• The investigation by the Health Ombud into Shonisani Lethole’s care found that the Tembisa Hospital was negligent and that his death was preventable and avoidable. 
• The ombud found that Lethole was, among other things, not fed for 100 hours and 54 minutes. 
• In addition, the hospital provided inadequate care, kept poor records and provided untruthful or inaccurate information to the investigators. 

The Tembisa Provincial Tertiary Hospital (TPTH), where Shonisani Lethole died after claiming he had been ill-treated and deprived of food for 48 hours, was “like a zoo of people supposed to look after patients”. 

These were some of the stern words from Health Ombudsman Professor Malegapuru Makgoba, who released his findings into the circumstances surrounding the care and death of Lethole in June last year.

Lethole died at the Tembisa Hospital after being admitted with breathing difficulties.

Shortly after being admitted, his father, Albert Lethole, said Shonisani had informed them he had been deprived of food and was ill-treated at the hospital.

On Thursday, 25 June, Lethole tweeted Health Minister Zweli Mkhize, informing him of the treatment at the hospital and that he had not eaten for 48 hours. Following Lethole’s death on 29 June 2020, Mkhize requested the ombud to urgently probe the matter.

According to Makgoba’s findings, TPTH was negligent in its treatment of Lethole, and provided untruthful or incomplete information to the ombud. 

The main findings were as follows:

• Lethole was not offered meals at TPTH for 100 hours and 54 minutes;
• Lethole died without knowing his Covid-19 test results;
• Lethole’s tweet on 25 June at 20:31 was just the “tip of an iceberg”;
• His tweet was authentic and truthful, and it uncovered severe systemic and governance deficiencies at TPTH; and
• TPTH was not fit for purpose nor “ready for Covid-19”. 

Meals not provided

“Lethole, from all the evidence, was not offered meals during his first 43 hours, 24 minutes of admission at TPTH since 23 June 2020… at 12:36… until Friday, 25 June 2020 at 08:00 at. The period was calculated as 43 hours, 24 minutes, from the recorded time of admission. However, if one added the eight hours, 36 minutes since the last meal at 04:00 at his home on 23 June, this period would total approximately 52 hours of involuntary fasting,” Makgoba noted in his report.

The ombud found that the hospital management failed to summon a single witness or a previously admitted patient to provide credible evidence to the investigation that breakfast, lunch and supper were delivered, served and eaten by Lethole at Casualty Isolation on 23 and 24 June.

“Therefore, Mr Lethole’s tweet to the [Mkhize] had merit and was found credible and truthful. The evidence from TPTH that meals were provided to Mr Lethole was found to be without foundation.”

In addition, while the hospital claimed that a nasogastric tube had been inserted following Lethole’s intubation on 27 June, Makgoba said that no such evidence was presented, leading to the conclusion that for another 57 hours and 30 minutes, Lethole was not fed at TPTH.

“This took place when he was most vulnerable and sedated. The… team of doctors and nurses conceded to the investigation to this negligent, callous and uncaring omission. This uncaring attitude represented gross medical negligence,” Makgoba said. 

Incorrect time of death

In addition, Makgoba found that Lethole’s time of death was inaccurately recorded. 

“Lethole died on 29 June 2020 at 22:30, and not on 27 June 2020 as his father firmly believed, nor on 28 June 2020 as some staff members strongly testified. Mr. Lethole’s death necessitated a rigorous verification process inclusive of telephone records to confirm his date of death due to these incongruities and inexplicable conflicting evidence obtained from the two clinical teams, caring for the same patient, in the same ward and the same hospital and from his family.

“There was a clinical team that swore under oath that he died on 28 June 2020, and the other clinical team equally declared that he died on 29 June 2020. All these transpired due to poor record-keeping and lack of proper communication.

“The truth was finally established through telephone records between the hospital and [Lethole’s father] Albert Lethole’s cellphone and confirmed by the evidence of Conny Mathibela, the operational manager for Ward 23, who made the call, that Lethole died on 29 June 2020 at 22:30.”

Makgoba said Lethole was certified dead on 30 June 2020 – 10 hours and 15 minutes after his lifeless body remained on his hospital bed. His family was only then notified of his passing at 08:50, as shown by the telephone call log records. 

Medical care inadequate 

There was no attempted effort to offer Lethole cardiopulmonary resuscitation (CPR), despite him being young and without any co-morbidities. Also, the decision for CPR not to be attempted was not documented, discussed with the patient or the family, the report found.

“This was established and confirmed through the completed Morbidity and Mortality form from TPTH, 41 days after his death. The decision made not to resuscitate Mr Lethole was ill-conceived and in contravention of the Tembisa Hospital Resuscitation Guidelines.

“Lethole’s medical care was characterised by inordinate delays of consultations, delays on following up on clinical decisions, delays on interventions, and delays in the timeous interpretation of results and the ‘appalling’ clinical record-keeping at TPTH.

“This was established by the investigation and supported by the independent reports of doctors Fareed Abdullah and Portia Ngwata, head of internal medicine at TPTH. The investigation by the Health Ombud and Dr Ngwata further found that Mr Lethole’s care was negligent… Dr. Ngwata put it that Mr. Lethole’s ‘mortality was preventable and avoidable’. “

Recommendations

Makgoba recommended the following:

• The Gauteng Health MEC, Dr. Nomathemba Mokgethi, must urgently appoint an independent forensic and audit firm to, inter alia, conduct a competency assessment of the leadership and management staff at TPTH;
• Mokgethi should also institute a disciplinary inquiry against Dr. Mogaladi, the CEO and accounting officer of TPTH for presiding over such a state of affairs; and
• The Gauteng Department of Health and TPTH should institute disciplinary inquiries into 19 staff members. 

“The recommendations made in this final report are meant to encourage and foster a culture of high-quality health care at TPTH. A culture that respects the dignity of patients, a culture that complies with the prescribed Norms and Standards of the National Health System and a culture that is consistent with the ethics and codes of good clinical practice,” Makgoba concluded.