Damning Report Released on Death of Businessman Shonisani Lethole at Tembisa Hospital

Shonisani Lethole was young, had no co-morbidities, and a fair chance to live. However, due to negligence at the Tembisa Tertiary Hospital – including not being fed for 100 hours – the Gauteng businessman who called himself Shoni did not make it.

These are some of the chilling findings contained in the 202-page report of the Health Ombudsman, Professor Malegapuru Makgoba, who was tasked with investigating the circumstances surrounding the death of Lethole at Tembisa Tertiary Hospital.

Lethole, 34, took to Twitter on 25 June, a few days before his death on 30 June last year, to complain to Health Minister, Dr Zweli Mkhize, of not being fed for 48 hours:

However, according to Makgoba, the tweet was just the tip of the iceberg.

The investigation was launched following a grievance lodged by Minister Mkhize as the main complainant, Lethole’s family and a group of 25 936 social activists, who signed a petition seeking justice.

The Ombudsman’s investigation revealed that Lethole had not been fed for more than 100 hours and 54 minutes.

“The first failure to offer him food was when he arrived at the hospital on the 23rd of June, to the time he got admitted to ward 23 on the 24th of June, around midnight, when he started to have food,” Makgoba explained.

The second time he did not have anything to eat was when he was sedated and put on mechanical ventilation, without the nasogastric tube being inserted.

“This started on the 27th of June when he was not fed until he died on the 29th of June,” said Makgoba.

The hospital’s CEO gave investigators five affidavits of patients who were apparently admitted with Lethole to prove that he ate.

However, one of the patients did not get a meal herself for two days at the hospital.

“[The patient] said their food service was very poor and she actually lost her [pregnancy]. The situation was unbearable and [no one] seemed to care. [The patient] didn’t even know Mr Lethole,” said Makgoba.

Makgoba painted a grim picture of hospital operations and the medical care that Lethole endured at the hands of the healthcare workers at the hospital.

In addition, medical care has been categorised as substandard by almost every witness interviewed, pointing to serious medical negligence.

This was confirmed and corroborated by the new Head of Internal Medicine at Tembisa Tertiary Hospital, and an independent expert looking after COVID-19 patients at Steve Biko Academic Hospital, Makgoba said.

“From the clinical records, she [the doctor from Steve Biko] went further to say Mr Lethole’s mortality was both avoidable and preventable because he was a young man at 34, with no comorbidities.”

In addition, the doctors’ notes were described as defective, appalling, with falsified descriptions, while some were missing.

The medical team never commented upon Lethole’s diagnostic tests until towards his dying days, which showed that he had severe pneumonia, stage four renal failure, gross deranged liver function, elevated systemic inflammatory markers and a positive COVID-19 result.

“He demised without knowing his COVID-19 results,” said Makgoba.

DA ‘Shocked’ by Health Ombudsman’s findings

Jack Bloom – DA Gauteng Shadow MEC for Health – said he is shocking by the damning findings.

It reveals a failure at every level, including denial of food for more than four days, poor record-keeping, falsified information, and general negligence that contributed to his death from Covid-19 complications.

Unbelievably, neither Mr Lethole or his family were informed of his positive Covid-19 test.

Bloom said he agrees with Makgoba’s finding that Tembisa Hospital should never have been designated for Covid-19 patients as it was not adequately resourced. Makgoba said: “It was not fit for purpose. The infrastructure was defective, the hospital was understaffed, the staff lacked the requisite experience and high-quality skills necessary to care for critically ill patients.”

According to Bloom these problems were well-known at the time when he questioned why Tembisa Hospital had been designated for Covid-19 patients. Bloom said:

The sad reality is that most public hospitals in Gauteng are poorly prepared to deal with the Covid-19 pandemic because of years of mismanagement, under-staffing and lack of equipment.

I suspect that Mr Lethole’s case is the tip of the ice-berg of many more cases of sub-standard care in our hospitals that has increased the mortality from Covid-19.

There needs to be accountability for what has been uncovered in Makgoba’s excellent report, but it should also serve as a wake-up call that there are longstanding problems in our public hospitals that need to be fixed urgently to ensure a decent health service.

11 Recommendations

Makgoba has made 11 recommendations after the report.

Highlighting the key ones, Makgoba said the Gauteng Health MEC, Nomathemba Mokgethi, should appoint an independent audit process to conduct an assessment of the leadership and management staff at the Tembisa Tertiary Hospital.

He also wants the team to review and revise hospital admissions, processes and corporate structure, in addition to the climate survey assessment of staff and patients.

Makgoba is also calling for the accounting officer and 19 staff members, including medical doctors, nursing staff and people in charge of food to be taken for a disciplinary process.

“During the course of our investigations, we found that the nurses and doctors didn’t work together. There was no team spirit. It was like a zoo of people that are supposed to look after patients,” said Makgoba.

The Professor is urging healthcare workers to view their profession as a calling and not another means to make money.

Meanwhile, he said this report provides everyone with an opportunity to improve.

“It is meant to foster a different culture from [the status quo],” he said.

Prof Makgoba said: “The investigation was also to bring closure to the family who had questions about their loved one’s death. We also tried to look into Tembisa Hospital and to fix what was broken and set them on a new footing. Pleased the management is here today.”

Shonisani was an entrepreneur and Managing partner at Lean Business Platform South Africa.

The full report can be downloaded here.

Sources include DA statement, SAnews.gov.za, Shonisani Lethole’s social media pages.