While we focus here on the nine deaths that Judge Mmonoa Teffo found to be unnatural, there were 144 deaths associated with the Life Esidimeni tragedy. Ultimately, these were human beings and for the world to know what happened to them is better than the world not knowing.
In the full judgment in the Life Esidimeni Inquest, Judge Mmonoa Teffo recently found that the deaths of nine people moved from Life Esidimeni facilities to understaffed and under-equipped NGOs "were negligently caused by the conduct of Ms Dorothy Qedani Mahlangu and Dr Makgabo Manamela". Mahlangu was the MEC for Health in Gauteng at the time of the deaths. Manamela was the head of the provincial health department's mental health directorate.
The case sets important legal precedents - maybe most notably by establishing that MECs and officials in health departments can in certain cases be held accountable for deaths that occur on their watch. The full judgment is very much worth reading, not just for the legal details, but also for the detailed picture it paints of the devastating events that occurred in Gauteng in 2016.
At one level, the inquest judgment by Teffo, as with then health ombud Professor Malegapuru Makgoba's report published on 1 February 2017 and the subsequent arbitration award read out on 19 March 2018 by former Deputy Chief Justice Dikgang Moseneke, simply bears witness to the horrific things that happened to vulnerable people who depended on the state for their care. These things happened after activists and mental health experts warned of the severe risks. And, as Judge Teffo concluded, the MEC and the Head of Department were in a position to stop it and should have stopped it, but did not.
As Judge Teffo wrote: "Ms Dorothy Qedani Mahlangu proceeded to terminate the contract between Life Esidimeni Care Centre and the Gauteng Department of Health despite numerous expert advice and warnings from the professionals in Mental Health and stakeholders. The deceased were further moved out of Life Esidimeni facilities to NGOs which were ill-equipped and inexperienced to provide proper and adequate mental health care. Ms Mahlangu's conduct led to regrettable and unfortunate deaths, some of which could have been avoided.
"Dr Makgabo Manamela proceeded to hastily facilitate the implementation of the plan against expert advice from professionals and stakeholders. She could have saved many lives. She visited the NGOs and could see that they were not adequately equipped and some of the personnel were not adequately qualified to care for the mental healthcare users. Some of the NGOs were licensed without following the prescribed protocols."
"Effectively," Judge Teffo concluded that Mahlangu and Manamela "created circumstances in which the deaths of the deceased were inevitable".
Nine unnatural deaths
We considered the journalistic and public interest merits of repeating the details of the nine deaths found to be unnatural here. We think the importance of bearing witness and acknowledging what happened to these human beings outweighs any arguments against recounting these facts. Ultimately, these were human beings and for the world to know what happened to them is better than the world not knowing.
While we focus here on the nine deaths that Judge Teffo found to be unnatural, there were 144 deaths associated with the Life Esidimeni tragedy. Those lives are remembered on a special memorial website.
Six of the nine unnatural deaths occurred in hospital (following their stays in NGOs) and three at NGOs themselves. In two of the nine cases, Judge Teffo found deaths to have been unnatural without postmortems having been performed. These were the deaths of Matlakala Elizabeth Motsoahae and Koketso Christopher Mogoerane.
Motsoahae was admitted from Precious Angels NGO (where she had been moved from Life Esidimeni) to Kalafong hospital with deep bedsores, a decreased level of consciousness, a lower respiratory tract infection, a septic hand, renal impairment and hypernatraemia (which is usually as a result of not drinking enough water). She died after a short stay in hospital. Judge Teffo found that the care that she received at Precious Angels NGO was insufficient.
Koketso Mogoerane was moved to Rebafenyi NGO, had lost significant weight and was distressed. The medication that he took increased appetite, and he did not appear to be getting enough food. With insufficient staff at Rebafenyi due to non-payment by the Department, there were no professional nurses, no dietician or social workers, and there was no one on duty when, at night, Mogoerane fell and died. His body was only discovered the following morning.
For the other seven deaths found to be unnatural, postmortems were conducted. In total, there were postmortems for 35 of the 140 deaths under consideration.
Virginia Machpelah had been determined not to be suitable for transfer to an NGO but was nevertheless transferred to Precious Angels NGO. Precious Angels NGO had both staff and food shortages and the staff it had were not trained to care for people like Virginia. She died emaciated and dehydrated, with gangrene in both of her feet, pale lungs and a congested liver. The medical evidence together with the circumstances of the NGO in which she died led to Judge Teffo's finding that the death was unnatural.
Terrence Chaba was wheelchair-bound. He died after staff from Precious Angels NGO took him to hospital where he was admitted as an unknown patient with threatening bedsores, dirty, having lost significant weight during his three months at the NGO, and with bronchopneumonia. Malnutrition likely made him susceptible to pneumonia. Whereas at Life Esidimeni his self-care and feeding had been under strict supervision, Precious Angels NGO did not have the qualified staff to provide this level of care.
Lucky Maseko lost almost half of his body weight in the three months prior to his death at Precious Angels NGO. He died not being able to breathe because he choked on large chunks of food.
Daniel Charles Josiah had lived at Life Esidimeni for 17 years and died less than two months after being moved to Precious Angels NGO. He was severely underweight and died of necrotising pneumonia. Staff at the NGO appeared not to have noticed how sick Mr Josiah had gotten and his mental illness meant that he would not have been able to articulate how he was feeling.
Sign up for free AllAfrica Newsletters
Get the latest in African news delivered straight to your inbox
Frans Dekker used a wheelchair and had been moved to Tshepong NGO where there was insufficient capacity to give him the care he needed. Mr Dekker died of septic bedsores on various parts of his body.
Charity Ratsoso had lived at Life Esidimeni for 14 years and was then moved to the Cullinan Care and Rehabilitation Centre and then to Anchor Home NGO. In the course of these moves, Mr Ratsoso's identity was lost. Staff at Anchor Home did not know what medication he should have been taking and not getting his medication meant that he had continuous seizures. He died not being able to breathe, likely when he inhaled food during a seizure. He weighed only 42kg.
Deborah Phetla was moved to Takalani Home having lived in institutions for 38 years. She was the first to die at Takalani. She only stayed at the facility for two nights and then died. She was moved into a room by herself and was not properly supervised. Despite being known at Life Esidimeni to be prone to eating rubbish, the lack of supervision meant that when she ate cardboard and paper, it was not noticed and she died when her larynx was cut either swallowing or coughing up a foreign object and she breathed in her own blood.
Note: SECTION27 was actively involved in attempting to prevent the Life Esidimeni tragedy and seeking justice for it in the eight years since. Spotlight is published by SECTION27, but is editorially independent - an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.
Sign-up below to receive the Spotlight newsletter
Email(Required)
Submit
