Gauteng Premier David Makhura should consider if Health MEC Qedani Mahlangu is fit to hold office, Health Ombudsman Malegapuru Makgoba said on Wednesday.
She had lost credibility and her actions and those of two senior officials were "chaotic, hurried, in a rush and a total shambles", he told reporters in Pretoria.
Mahlangu was reported to have resigned on Wednesday.
He was briefing media on the outcome of an investigation into the deaths of mentally ill patients transferred from the Life Esidimeni facility to several NGOs in 2016, as part of the provincial health department's cost-cutting measures. He released his report into the matter on Wednesday.
Makgoba said Mahlangu initially claimed that 36 patients had died.
His investigation uncovered that 94 mentally ill patients died between March 23 and December 19, 2016. He suspected the number could be higher. Many families were not informed about the deaths of their relatives.
Makgoba said 18 out of 47 transferred patients died at Precious Angels NGO shortly after Health Minister Aaron Motsoaledi instructed him to investigate.
All 27 NGOs did not have valid licences. Makgoba said this was unlawful, as the victims were vulnerable. All the NGOs had to face the law, he said.
One of the family members broke down during the briefing as Motsoaledi spoke about the reasons for the investigation.
"I'm not embarrassed," Motsoaledi said.
"I'm distressed and very angry. Something like this should have been avoided."
Life Esidimeni looked after about 2 000 patients and got its funding from the department.
Makgoba said he interviewed more than 70 witnesses and also worked with eight psychiatric experts.