Why did 94 psychiatric patients have to die?

Gauteng health MEC Qedani Mahlangu

Timeline of events

June 2016: The Gauteng health department transfers about 1 300 psychiatric patients from Life Healthcare Esidimeni to 122 NGOs to save costs.

Shortly after being transferred, 36 patients die resulting in calls for Mahlangu’s resignation.

September 2016: Health ombudsman, Professor Malegapuru Makgoba is asked by Health Minister Aaron Motsoaledi to investigate the matter.

October 2016: Several lobby groups and families of patients estimate the death toll has risen to at least 60. Mahlangu is accused of under-reporting the deaths. Calls for her head and criminal charges to be brought against her, increase.

February 2017: The health ombudsman’s report is released. He points a finger at Mahlangu and others who are responsible for the deaths.


Health ombudsman Professor Malegapuru Makgoba

Prof. Makgoba’s report

  • More than 1 300 patients were transferred from Life Esidimeni to hospitals and 27 unlicensed NGOs, some of which operated unlawfully.
  • When Mahlangu said on September 13 that 36 patients had died, 77 patients had already lost their lives. “I met the MEC on November 29 last year and asked her how many patients had died, she answered 40. I asked the head of department and he said 37, I asked the director and he said 48. These are three of the most senior people and they don’t know how many patients died?”
  • Numbers of deaths to rise as many corpses have not been identified.
  • Only one of the people who died, died from a mental illness. The rest died from dehydration, malnutrition, cold,  diarrhea, heart attacks and epilepsy.

Negligent or reckless actions

  • Overcrowding in the NGOs
  • Inadequate transfer of frail and sickly mental patients
  • NGOs had no qualified staff and skills; improper heating during winter; lack of food; transferred patients without the knowledge of their families
  • Some of the NGOs operated under invalid licences
  • All patients who died in those NGOs died in unlawful circumstances

80% of deaths occurred in five NGOs

  • Precious Angels (20)
  • Cullinan Care and Rehabilitation Centre (CCRC) Siyabadinga / Anchor (25)
  • Mosego / Takalani (15)
  • Tshepong (10)
  • Hephzibah (5)
  • 11 NGOs with no deaths
  • For every one death at the hospitals there were 19 deaths at the NGOs

The key players

Makgoba said three key players in the project were Mahlangu, her head of department Dr Tiego Ephraim Selebano, and her director, Dr Makgabo Manamela.

“The decision was reckless, unwise and flawed with inadequate planning and a chaotic and rushed or hurried implementation process.”

Makgoba said some executions of the project showed a total disregard of the rights of patients and their families, including the right to human dignity.


  • The gauteng Mental Health Marathon project must be cut.
  • Disciplinary action must be instituted against Dr Tiego Ephraim Selebano and Dr Makgabo Manamela for gross misconduct.
  • They must be suspended for tampering with evidence.
  • Corrective and ethical action must be taken against five deputy directors, the chairperson of the Mental Health Review Board (MHRB) and the CEO of the CCRC.
  • All remedial action must be instituted in 45 days and progress reported to the CEO of the Office of Health Standards Compliance.
  • Police findings must be shared with the appropriate agencies.
  • The department must review all 27 NGOs and de-register those which do not meet health care standards.


Caxton Central

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