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 on March 27, 2021, as an outpatient for the routine flushing of his chemotherapy port. Moments after standing up from the seated procedure, he collapsed. A CT scan confirmed a cerebral air embolism, which led to a stroke and seizures.

The Ombud did not find evidence of clinical negligence. The investigation noted that while an outpatient assessment was completed, it was not documented — a long-standing administrative gap linked to an informal “courtesy arrangement” in place for about 15 years. Under this arrangement, patients undergoing outpatient port procedures were not registered and no formal medical file was created.

Specialists confirmed a strong temporal link between the flushing procedure and the embolism. Dr Mabubula died on June 3, 2021, from complications, although his cancer remained the formal recorded cause of death.

The Ombud recommended that WDGMC formalise its clinical protocols for such procedures and ensure that all patients receive complete and accurate documentation. The report also advises that psychological support be offered to the Mabubula family — not mediation related to compensation, as previously implied.

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