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‘How can man die better’ Mr Shonisani Al Junior Lethole Report into the circumstances surrounding the care and death of Mr Shonisani Al Junior Lethole at Tembisa 1 Provincial Tertiary Hospital THE REPORT INTO THE CIRCUMSTANCES SURROUNDING THE CARE AND THE DEATH OF MR SHONISANI LETHOLE AT TEMBISA PROVINCIAL TERTIARY HOSPITAL REFERENCE #: 19109 Authored by: Professor Malegapuru W Makgoba MB., ChB., (Natal); D.Phil., (Oxon); FRCP (Lond); FRS (SA); OMS. Foreign Associate Member of the National Academy of Medicine (USA) Health Ombud: Republic of South Africa ‘How can man die better’ Mr Shonisani Al Junior Lethole Report into the circumstances surrounding the care and death of Mr Shonisani Al Junior Lethole at Tembisa 2 Provincial Tertiary Hospital The Health Ombud wishes to thank Dr. Lekopane Mogaladi, Chief Executive Officer (CEO) of Tembisa Provincial Tertiary Hospital (TPTH) for all the assistance and cooperation he provided to the investigation. To the many witnesses who all participated and provided evidence, some against great odds, the Health Ombud is very grateful. This investigation would not be what it is without the tireless hard work and dedication of Ms. Helen Mamodiehi Phetoane, Senior Investigator Health Care Cases at the Office of Health Standards Compliance (OHSC). I am very grateful to her. The Health Ombud is also grateful to Dr. Fareed Abdullah, Director: Office of AIDS and TB Research at the SAMRC and Clinician in charge of COVID-19 patients at Steve Biko Academic Hospital, for independently analysing and reviewing the Clinical Notes of Mr. Shonisani Lethole. The Health Ombud is also indebted to Dr. Portia Ngwata, Head of Internal Medicine at TPTH who provided another nuanced independent analysis and review of Mr. Lethole’s Clinical Records following the provision of the Health Ombud’s preliminary report. ‘How can man die better’ Mr Shonisani Al Junior Lethole Report into the circumstances surrounding the care and death of Mr Shonisani Al Junior Lethole at Tembisa 3 Provincial Tertiary Hospital TABLE OF CONTENTS LIST OF ABBREVIATIONS/ACRONYMS ..................................................................................................... 6 1. EXECUTIVE SUMMARY .................................................................................................................... 8 2. BACKGROUND AND INTRODUCTION ............................................................................................ 21 3. POWERS AND JURISDICTION OF THE HEALTH OMBUD ................................................................ 25 4. THE COMPLAINT ............................................................................................................................ 26 5. METHODOLOGY AND APPROACH TO THE INVESTIGATION .......................................................... 28 .......................................................................................................................................................... 32 6. NARRATIVE BY THE FATHER, MOTHER, SPOKESPERSON, THE GIRLFRIEND AND OTHER WITNESSES ............................................................................................................................................ 32 7. INVESTIGATIONS AND FINDINGS .................................................................................................. 49 8. THE SARS-CoV-2 (COVID-19) TEST RESULTS .................................................................................. 69 9. THE CARE RENDERED TO MR. LETHOLE BY THE TPTH STAFF ........................................................ 75 10. THE TIMELINE OF CARE: MR. SHONISANI LETHOLE’s JOURNEY .................................................... 76 10.1 Collected, but Ignored Baseline Admission Investigations ....................................................... 92 10.2 Certification of Mr. Lethole’s Death on the 30th June 2020...................................................... 96 10.3 Gauteng COVID-19 Morbidity and Mortality Reporting Template ........................................... 97 10.4 Consolidated Reflections on the Care provided to Mr. Lethole by the three of TPTH's Senior Consultant Physicians ....................................................................................................................... 98 10.5 Other Patients who passed on at A & E Isolation and Ward 23 ............................................. 103 10.6 Poor Communication and Collaboration among Health Care providers ................................ 104 10.7 Inadequate Leadership and Oversight .................................................................................... 108 10.8 The Nurses refused to assist Mr. Lethole to go to the bathroom .......................................... 