On September 1, 2016, former Gauteng health MEC Qedani Mahlangu claimed to set the record straight about the deaths of 36 patients who were moved from the Life Esidimeni facility to various nongovernmental organisations.
News24 takes a look at what she said then, and what health ombud, Professor Malegapuru Makgoba and his team of inspectors eventually found. The ombud laid the responsibility of at least 94 patients' deaths at Mahlangu and two other colleagues' feet in a report last Wednesday.
Mahlangu resigned shortly before Makgoba announced his findings.
Qedani Mahlangu (QM):
"We strive towards making sure that all mental care users are afforded services in a humane and dignified manner in whatever we do and the mantra we have, from all the levels of care in the department is 'Our patient is king. Whatever we do, our first intention is to do no harm'."
Sub-standard care prevailed under the department's oversight. The patients were transferred to and received by NGOs without any health professionals involved.
"There's 122 NGOs that have been functioning for a period of 10 years. The only new NGOs are about 14 of them. Yes, the places were audited before. They looked at the basic things and those basics were met."
Due to lack of capacity, skills and competence to care for the patients, some frail patients were again transferred, this time to general hospitals, or other NGOs for better care.
Out of the 25 NGOs visited, 22 did not have the capacity, skill, and competence to deal with the influx of mentally-ill patients.
"Our quest is to ensure that these patients are given the medical care. They are seen by the care workers, they are fed, they are bathed, everything else is done for them because we would want to do what's in the best interest of these [patients]."
Care for the mentally-ill patients was compromised because their clinical records and treatment histories were not made available to the NGOs. Most of the NGOs did not have the required skill and competence to care for the mentally-ill patients.
The NGOs started recruiting health professionals only two to three months after patients were received. This could be what caused their deaths.
Lack of competence or skill to administer medication led to the relapse of some patients. Lack of money meant the NGOs could not buy nutritious food or clean linen, or recruit staff.
"For a child I think we are spending about R2,500 or so [at Life Esidimeni per month]. For adults about R3,500 or something like that. And remember now we are also increasing the capacity of our care workers and they are going to be trained through and through.
"Most importantly, most of the workers who were working at Life, be it cleaners, nurses, have been absorbed in the same facilities [NGOs] we are talking about. So the cost saving we have done, we have reinvested the money back to the NGOs."
The NGOs employed unskilled, non-professional, or untrained staff. They were not in a position to assess patients' medical conditions or their records.
The NGOs only got money from the department three to four months after receiving patients from Life Esidimeni, likely leading to shortages of food, linen, and clothing.
Staff at the NGOs were not paid and thus left feeling aggrieved.