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HomeFrom the FrontlinesAudit explains Eastern Cape’s devastatingly high COVID death toll

Audit explains Eastern Cape’s devastatingly high COVID death toll

Eastern Cape Health has effectively collapsed, reports Daily Maverick. Its accounts are overdrawn by R979m and it’s facing medico-legal claims of more than R40bn, while an audit conducted to to explain its disproportionately high mortality rate during the COVID-19 pandemic, details reveals a system riddled with inefficiency, neglect, corruption and mismanagement.

The audit was performed, on the request of the department, by doctors John Black, head of the Infectious Diseases and HIV Unit at Livingstone Hospital; Margaret Ntlangula from Eastern Cape Health; Dr Jenny Nash, rural health expert and specialist family physician; Dave Stead, head of medicine at Cecilia Makiwane Hospital in East London; Dr Ramprakash Kaswa from the Department of Family Medicine and Rural Health at Walter Sisulu University; Prof Mervyn Williams, former head of cardiothoracics at the Livingstone Hospital Complex and Dr Ruvimbo Chingonzoh, a provincial epidemiologist at the National Institute for Communicable Diseases.

Their research looked into the deaths in the Eastern Cape during South Africa’s second wave of coronavirus infections. The second wave was driven by the Beta variant first identified in Nelson Mandela Bay in the Eastern Cape. In the Eastern Cape, the wave started in late October 2020 and continued to January 2021.

The toll taken by the new wave of infections saw the provincial recovery rate drop below 88%.

The report on the deaths in the province has never been officially released by Eastern Cape Health — despite several requests for the full report, writes Estelle Ellis for Daily Maverick.

The Medical Research Council’s estimate of 764 deaths per 100,000 of the population puts the Eastern Cape death rate among the highest in the world and by far the highest in South Africa.

Lack of leadership and care from provincial healthcare facilities is glaring, says the report: at the pandemic’s height, many patients were not assessed daily (26%); some were not seen for clinical assessments for up to seven days, and in 77% of cases, for up to three days, while 13% of patients were not assessed for more than six days.

The audit also uncovered missing prescriptions and treatment charts for both COVID-19 and non-COVID conditions, poor glucose monitoring in diabetic patients, and no access to insulin. In some cases blood work had not been done, blood results were undocumented, often not followed up; lumbar punctures were not done, neither were CT scans; and no work-up plans were done to deal with seizures or fits.

Only in 16 out of 129 records assessed did the audit team NOT find any concerns in how patients were handled.

In December 2020, emergency responder Dr Imtiaz Sooliman from Gift of the Givers called the second COVID-19 wave in the Eastern Cape as a “total disaster”.

This was due to a combination of patients arriving at the hospital already severely hypoxic (low levels of oxygen in their blood) because of COVID pneumonia, overwhelmed staff, a stigma attached to treating COVID-19 patients and complete systemic collapse aggravated by then Health MEC Sindiswa Gomba (later fired).

The audit’s findings are currently based on numbers and hospital records, but will be followed up by a qualitative audit, involving interviews and personal experiences of staff, including:

• That numerous patients arrived at hospitals only when their oxygen saturation (sats) were already dangerously low;
• That delays in supplying most hospitals with high-flow oxygen restricted the treatment options available as patients’ conditions deteriorated;
• That often, community service doctors were the last people standing in rural hospitals and had to look after patients; and
• That overwhelmed hospitals “missed” follow-up assessments of patients with some dying after their conditions had not been assessed for up to six days.

The audit was performed on the request of the department, by doctors John Black, head: Infectious Diseases and HIV Unit, Livingstone Hospital; Margaret Ntlangula (provincial health department); Dr Jenny Nash, rural health expert/ specialist family physician; Dave Stead, head of medicine at Cecilia Makiwane Hospital, East London; Dr Ramprakash Kaswa, Walter Sisulu University; Prof Mervyn Williams, former head of cardiothoracics, Livingstone Hospital Complex and Dr Ruvimbo Chingonzoh, National Institute for Communicable Diseases.

