A damning report from the Office of the Health Ombudsman has revealed deep systemic failures in both public and private healthcare sectors, linked to the deaths of patients at facilities in Limpopo and Johannesburg. The findings have prompted strong condemnation from the Health Minister, who described some of the uncovered conduct as “criminal.”
The investigations focused on two cases: one at the public Pietersburg Hospital in Limpopo, and the other at the Donald Gordon Medical Centre in Johannesburg.
At Pietersburg Hospital, the report details substandard care, a critical lack of clinical supervision, and the shocking falsification of medical records by staff. The probe into a related death that originated at the Rethabile Community Health Centre found that staff falsified records upon learning of the impending investigation, with perpetrators later admitting to the act.
At Donald Gordon Medical Centre, the report confirms that a medical procedure caused a fatal air embolism leading to a stroke. It also uncovered serious, long-term lapses in fundamental recordkeeping. The ombudsman found the hospital had a practice spanning approximately 15 years of not documenting outpatient encounters at its oncology clinic, ostensibly to save patients expenses—a practice stated to be against the law.
In an interview, Health Ombudsman Professor Taole Mokoena elaborated on the widespread systemic issues, particularly within public hospitals. He cited a cascade of problems: severe staff shortages, the filling of senior and administrative positions with acting personnel, and the placement of inadequately trained nurses in emergency reception roles.
“We have enrolled nursing nurses working on their own without supervision from professional nurses,” stated Professor Mokoena. He further highlighted missing and poorly maintained equipment, and a critical failure in maintaining reliable hospital records, which he described as “widespread.”
“The hospitals are not keeping good and reliable hospital records,” Mokoena explained. “This makes it difficult to carry on continuity of care… There’s not sufficient recording to inform the ones that are taking over what had transpired before.”
While cautioning against generalizing the specific act of falsification, the Ombudsman emphasized that inadequate recordkeeping is a pervasive issue. His office reviewed random samples of patient records at the bulk provincial hospital involved to assess the permeation of insufficient supervision.
Regarding the private sector case, Professor Mokoena clarified that the fatal air embolism was a “very rare occurrence” not necessarily due to specific negligence. However, the uncovered recordkeeping breach was severe. “The law directs that every patient’s encounter must be recorded and the records must be kept for an extended period,” he said, confirming the hospital’s practice was a violation.
The reports have raised urgent questions about accountability, regulatory oversight, and the safety guarantees within both the strained public health system and the fee-based private sector. The Office of the Health Ombudsman has presented its findings to the relevant authorities for further action.