Litany of poor medical treatment for Shonisani Lethole at Tembisa hospital
Lethole's body remained in hospital bed for 10 hours after death
Shonisani Lethole's lifeless body spent 10 hours and 15 minutes on the Tembisa Provincial Tertiary Hospital bed until a doctor certified him dead the next day.
Lethole, 34, died on June 29 at 10.30pm, as recorded by a professional nurse.
The doctor on duty was called twice by nursing staff to certify Lethole's death. Dr Babayombe Bangala did not respond.
It turns out Bangala was busy resuscitating another patient in another ward, who ultimately died.
Bangala failed to follow up on the request from his colleagues to assist and knocked off without certifying Lethole dead.
This is contained in the report released by the health ombud on Wednesday on the circumstances surrounding the care and the death of Lethole at Tembisa Provincial Tertiary Hospital on June 29.
After being admitted to hospital, Lethole 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.
The care was provided by well-meaning but inexperienced and inadequately supervised health-care practitioners in an unsuitable and not fit for purpose environment.Health ombud report
Following his death, Mkhize asked the ombud to investigate Lethole's stay at the hospital, one of the designated hospitals for managing Covid-19 cases.
The report found that Lethole died of overwhelming SARS-CoV-2-induced Acute Respiratory Distress Syndrome, with multisystem dysfunction compounded by poor and negligent medical care.
It also found that Lethole was not offered food during his stay in hospital for a total of 100 hours and 54 minutes.
The ombud found that it was only on June 26 at 9.55am - 69 hours and 19 minutes after Lethole had been admitted at the hospital on June 23 at 12.36pm - that two medical practitioners could assess his condition.
These practitioners were on call when Lethole was admitted.
Outcome 'could have been different'
The report said Lethole's death was preventable and avoidable.
The ombud also relied on Dr Portia Ngwata, head of internal medicine at the hospital, who provided an independent analysis and review of Lethole’s clinical records after the release of the health ombud’s preliminary report in December to affected parties.
The ombud found 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 the hospital.
“Had all these been attended to, the outcome of Mr Lethole’s condition would likely have been different,” the report said.
It said Lethole was not regularly evaluated and monitored as would be the norm befitting the severity of his condition.
“He was left for prolonged periods of low oxygen saturation, which would no doubt have resulted in further systemic tissue injuries contributing to his deteriorating health condition.”
The report found there was a complete mismatch between the severity of his medical condition and the level and environment of his care.
“The care was provided by well-meaning but inexperienced and inadequately supervised health-care practitioners in an unsuitable and not fit for purpose environment.”
The ombud recommended that disciplinary action be taken against 19 hospital staff, including some doctors and nurses, for their role in Lethole's death.
Gauteng health MEC Dr Nomathemba Mokgethi said the department was committed to implementing the recommendations of the report.
“The department will also use the report to help improve the patient experience of care and provide quality dignified services in our facilities,” Mokgethi said.
The hospital said it was studying the contents of the report and its implications and would advise on the way forward after receiving legal advice from its legal team.