Death of patient: Shonisani Lethole was not offered food for more than 100 hours in hospital
Action must be taken against 19 Tembisa Hospital staff, health ombud says
The care rendered to the late Shonisani Lethole in Tembisa Hospital in June last year was not only substandard but also negligent, according to the report of the health ombud released on Wednesday.
This is one of the main findings made by the ombudsman after he undertook investigations into the care and death of Lethole at the hospital on June 30 last year.
Lethole had tested positive for Covid-19.
Before he died, Lethole, 34, took to social media to reach out to health minister Dr Zweli Mkhize about what he termed deplorable conditions at the hospital and claimed he was being starved.
Mkhize lodged a complaint with the health ombudsman Dr Malegapuru Makgoba and an investigation into Lethole's death was launched.
Makgoba found that Lethole was not offered food during his stay in hospital for a total of 100 hours and 54 minutes.
He was not offered food for 43 hours and 24 minutes after his admission to the hospital on June 23 last year.
This uncaring attitude represented gross medical negligence.Dr Malegapuru Makgoba
From June 27, after Lethole was sedated and intubated, he did not receive feeding until his death on June 29 at 10.30pm.
“So, for another 57 hours, 30 minutes, Mr Shonisani Lethole was to endure not being fed at the Tembisa Provincial Tertiary Hospital,” Makgoba said.
He said this took place when he was most vulnerable and sedated.
“The health-care professional team of doctors and nurses conceded to the investigation to this negligent, callous and uncaring omission.
“This uncaring attitude represented gross medical negligence,” Makgoba said.
The ombud said Lethole was tested for Covid-19 on June 23 at the hospital and died without receiving his Covid-19 test results.
He said 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 timely interpretation of results and the “appalling” clinical record-keeping at the hospital.
It took about 69 hours and 19 minutes before two registered medical practitioners could assess Lethole’s condition for the first time since admission at the casualty Covid-19 isolation ward, he said.
This delay was unexplainable, he added, since the medical practitioners were on-call as indicated by the roster on the day of his admission.
Makgoba recommended that Gauteng health MEC Dr Nomathemba Mokgethi must urgently appoint an independent forensic and audit firm to, among others, conduct a “fit for purpose” competency assessment of the leadership and management staff at the hospital.
The firm should also review and revise the hospital’s admission policy and processes to bring these in line with the universally acceptable caring mission of a hospital and universally practised norms and standards of hospital admissions.
Makgoba said Mokgethi should institute a disciplinary inquiry against Dr Lekopane Mogaladi, the CEO and accounting officer of the hospital, for presiding over such a state of affairs.
He said among other transgressions, Mogaladi failed to report missing clinical notes to the police as required by law.
Makgoba said the department of health should also institute disciplinary action against 19 staff members for, among others, failure of duty to care, and for claiming that food was given to Lethole while knowing this was not true.
“Tembisa Hospital should not have been designated a Covid-19 hospital,” he said.
He said the management at the hospital had not done their job, but the individual health-care professionals involved in providing care also failed to discharge their responsibilities and their conduct could not be fully explained by the broader systemic issues.
“Tembisa Hospital and its medical team of health providers must take accountability and responsibility for this substandard and negligent care provided Mr Lethole.”