Their research looked into the province’s deaths during the second wave of coronavirus infections, from late October 2020 until January 2021.

The report on the region’s deaths has never been officially released by the Eastern Cape Health Department, which mainly blamed the high death toll on patients’ late arrival at health facilities.

In November 2020, the province’s death statistics were claimed to be around 63 per 100,000 with a higher rate in the two metros, but later, former Health Minister Dr Zweli Mkhize requested an audit: hospital stats at the height of the wave showed 26% of the patients admitted to hospitals had died, 75% of deaths occurring in the public sector.

In December, the province recorded more than 600 deaths, including 137 health workers, in the first fortnight.

By 7 February this year, 16,361 people in the province were confirmed dead of COVID-19-related complications in just under two years. The Medical Research Council estimated another 50,257 excess deaths due to natural causes in May 2020. Their estimation of 764 per 100,000 of the population puts the Eastern Cape death rate among the highest in the world, and by far the highest in South Africa.

The audit highlights the dire conditions at the time. However, current superintendent-general Dr Rolene Wagner, appointed in August 2021 after the end of the third wave of COVID, has promised to tackle hospital conditions. Yet the department is (still) in serious financial trouble and is now negotiating with creditors for lifesaving medicine.

A glimpse into how understocked hospitals were at the time is reflected in a “shopping list” Sooliman asked for when he intervened in the crisis.

The teams needed coveralls, disposable gowns, shoes and caps, surgical masks, N95 masks, sterile and non-sterile gloves, aprons, goggles, visors, hand sanitisers, soap, masking tape for the floor, 50 brown paper bags for masks, a hanging rack for PPE gowns, coat hangers, large buckets, drying racks, Prestik and Koki pens.

Ward outreach teams asked for oximeters, blood pressure cuffs, hats and sunscreen. The doctors asked for 50 oxygen ports and pulse oximeters.

For the audit’s purposes, hospitals were chosen for their high admission rates and death rates, and the review included a look at bed capacity, equipment availability, clinical governance and referrals. Teams from the National Department of Health and the NICD chose the facilities to represent district, regional and tertiary hospitals. Files were randomly selected from each facility by the NICD, which provided a list per facility.

The review found that the oxygen saturation of patients who had arrived at these hospitals was very low — either from having waited too long or being delayed for too long before they accessed care. But after admission, there was also slow progress in escalating treatment due to insufficient oxygen ports and a lack of high flow oxygen, nasal cannulae and other equipment. Some patients had neither IV lines for drips nor high flow oxygen.

Other findings from the patient review include:
• Some patients waited up to two days for admission to COVID-19 wards due to bed shortages;
• A third of patients who died were admitted from home;
• Sats on average for patients who died were 80% (normal sats are between 95% and 100%). At Cecilia Makiwane Hospital, patients were seen who on average presented with sats at 79%, Livingstone 73%, Mthatha 80%, Taylor Bequest Hospital 81.5%, 80% at Uitenhage Provincial Hospital and 80.5% at Victoria Hospital;
• Critical care was offered to only a fraction of patients with just 2% having accessed High Care and only 3% having been seen in the intensive care unit.

Investigators raised concerns over the oxygen therapy administered in about one third of cases, most being at the remote Taylor Bequest Hospital in Matatiele and Victoria Hospital in Alice. There was little information on patient charts, with almost no details recorded, no monitoring tools were used to make decisions, and treatment charts and laboratory results were missing.

In many cases there were also no plans to escalate oxygen therapy, and the team found substandard oxygen saturation monitoring. There was also a lack of action taken to address suboptimal oxygen when this showed up on vitals monitoring.

The review team also highlighted the lack of information written in the patient charts, with almost no details recorded including the height and weight of patients, no monitoring tools were used to make decisions, treatment charts were missing and laboratory results were missing.

