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HomeMedico-LegalTribunal upholds ‘grossly negligent’ ruling against Tembisa Hospital CEO and staff

Tribunal upholds ‘grossly negligent’ ruling against Tembisa Hospital CEO and staff

After the death of a critically ill Tembisa Hospital patient, who was not fed for two days before he died, an independent ad hoc tribunal has ruled that the staff and management, including former CEO Dr Lokopane Mogaladi, were grossly negligent and should be disciplined for their roles in his demise.

Shonisani Lethole was admitted to the hospital on 23 June 2020 with COVID-19: he had chest pains, was weak and battling to breathe, reports GroundUp. He was intubated on 27 June, and died two days later.

But before he died, Lethole took to Twitter on 25 June to describe the unbearable and uncaring conditions he was experiencing, saying he had not eaten for two days.

An ombud investigation was prompted by a complaint by the Health Minister, and Health Ombud Professor Malegapuru Makgoba found that Lethole had been denied food for “100 hours and 54 minutes” and that medical staff had been grossly negligent. He recommended that 18 staff, including doctors and nurses, should face disciplinary action.

Mogaladi was suspended almost immediately afterwards.

An appeal tribunal, set up under the National Health Act and comprising Professor Rudo Mathivha and Professor Ebrahim Variava, and retired Constitutional Court Judge Bess Nkabinde, considered appeals by Mogaladi and Dr Makhosazane Ngobese, head of the Covid unit at the time, against the ombud’s findings and recommendations.

Mogaladi and Ngobese raised several grounds of appeal, including that there was no valid complaint, that the ombud had acted beyond his mandate and that his findings were not supported by the evidence.

The tribunal returned two decisions. Nkabinde said she would have upheld the appeal in its entirety. But the majority, Professors Mathivha and Variava, while setting aside some of the ombud’s recommendations, said Mogaladi and Ngobese should still be disciplined.

Regarding Mogaladi, they said he should be disciplined for presiding over a hospital “that on two separate occasions could not provide Lethole food for prolonged periods”, and a “health establishment that showed poor record-keeping”. He should also face charges relating to substandard care at the hospital.

Regarding Ngobese, they set aside the findings against her except one, that she should face a disciplinary inquiry for her failure to ensure that critical care equipment in the Covid ward was available and functioning properly.

The two professors said they differed with Nkabinde on the question of accountability.

“While we recognise the immense challenges brought by the pandemic, the norms and standards regulations remained applicable.

“Where we find, on a fair consideration of the facts, that these norms and standards have not been fulfilled, and where there is a prima facie indication that the appellants had some responsibility in relation to their non-fulfilment, we consider it … important to recommend an accountability process follows,” they said.

Nkabinde emphasised the impact of the pandemic on hospitals and said based on the rationality and procedural fairness grounds of appeal, the appeals should succeed.

“This conclusion should not, however, be understood to suggest that no one should be held accountable when a proper case is made. It is difficult to accept a loss of life … but adverse factual findings and remedial action should be rational and should be right, just and fair.”

She said her judgment did not stop the Health Department from taking steps to fix the systematic issues at the hospital or disciplining those “properly found” wanting in upholding a high standard of professionalism.


GroundUp article – Tembisa Hospital CEO and senior officials must face disciplinary action, tribunal rules (Creative Commons Licence)


See more from MedicalBrief archives:


3 832 die in Gauteng’s public hospitals from ‘negligent’ SAEs


Serious adverse event stats keep climbing in Gauteng government hospitals


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