5 times Tembisa Hospital staff dropped the ball in tragic Shonisani Lethole case
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Johannesburg - Health ombudsman Professor Malegapuru Makgoba’s scathing report on the death of Shonisani Lethole has exposed negligence at the hands of doctors, nurses and staff at Tembisa Hospital.
Makgoba has also called on the new Gauteng Health MEC, Dr Nomathemba Mokgethi, to urgently appoint an independent forensic firm to determine if the hospital’s leadership, led by chief executive Dr Lekopane Mogaladi, was fit for purpose.
In addition, Makgoba wants a disciplinary panel, consisting of a senior medical doctor, a senior nurse and senior legal counsel with experience in medico-legal matters, to form part of the panel that would take action against at least 10 doctors, nurses, a clinical associate and workers, who have been flagged as failing to provide duty of care to Lethole, lying under oath, falsifying information and acting improperly.
Lethole was a 34-year-old businessman who reported to the hospital on June 23 last year, severely ill, with difficulty breathing and body weakness for about two days before he was admitted to hospital, where he was admitted to the Casualty Covid-19 isolation ward.
He had Covid-19 pneumonia.
His death was preventable and avoidable, Dr Portia Ngwata, the head of internal medicine at the same hospital, told Makgoba during the investigation.
Makgoba’s report details the numerous times health workers failed to act, compromising Lethole’s health.
In one instance, said Makgoba, X-rays and blood tests conducted on Lethole on June 23 confirmed he was severely ill with multiple systemic tissue injuries to the kidneys, liver, lungs and skeletal muscles, and with a systemic inflammatory response.
But nobody noticed.
“However, these critical results were not seen, reviewed, interpreted or repeated and acted upon timeously by the senior doctors caring for him. Mr Lethole had Stage 4 renal failure as determined by the Glomerular Filtration Rate and high blood potassium on admission that were never attended to or reviewed throughout his stay at Tembisa Hospital,” said Makgoba.
Lethole was at the hospital for over 150, hours and for a period of 100 hours he was not fed. When his parents attempted to deliver KFC and Nandos to him, they were unable to, as cleaners were scared to enter the Covid-19 ward.
The ombud found that Lethole’s desperate tweets to Health Minister Zweli Mkhize were substantiated and credible, finding that several staffers at the hospital lied when they said Lethole had been fed.
In his first 43 hours at the hospital, he was not fed. And again, later, Dr Urmson had failed to insert the nasogastric tube (used for feeding), leading to another 57 hours without food while he was intubated and sedated.
“Dr Urmson verbally testified and confirmed that she only ordered this (nasogastric tube feeding) later when Mr Lethole was reported vomiting, but her order was not followed up and acted upon.
“This omission was recognised by Dr Molehe that Dr Urmson had not inserted the nasogastric tube during intubation. Dr Urmson’s order was not even documented in the clinical notes,” said Makgoba.
Makgoba said Urmson had said she had requested a nurse to insert the tube, but in her report to the hospital’s chief executive, she claimed to have inserted the tube herself.
“Both versions could not be true. No other witness who cared for Mr Lethole ever saw an inserted nasogastric tube. So, for another 57 hours, 30 minutes, Mr Lethole was to endure not being fed at Tembisa Hospital.
“This took place when he was most vulnerable and sedated. The health-care professional team of doctors and nurses conceded to the investigation to this negligent, callous and uncaring omission. This uncaring attitude represented gross medical negligence.
“So, for 100 hours 54 minutes of his total stay of 153 hours 54 minutes (65.6% of the time of his stay) at Tembisa Hospital, Mr Lethole did not receive any meals on two separate occasions.
“The health establishment and its management must shoulder the accountability and responsibility for these failures,” said Makgoba.
3. EVEN IN DEATH
But even his date of death was cause for dispute among health workers who were supposedly working together to save Lethole’s life, Makgoba found.
The ombud eventually determined that Lethole had died on June 29, and not June 28 as some staff had strongly testified, and not on June 30, the date his parents had been given and upon which he had been certified dead.
“Mr Lethole died on June 29 at 10.30pm, and not on June 27 as his father firmly believed, nor on June 28 as some staff members strongly testified. Mr Lethole’s death necessitated a rigorous verification process inclusive of telephone records to confirm his date of death due to these incongruities and inexplicable conflicting evidence obtained from the two clinical teams, caring for the same patient, in the same ward and the same hospital, and from his family.
“There was a clinical team that swore under oath that he died on June 28, and the other clinical team equally declared that he died on June 29. All this transpired due to poor record-keeping and lack of proper communication,” said Makgoba.
He said they eventually arrived at the truth by using telephone records between the hospital and Lethole’s father, Albert, and also the evidence of operations manager Conny Mathibela, who made the call to the father on June 29.
“Mr Lethole, demised on June 29, at 10.30pm as recorded by professional nurse Zitha.”
4. DOCTOR GOES AWOL
When Lethole eventually did succumb, the doctor on call failed to respond to calls from the nursing staff to conduct the necessary death certification processes. Lethole was eventually only certified dead 10 hours later, on June 30, Makgoba found.
“Dr Bangala was called twice by the nursing staff to come to certify Mr Lethole timeously but never turned up. He failed to hand over to his colleagues.
“Mr Shonisani Lethole was certified on June 30, 10 hours 15 minutes after his lifeless body remained on his hospital bed, until Dr Marole around 8am retrospectively certified him, and the family was only then notified of his passing at 8.50am as shown by the telephone call log records,” said Makgoba.
5. NO CPR
Tembisa Hospital staff also failed to perform CPR on Lethole, a decision Makgoba described as “ill-conceived” and against the hospital’s resuscitation guidelines.
“There was no attempted effort to offer Mr Lethole CPR, despite being young and without any co-morbidities. Also, the decision for CPR not to be attempted was not documented, discussed with the patient or the family.
“This was established and confirmed through the completed Morbidity and Mortality form from TPTH 41 days after his death,” said Makgoba.
The health ombud found that the patient had not been regularly monitored at the hospital and was left to fend for himself.