These are the people to blame for the deaths of 94 patients – 18 key findings from the Health Ombud report

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Here are the 18 key findings by Health Ombud Malegapuru Makgoba.

1. The Gauteng Mental Health Marathon Project must be de-established.

2. The Premier of the Gauteng Province must‚ in the light of the findings herein‚ consider the suitability of MEC Qedani Dorothy Mahlangu to continue in her current role as MEC for Health.

3. Disciplinary proceedings must be instituted against Dr Tiego Ephraim Selebano for gross misconduct and/ or incompetence in compliance with the Disciplinary Code and Procedure applicable to SMS members in the Public Service. In the light of Dr Selebano’s conduct during the course of the investigation‚ which includes tampering with evidence‚ it is recommended that the Premier should consider suspending him pending his disciplinary hearing‚ subject to compliance with the Disciplinary Code and Procedure applicable to SMS members in the Public Service.

4. Disciplinary proceedings must be instituted against Dr Makgabo Manamela for gross misconduct and/ or incompetence in compliance with Disciplinary Code and Procedure applicable to SMS members in the public service. In the light of Dr Makgabo Manamela’s conduct during the course of the investigation‚ which includes tampering with evidence‚ it is recommended that consideration be given to suspending her pending her disciplinary hearing‚ subject to compliance with the Disciplinary Code and Procedure applicable to SMS members in the public service.

5. The findings against Drs. M Manamela and TE Selebano must be reported to their respective professional bodies for appropriate remedial action with regard professional and ethical conduct.

6. Corrective disciplinary action must be taken against members of the GDoMH: Ms. S Mashile (Deputy Director); Mr. F Thobane (Deputy Director); Ms. H Jacobus (Deputy Director); Ms. S Sennelo (Deputy Director); Dr. S Lenkwane‚ (Deputy Director); Mr. M Pitsi (Chief Director); Ms. D Masondo (Chair MHRB)‚ Ms. M Nyatlo (CEO of CCRC)‚ Ms. M Malaza (Acting CEO of CCRC) in compliance with the Disciplinary Code and Procedures applicable to them‚ for failing to exercise their Fiduciary duties and responsibilities. They allowed fear to cloud and override their fiduciary responsibilities and thus failed to report this matter earlier to relevant authorities. Fiduciary responsibility is essential for good corporate governance;

7. All the remedial actions recommended above must be instituted within 45 days and progress be reported to the Chief Executive Officer of the Office of Health Standards Compliance within 90 days.

8. The Ombud fully supports the ongoing SAPS and Forensic investigations under way. The findings and outcomes of these investigations must be shared with appropriate agencies so that appropriate action where deemed justified can be taken.

9. The National Minister of Health should request the SAHRC to undertake a systematic and systemic review of human rights compliance and possible violations nationally related to Mental Health.

10. Appropriate legal proceedings should be instituted or administrative action taken against the NGOs that were found to have been operating unlawfully and where MCHUs died.

11. In light of the findings in the report‚ the NDoH must review all 27 NGOs involved in the Gauteng Marathon project; those that do not meet health care standards should be de-registered‚ closed down and their licenses revoked in compliance with the law.

12. The National Minister of Health must with immediate effect appoint a task team to review the licensing regulations and procedures to ensure they comply with the National Health Act‚ the Mental Health Care Act 2002 and Norms and Standards. The newly established process must ensure that NGO certification is done through the OHSC. This newly established licensing process should form the first line of protection for the mentally ill. Currently‚ this does not seem to be the case.

13. All patients from LE currently placed in unlawful NGOs‚ must be urgently removed and placed in appropriate Health Establishments within the Province where competencies to take care of their specialized needs are constantly available‚ this must be done within 45 days to reduce risk and save life; simultaneously‚ a full assessment and costing must be undertaken.

14. There is an urgent need to review the NHA 2003 and the MCHA 2002 to harmonise and bring alignment to different spheres of government. Centralisation of certain functions and powers of the MHCA must revert back to the National Health Minister‚ While Schedule 4‚ Part A of the Constitution and Sections 3 subsection 2; section 21‚ subsection l ‚ section 25‚ subsection 1 and 2‚ sections 48 and 49 and section 90 of the National Health Act. No. 61‚ 2003‚ recognize and define Health as a concurrent competence between the National and Provincial government spheres the findings and lessons of this investigation merits such a review.

Furthermore‚ projects of high impact on the quality and reputation of the national health system and whose outcomes undermine human dignity‚ human well-being and human life must not be permitted nor be undertaken without the expressed permission of the National Health Minister or his/her nominee.

15. Projects such as the GMMP must not in future be undertaken without a clear policy framework‚ without guidelines and without oversight mechanisms and permission from the National Health Minister; where such policy framework exists the National Health Minister must ensure proper oversight and compliance.

16. This investigation has clearly shown that for deinstitutionalisation to be undertaken properly‚ the primary and specialist multidisciplinary teams that are community based mental health care services must be focused upon‚ must be resourced and must be developed before the process is started. It will most probably require more financial and human resource investment initially for deinstitutionalisation to take root. Sufficient budget should be allocated for the implementation.

17. The National Minister of Health must lead and facilitate a process jointly with the Premier of the Province to contact all affected individuals and families and enter into an Alternative Dispute Resolution process.

This recommendation is based on the ‘low trust’‚anger‚ frustration‚ loss of confidence’ in the current leadership of the GDoH by many stakeholders.

The National Department of Health must respond humanely and in the best interest of affected individuals‚ families‚ relatives and the nation. The process must incorporate and respect the diverse cultures nd traditions of those concerned.

The response must include an unconditional apology to families and relatives of deceased and live patients who were subjected to this avoidable trauma; and as a result of the emotional and psychological trauma the relatives have endured‚ psychological counselling and support must be provided immediately.

The outcome of such process should determine the way forward such as mechanisms of redress and compensation.

A credible prominent South African with an established track record should lead such a process.

18. The Gauteng Mental Health Review Board was found to be moribund‚ ineffective and without authority and without independence. As a structure its terms of reference must be clearly defined and strengthened in line with the National Health Act and the Mental Health Care Act 2002 and its independence and authority re-established.

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