Health ombud finds negligence in case of teen rape victim Zenizole Vena

An investigation by the health ombud has found there was negligence in how a 15-year-old rape victim was handled by staff at Motherwell Clinic in Gqeberha, where she first sought help before she died.

Health ombud Prof Taole Mokoena released findings of the investigation in Pretoria on Tuesday. 

His probe had sought to ascertain if Zenizole Vena died as a result of neglect, was denied care at the clinic and whether the clinic staff failed to refer her to the next level of care.

A complaint had been lodged by the DA’s shadow minister of health, Michéle Clarke, in September 2022.

Mokoena found that Vena had reported to the clinic while in a dire condition, accompanied by an elderly woman, after suffering a horrific rape. 

“The healthcare workers who attended to Vena at the clinic did not touch or examine her with the belief that every sexual assault case should be referred to the [police],” the report revealed.

She was instead instructed to go to the Motherwell police station — 2km away — as staff erroneously believed “nurses are not allowed to touch rape victims to avoid tampering with evidence.

“Despite their belief, the two nurses did not arrange transport to take the escort [an elderly lady] and victim to MPSCSC or call the police to come to Motherwell NU11 Clinic to take over the case.

“One of the nurses indicated she only took the patient’s vital health data, which was written in a personal diary but not in the approved Patient Administration Record,” found the report.

Vena and the elderly woman, neither of whom had money for a taxi, trekked to the police station. Vena collapsed, had seizures and wet her pants on the side of the road. 

A taxi driver offered to take them to the police station as Vena could no longer walk or talk. 

The report found that upon arrival at the police station, Vena was not immediately attended to by the police.

An hour-and-a-half later she was found dead on the floor in the charge office. 

Commenting on this, Mokoena said: “It is quite disturbing that a basic human instinct to assist a person in distress, particularly a child, does not seem to exist within the South African Police Service [at the] Motherwell police station.” 

Paramedics at the scene declared Vena dead. 

Based on the verbal and documentary evidence gathered, it was concluded that both healthcare workers concerned failed to refer Vena to the next level of care needed.

“It was evident that she was not attended to in a manner consistent with the nature and severity of her health condition.

“The nurses’ conduct of failing to refer Vena to the next level of care violated the provisions of the norms and standards regulations for different categories of health establishments,” read the report.

Commenting on what led to Vena's death, Mokoena’s report said: “According to the state pathologist, a white substance was found in the deceased's stomach that looked like tablets. There were no severe injuries that might have caused her death.

“A toxicology report indicated that the cause of death could be in keeping with a high level of Trimethoprim drug, also known as Cotrimoxazalem which was found in the stomach content, blood, eye fluids and bile. These levels were much higher than the normal levels found in people taking the same medication for therapeutic purposes.

“It appeared that Ms Vena ingested a lot of Trimethoprim tablets. There was no alcohol or other intoxicant substance in her bloodstream.

“Based on the evidence obtained, it can be concluded that Ms Vena was not attended to in a manner consistent with the nature and severity of her health condition at Motherwell Clinic.”

The report further revealed that though the clinic conducted an internal probe, no action was taken against the two nurses. 

The report highlighted a number of challenges faced by the clinic, including staff shortages. One area of concern, however, was how the nurses claimed “they were not aware of Motherwell NU11 Clinic's sexual assault standard operating procedure”. 

The clinic did not have a working landline, and the only cellphone used in the clinic was in the possession of a senior nurse who was on leave when the incident happened. 

Meanwhile, police had brought three people in for questioning concerning Vena's rape and death. Two of them claimed to have seen Vena take pills. 

All three minors were released into their parents’ care, and the matter is yet to be decided upon by the deputy director of public prosecutions. 

The ombud gave a long list of recommendations, including disciplinary hearings against the nurses. He also called for the referral of the nurses to the SA Nursing Council for investigation into their misconduct. 

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