How did 36 people die?

As questions swirl around over what could have led to the shocking number of deaths of psychiatric patients in Gauteng – 36 in two months – Health Minister Aaron Motsoaledi has called on one man he expects to connect the dots and provide answers.

This is Health Ombudsman Professor Malegapuru Makgoba, who was asked this week to probe the mystery surrounding these mentally ill patients, who died – after being transferred from healthcare facility Life Esidimeni to save costs – while under the care of government-appointed establishments in Gauteng.

At least 1 300 patients were relocated to various community-based centres.

Makgoba, who is still setting up his new office since he was appointed in June, said: “I was shocked when I heard the news ... [and I] did not know I would be asked to investigate. You see [the media reports] and ask yourself: ‘What has really happened?’” he said.

Once he is able to answer this question, he will have to make recommendations on how to improve the plight of the mentally ill in the province and prevent the tragedy from recurring.

Makgoba said since he started setting up office and recruiting staff, he already had three cases, all of which were about to be concluded.

“This latest case is not my first big one, but it is my first urgent one because of its scale,” he said.

By Friday, the ombudsman was yet to receive any documents to enable him to start his probe, but he told City Press that as soon as he was asked to look into the matter, he moved swiftly to assemble a team of experts, including pychiatrists, to assist him.

Makgoba was so committed to resolving this case that he would be putting on hold several of his usual weekend jaunts to visit his elderly mother, who lives in Sekhukhune in Limpopo.

“This is an urgent case and I would like to complete it as quickly as possible. Since I was notified by the health minister, I have tried to prepare myself.

“As soon as I get something, I will kick-start the process. I am just waiting to receive the necessary documents.”

Makgoba said he was thinking about the families of the deceased patients, who were possibly finding it hard to accept the deaths, especially since they did not know how the tragedies occurred.

“Their relatives must be in terrible pain and the sooner we conclude the investigation, the better. Human beings work better when they understand what happened,” he said.

Where will he start?

“Firstly, I must have the clinical files and records of each patient in my possession. As a physician and doctor, you cannot investigate without understanding clinical history. You would expect that during patient transfers, their fingerprints and medical histories were noted and handed over to the new care centres.”

However, the Gauteng health department said in several media interviews this week that some patients were transferred to new care facilities without clinical files detailing their medical history, and that it had been waiting for these files from Life Esidimeni since the relocation process took place earlier this year.

Makgoba said the case appeared complex. “It looks like there are many angles to the story.”

Once he received patient records, Makgoba said he would elicit help “from experts in mental health, such as three or four psychiatrists.

In fact, I have already put some of them on call, informing them of the urgency of the investigation.

“Thirdly, there will be an inspection of the various establishments where patients were placed to assess whether they met key national standards. I have a team of 10 people ready to go to evaluate these establishments,” he said.

“Next, I am going to need all postmortem reports prepared by the pathologist. We will then interview a range of witnesses, from nongovernmental organisations to nursing staff to government officials, and they will all speak under oath and on record.

“Lastly, we will collate all the information and prepare a report.”

Makgoba reiterated that the number of fatalities was of serious concern. In the medical profession, he said, the death of a psychiatric patient was the exception rather than the rule.

“In all branches of medicine, mental patients who are properly cared for rarely die. Psychiatry must have the least mortality rate than any other branch of medicine,” he said.

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