A damning investigation by the Health Ombud has found that a psychiatric patient who died at the George Mukhari Academic Hospital in 2024 was denied food and medication as a form of punishment while in care.
Health Ombud Taole Resetselemang Mokoena on Tuesday released findings into the death of 35-year-old patient Lerato Mohlamme, who died from burn injuries sustained at the facility.
According to the report, Mohlamme was allegedly deprived of meals and had prescribed medication deliberately withheld while she was in seclusion. Medical records were also falsified to indicate that treatment had been administered.
“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, and medical records were falsified.”
The investigation uncovered what the Ombud described as serious clinical, procedural and ethical failures in her care.
It found that her admission to the psychiatric unit did not follow proper protocol, which requires independent assessments by two doctors before involuntary admission. The report said this failure rendered her admission invalid.
Mohlamme had reportedly disclosed a history of sexual assault, but the hospital allegedly failed to properly assess, document or report the matter to police as required by law.
The report also highlighted unsafe conditions in the psychiatric ward, including poorly located seclusion rooms lacking adequate monitoring systems. Safety concerns raised by patients, including fire risks, were reportedly dismissed by nursing staff.
During the incident, the patient was not thoroughly searched before being placed in seclusion, and emergency response was delayed when a fire broke out. The Ombud found that emergency exits were locked and keys were either misplaced or concealed.
It was further noted that mattresses used in the unit were not flame-resistant. Post-mortem findings indicated that Mohlamme was still alive when the fire started.
The Health Ombud has recommended disciplinary action against implicated healthcare workers and called for urgent corrective measures.
“Protecting the dignity, safety and rights of mental healthcare users is not optional; it is a constitutional and legislative obligation,” Mokoena said.
He added that Mohlamme’s death represents both a personal tragedy and a broader warning about systemic failures in the care of vulnerable patients.