The Health Ombudsman has slammed the conduct of staff at Motherwall Clinic in Gqeberha, who turned away a 15-year-old rape victim seeking help before she later died on the floor of a police station 2km away.
An investigation by the ombud found negligence in how the teenager was handled by staff at the clinic, where she first sought help before her death, after being kidnapped and gang raped during a four-day hostage ordeal.
TimesLIVE reports that Health Ombud Professor Taole Mokoena released findings of the investigation this week, after a probe which 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, who said Vena was failed by both the clinic and the police.
Accompanied by an elderly woman, Vena had arrived at the clinic in a dire condition after the horrific rape, but according to the report, staff did not touch or examine her, believing sexual assault cases should be referred to the police.
Although she was instead told to go to the Motherwell police station – 2km away – as staff believed “nurses are not allowed to touch rape victims to avoid tampering with evidence”, the two nurses in attendance did not arrange transport to take her or her escort to Motherwell Police Station Community Service Centre (MPS CSC) or call the police to the clinic to take over the case.
"One of the nurses said 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 woman, neither of whom had money for a taxi, started walking to the police station, but the girl collapsed and had seizures on the side of the road.
A taxi driver offered to drive them to the SAPS office.
On arrival at the police station, she was not immediately attended to, and a full hour and a half later, was found dead on the floor of the charge office.
Mokoena said: “It is 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.”
Based on the verbal and documentary evidence gathered, it was concluded that the two clinic staff had failed to refer Vena to the next level of care needed.
“It was evident she was not attended to in a manner consistent with the nature and severity of her condition… their conduct of failing to refer Vena to the next level of care violated the provisions of the norms and standards regulations …” read the report.”
According to the state pathologist, a white substance was found in the teenager’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 …a high level of Trimethoprim drug, also known as Cotrimoxazalem, found in the stomach content, blood, eye fluids and bile. These levels were much higher than the normal levels found in people taking the medication for therapeutic purposes.”
There was no alcohol or other intoxicant substance in her bloodstream.
“Based on the evidence, it can be concluded she was not attended to in a manner consistent with the nature and severity of her condition at Motherwell Clinic.”
The report further revealed that although the clinic conducted an internal probe, no action was taken against the two nurses, and highlighted various challenges faced by the clinic, including staff shortages. A particular area of concern was how the nurses claimed they they were unaware of Motherwell NU11 Clinic’s sexual assault standard operating procedure.
The clinic did not have a working landline, and the only cellphone was in the possession of a senior nurse who was on leave at the time.
Police took in three people for questioning concerning Vena’s rape and death, and all three minors were released into their parents’ care, while the matter is being decided upon by the deputy director of public prosecutions.
The ombud gave a long list of recommendations, including disciplinary hearings against the nurses, and called for their referral to the SA Nursing Council for misconduct investigation.
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