JOHANNESBURG – An investigation by the Health Ombud has found a woman who died at the George Mukhari Academic Hospital in 2024 was denied food and medication as punishment.
On Tuesday, Health Ombud Taole Resetselemang Mokoena released a report into the death of psychiatric patient Lerato Mohlamme. The thirty-five-year-old died of burns at the hospital.
“The patient was denied food as a form of punishment while she was in seclusion,” Mokoena said.
“The prescribed medicines were deliberately withheld as a form of punishment. However, medical records were falsified to indicate that the treatment was administered.”
Mokoena said serious procedural, clinical and ethical failures were identified in the care of Mohlamme.
He said the patient’s admission process did not follow the prescribed requirements.
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“Two doctors should have independently examined the patient and committed her to psychiatric in-hospital treatment. Thus, this lapse rendered the admission invalid.”
While Mohlamme gave a history of alleged sexual assault, Mokoena said the hospital had failed to appropriately assess, document and report the incident to the police as required by law.
“The required safety procedures were not followed during her seclusion process. The seclusion room was poorly located and far from the nurses’ rooms and lacked adequate monitoring systems or devices.”
The Ombud said that while safety fire concerns were raised by some of the patients in the unit, these were dismissed by the nursing staff.
“The patient was not thoroughly searched when she was committed to the seclusion room. There were also critical delays in accessing the seclusion rooms when the fire broke out.”
Emergency exits were locked, and the keys were misplaced or hidden, said Mokoena. He said mattresses used in the psychiatric unit were not flame-resistant.
Mohlamme’s post-mortem results indicated that she was alive when the fire broke out.
Following the investigation, the Health Ombud has recommended that disciplinary measures be instituted against the implicated health professionals.
“Protecting the dignity, safety, and the right of mental healthcare users is not an option; it is a constitutional and legislative imperative,” Mokoena said.
He added: “Her death is not only a personal tragedy to them, but it is also a profound reminder of the responsibility that we carry to protect the most vulnerable among us.”