted witnesses they need to subpoena them.

Dirk Groenewald‚ acting for Solidarity and three families‚ and Hassim said they would subpoena Mahlangu.

17 family members will testify for Section 27 and three will testify for Groenewald who is representing three victims. Many others have provided written testimony.

Moseneke is chairing the hearings and explaining to family members every aspect of each day to include them.

Here is the list of 55 names:

• Felicity Adams
• Diederik Johannes Botha
• Terence Maphea Chaba
• Fredrick Colitz
• Thembesile Lillian Dlamini
• Mehmona Dubree
• Nellie Johanna Du Toit
• Joseph William Golden
• Joseph Gumede
• Sizwe Thabang Hlatshwayo
• Daniel Charles Josiah
• Maureen Khunjwa
• Masweet Kozwale
• Christina Lala
• Mothofela Leroabe
• David Letoaba
• Hendrick Ranthopi Maboe
• Virginia Machpelah
• Matsobane John Mahloko
• Christopher Makhoba
• Happy Makhubela
• Raisibe Rahab Mangena
• Nathaniel (Solly) Mashigo‚
• Mangana Eric Mashiloane
• Josephina Mhlongo
• Reynock Mncube
• Jabulane Godfrey Mnisi
• Lucky Jeremiah Modise
• Christopher Mogwerane
• Jonas Modike
• Bernika Mokaneng
• Ntswelengwe Mokgethi
• Sophia Manyana Molefe
• Mameisi Sina Mosalo
• Caswell Mosiane
• Matlakala Elizabeth Motsoahae
• Siyabulela Roger Msimanga
• Emily Mthembu
• Pio Sibusiso Mthombeni
• Peter Mvundla
• Vuyo Aaron Nqgondwane
• Julian Anthony Petersen
• Deborah Phetla
• Charity Ratsotso
• Dawid Johannes Senekal
• Busisiwe Shabalala
• Joy Nomsa Simamane
• Alfred Sithole
• Bhekumuzi Sithole
• Phoebe Jesween Marcia Soudom
• Charles Stewart
• Johanna Tladi
• Motshabisi Michael Tlholwe
• Julia Kedibone Tshawe
• Cindy Van Rooyen