Health Ombud reveals serious breaches at South African hospitals

The Health Ombud has exposed serious clinical and ethical breaches in two separate investigations. One at Limpopo’s Rethabile Community Health Centre (RCHC) and Pietersburg Provincial Tertiary Hospital (PPTH), and another at Johannesburg’s Wits Donald Gordon Medical Centre (WDGMC). Both cases resulted in preventable patient harm, including death.

Case 1: Avoidable death and falsified records in Limpopo

Pitsi Eliphuz Ramphele, nephew of struggle icon Dr Mamphela Ramphele, died on November 28 2024, after seeking emergency care for severe abdominal pain.

Findings at RCHC indicate that Ramphele waited nearly four hours just to get a patient file. Despite worsening symptoms, no doctor examined him. At 3.30pm he was referred to a doctor, but none were available. Security staff told him to go home at 3.53pm. His waiting time in total was around eight hours, which was far above national standards.

To make matters worse, two nurses falsified clinical records to hide their failure to provide medical care. It is believed that they backdated patient notes and even forged a Standard Operating Procedure. They face referral to the South African Nursing Council.

Failures at PPTH

Ramphele was admitted with Acute Small Bowel Obstruction. He went 21 hours without a medical review.

Key warning signs, which included faeculent fluid in his NG tube, were ignored. He was wrongly advised to start a soft diet, worsening the obstruction.

A postmortem showed bowel perforations leading to septic shock. The Ombud concluded his life could have been saved with proper monitoring and timely surgery. Junior clinicians were left unsupervised, while essential equipment was missing from the ward. Doctors involved face referral to the HPCSA.

Case 2: Fatal air embolism after routine procedure at Wits Donald Gordon

Dr Edward Mabubula arrived at WDGMC as an outpatient on March 27, 2021 for the routine flushing of his chemotherapy port. Immediately after standing up from the seated procedure, he collapsed. A CT scan later showed a cerebral air embolism, which caused a stroke and seizures.

The Ombud found a serious documentation failure:

WDGMC relied on a 15-year informal “courtesy arrangement”. Patients receiving outpatient port procedures were not registered and no medical file or assessment was completed before the procedure.

Specialists confirmed a strong link between the flushing procedure and the embolism. Dr Mabubula died on June 3, 2021 as a result of complications, although his cancer was listed as the formal cause of death.

The Ombud ordered the hospital to implement proper clinical protocols and ensure every patient receives full documentation. Mediation is recommended to address the family’s compensation request.

According to the Ombud, both cases highlight opposite ends of a dangerous spectrum.

Public sector: resource shortages, poor supervision, unethical cover-ups

Private sector: shortcuts and undocumented practices despite better resources

Both undermine patient safety and accountability.

IOL