Eight years after the tragic deaths of 141 mental healthcare patients who were moved from Life Esidimeni care facilities, the Gauteng High Court, Pretoria, on Wednesday recommended that the former Gauteng Health MEC, Qedani Mahlangu and the former Director of the Mental Health Directorate, Dr Makgabo Manamela, be held responsible for the deaths of nine of the patients.
Judge Mmonoa Teffo said these patients had lost their lives due to their negligence.
It is now up to the National Prosecuting Authority to decide whether they should be prosecuted on charges of culpable homicide.
The judge mostly only read out her findings following the inquest into the Life Esidimeni tragedy. She, however, did at the start of her judgment comment that Mahlangu “ignored expert advice” that the patients should not be removed to alternative care centres, many of which were not equipped to deal with them.
“She could have saved many lives as she visited the various NGOs and saw that they were not adequately equipped.” The judge added that Mahlangu proceed to terminate the contract between the Life Esidimeni care centre and the department despite the warnings from mental healthcare experts and other stakeholders
Judge Teffo said the patients were moved to NGOs which were not equipped to deal with them and had inexperienced staff who could not give proper and adequate care in providing mental healthcare.
The judge added that both Mahlangu and Manamela created the circumstances in which the deaths were inevitable.
“Having heard all the evidence in this inquest, I have come to the conclusion that the deaths of the deceased were due to the negligence of Miss Mahlangu and Dr Manamela,” Judge Teffo said.
The patients - most of whom died in 2016 - were mostly moved to 27 unlicensed NGOs which the court was told during the inquest could not care for them.
In nearly all the deaths - apart from one - where no autopsies were conducted, the judge said she was unable to make a finding. In certain of the other deaths she also could not make findings, although autopsies were performed in some of these cases.
It was only in relation to the deaths in which enough evidence was proved to show negligence on the part of Mahlangu and Manamela that the judge recommended to the NPA that they could be held criminally liable for the deaths.
The inquest into the deaths began virtually on July 18, 2021. At the inquest, Section 27, who represented 44 of the families of the deceased, argued that Mahlangu and Manamela should be charged with culpable homicide for their involvement in the tragic deaths of the mental healthcare users who were relocated from Life Esidimeni in 2015 and 2016.
Many of the patients died of neglect, starvation and other health factors, such as bedsores.
Section27 in its closing arguments last year (based on the evidence already before the court) argued that the deaths of at least 10 of the mental healthcare users were caused by the conduct of Mahlangu and Manamela.
The arguments included that Mahlangu made the initial decision to terminate the Life Esidimeni contract. She then continued to make a series of reckless decisions in relation to the project for months while chairing project team meetings.
Section27 said these included putting pressure on the Gauteng Department of Health officials to implement the termination (of the) project over an extremely short period of time.
“Mahlangu made these decisions having been warned of the risks of termination, the impracticalities of continuing with the implementation of the project and the insufficiency of measures in place to mitigate the risks and impracticalities,” Section27 submitted.
It also argued that Manamela was the de facto project leader and directly involved in the implementation of the termination project.
“She signed licences for NGOs that she knew had not been properly assessed and then failed to ensure that they were paid timeously. She was warned both before and during the implementation of the project about risks and failed to mitigate these risks sufficiently,” Section27 said.
Mahlangu maintained that she did not make the decision to terminate the contract with Life Esidimeni and was not involved in the implementation and execution of the termination project.
She said only officials involved in implementation may have a case to answer. She was of the view that their conduct fell short of the requirements for liability.
When it was pointed out that she was informed about the implementation, she argued that she was misled. As a result, she said, the judge should not make a recommendation that she be prosecuted.
Manamela maintained her innocence and said she did not take the decision to terminate the contract with Life Esidimeni and had previously drafted a plan to reduce beds at Life Esidimeni in phases.
She oversaw the implementation team and tried to assist when problems arose, she said.
The DA, meanwhile welcomed Judge Teffo’s finding that Mahlangu and Manamela were negligent in causing the deaths of nine Life Esidimeni patients.
DA Gauteng health spokesperson Jack Bloom said the findings were a severe indictment that should lead to culpable homicide charges against Mahlangu and Manamela.
“It is a pity that the lack of autopsies for the other Esidimeni deaths precluded a firm negligence finding for the other deaths. Other charges should also be laid against all those who can be identified as causing the suffering of the Esidimeni patients,” Bloom said.
The Gauteng Provincial Government fully accepted the judgement. “We are pleased this process that brought so much pain and suffering to those who lost their loved ones, as well as the survivors whose human rights were grossly violated by this tragedy, is nearing its end.
“This judgement closes a painful chapter, not only for the affected families but for us as the Gauteng Provincial Government,” said Premier Panyaza Lesufi. “The provincial government sympathise with the bereaved and affected families and understands that the Life Esidimeni inquest was incredibly important for families to find closure and for accountability.”
Puseletso Jaure, CEO of Life Nkanyisa, said: “This has been a long, heartbreaking and difficult process for everyone involved and especially the affected families. It is our hope that they may find solace and closure as they come to terms with the outcome.
“The Esidimeni tragedy and today’s judgment should make us all reflect on how our healthcare stakeholders can work together to bring about systemic reform that prioritises the needs of the most vulnerable patients in our society.
“We would advocate for and support a review of how healthcare services for these vulnerable patients are provided, so that we embed best practice and the highest standards of patient care.
“To do this we should utilise the strengths and draw on the perspectives of the entire healthcare community, in particular the NPOs, healthcare professionals, public and private providers, vulnerable patients and their families, and civil society groups. From this tragedy must come a better system and a renewed commitment to place quality patient care at the centre of healthcare.”
By late last night, the NPA had yet to comment.
Pretoria News
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