A second audit specifically in the three rural districts with the highest fatality rates was commissioned by the Department of Health in 2021 with the current MEC of Health, Nomakhosazana Meth saying that this will be done in conjunction with experts from the World Health Organization. At the time, epidemiological reports showed that 44% of patients admitted for COVID-19 died in hospital in the Joe Gqabi District, which has the highest case fatality rate in the Eastern Cape.

In a further analysis, Maverick quotes Prof Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at Wits University, who said the Eastern Cape public health system was very weak on numerous proxy indicators, “including financial management, with irregular expenditure levels suggestive of endemic corruption and mismanagement”.

But at the height of the first wave of infections, the province was already in trouble. Dr Sibongile Zungu, from the National Department of Health, was appointed to head the province’s COVID-19 response, and said calls for the department to be placed under administration were misplaced because “we continue supporting infected people to recover”.

“Most of the deaths occurred in general wards — which means critical care beds were unavailable. This is aside from the other info presented on the quality of care.

“The province was also unable to coordinate care with the private sector — which was also short of beds during the wave peaks. A difficulty with the Eastern Cape at present is that their budget is being cut due to the population movement to the Western Cape.

“Theoretically they should be experiencing lower patient demand. But the reality is the administration is so weak that they cannot cope with complex transitions.

“The presentation concludes with approaches to deal with the clinical care failures. The problem is, however, very deep in the Eastern Cape. Leadership is lacking at many levels, making it difficult to implement logical measures to achieve service improvement.

“This is not the only province in this condition — but it is of concern due to the population size of the province,” he said.

Van den Heever said an analysis of maternal mortality rates before the pandemic hit — coupled with the Office of Health Standards Compliance facility audits (weighted by bed numbers) up to 2018/19 — had already shown the Eastern Cape to be a disaster.

“The Office of Health Standards Compliance has a minimum standard of 80%. The Eastern Cape is around 58%.”

Dean of the faculty of health sciences at Wits University, Prof Shabir Madhi, said that with a COVID-19 attributable mortality rate of about 609 per 100,000 people, deaths in the province during the pandemic were way above those of the Western Cape at 378 per 100,000.

“The figures speak for themselves with regard to a dysfunctional healthcare system that cannot be rescued in the midst of a crisis. Unfortunately, KwaZulu-Natal and the Northern Cape were not much better off, with death rates way above the national average of 494 per 100,000,” Madhi said.

By the December 2020/January 2021 wave, the province’s health department was bankrupt. Last week, the standing committee on public finances in the province heard that the health department, given its enormous financial problems, might have no choice but to submit to administration.

Superintendent-General Wagner said many of the concerns addressed in the report have been or are being addressed. “The department has developed a project plan to implement the recommendations of the assessment in November 2021. The vaccination programme is being ramped up to reach as many of the high-risk populations as possible and we are working to secure stock of essential medicines. Negotiations are taking place with major suppliers to extend the credit for another two months with the promise to settle the accounts in the new financial year,” she said. She did not believe the department should be placed under administration.

“The financial woes are not from financial misconduct or mismanagement, but from lump sum payments in medico-legal claims settlements… We are trying to stop the haemorrhaging.”


Daily Maverick article – A losing battle: Why mortality rates in one province rocketed during the Covid-19 second wave (Open access)


Daily Maverick article – Death and dying in the Eastern Cape: Never coming back: Covid-19 ripped through the Eastern Cape, leaving a trail of broken hearts in its wake part two (Open access)
Daily Maverick article – Province of disaster: Confessions, chaos and spin — responses to the shocking number of Covid-19 deaths (Open access)


See more from MedicalBrief archives:


MSF: Support to Livingstone Hospital extended for another month amid Eastern Cape COVID-19 infection surge


MRC: Eastern Cape COVID-19 deaths 'vastly underestimated'


WHO to investigate Eastern Cape’s high COVID-19 death rate


DA: Massive COVID-19 spike in Eastern Cape should sound alarm bells


Eastern Cape application to freeze R364m in medical negligence awards




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