109 10.9 Lethole’s family concerns ....................................................................................................... 110 10.10 The Inaccuracies and Inconsistencies in the reports submitted to the Health Ombud and the former MEC for Health. ‘An Administrative Bungle’ ....................................................................... 111 11. RECORDING AND RECORD KEEPING ........................................................................................... 139 12. FINDINGS DEMONSTRATED THAT TPTH WAS NEITHER ‘FIT NOR READY’ FOR PURPOSE AS A DESIGNATED COVID-19 HOSPITAL ...................................................................................................... 143 13. THE WILLINGNESS TO CORRECT THE IDENTIFIED SHORTFALLS .................................................. 148 14. REVIEW OF CLINICAL NOTES: PATIENT SL BY DR. FAREED ABDULLAH ....................................... 149 Triage and Management at Tembisa Emergency Department ................................................... 150 15. PRE-CONCLUSION ANALYSIS OF THE RESPONSES TO THE PRELIMINARY REPORT ..................... 165 16. CONCLUSION ............................................................................................................................... 185 ‘How can man die better’ Mr Shonisani Al Junior Lethole Report into the circumstances surrounding the care and death of Mr Shonisani Al Junior Lethole at Tembisa 4 Provincial Tertiary Hospital 17. RECOMMENDATIONS .................................................................................................................. 189 18. REFERENCES ................................................................................................................................ 197 19. LIST OF MEDIA ARTICLES/CLIPS ON CASE REF: 19109 ................................................................. 200 20. LIST OF ANNEXURES .................................................................................................................... 202 ‘How can man die better’ Mr Shonisani Al Junior Lethole Report into the circumstances surrounding the care and death of Mr Shonisani Al Junior Lethole at Tembisa 5 Provincial Tertiary Hospital LIST OF ABBREVIATIONS/ACRONYMS A & E Accident and Emergency ABG Arterial Blood Gas ARDS Acute Respiratory Distress Syndrome CAP Community-Acquired Pneumonia CEO Chief Executive Officer ClinA. Clinical Associate CCTV Closed-Circuit Television CRP C-reactive protein COVID-19 Coronavirus disease of 2019 CXR Chest X-ray ECG Electrocardiogram ET tube Endotracheal tube FBC Full Blood Count FiO2 Fraction of Inspired Oxygen GDOH Gauteng Department of Health GPCC Gauteng Province Command Council GPS Global Positioning System GRF Glomerular filtration rate HPCSA Health Professions Council of South Africa ICU Intensive care unit IT Information Technology LFT Liver Function Tests M&M Morbidity and Mortality NAD No abnormalities detected NG tube Nasogastric tube NHLS National Health Laboratory Services NMC Notifiable Medical Conditions OHSC Office of Health Standards Compliance OM Operational Manager P/F Ratio of the arterial partial pressure to fractional inspired Oxygen PPE Personal Protective Equipment PUI Person Under Investigation QA Quality Assurance QIP Quality Improvement Plan. SAMRC/ MRC South African Medical Research Council SAPS South African Police Service SARS-CoV-2 Severe Acute Respiratory Syndrome Coronavirus- 2 SOP Standard Operating Procedure ‘How can man die better’ Mr Shonisani Al Junior Lethole Report into the circumstances surrounding the care and death of Mr Shonisani Al Junior Lethole at Tembisa 6 Provincial Tertiary Hospital TPTH Tembisa Provincial Tertiary Hospital U & E Urea and Electrolytes blood tests WHO World Health Organisation ‘How can man die better’ Mr Shonisani Al Junior Lethole Report into the circumstances surrounding the care and death of Mr Shonisani Al Junior Lethole at Tembisa 7 Provincial Tertiary Hospital 1. EXECUTIVE SUMMARY “There is no more difficult art to acquire than the art of observation, and for some men, it is quite as difficult to record an observation in brief and in plain language” ~ Sir William Osler This Report of the Health Ombud is in terms of Section 81(A) of the National Health Act, 2003 (Act No.61 of 2003). The report communicates the findings and recommendations of the investigation that was undertaken succedent to a complaint lodged by the Minister of Health, Dr. Zwelini Mkhize for the Health Ombud to investigate the circumstances surrounding the care and death of Mr. Shonisani Lethole at Tembisa Provincial Tertiary Hospital (TPTH) in Gauteng Province. The Health Ombud commenced investigating the allegations levelled against TPTH from the 6th July 2020. A preliminary report was prepared and forwarded to all those

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