The Gauteng health department breached an agreement that the Life Esidimeni patients would not be moved to inferior facilities, Health Minister Aaron Motsoaledi has said.
He first learned of the provincial department's intention to move mentally-ill patients to unlicensed NGOs when he was threatened with court action to stop the move, he said in a reply to a Parliamentary question on Monday.
The court application came from the South African Depression and Anxiety Group (Sadag) and public interest law group Section 27.
Health department director-general Malebona Matsoso then contacted the province to find out what had happened, and set up a meeting between the province, Sadag and Section 27, Motsoaledi explained.
"This meeting culminated in an agreement being signed between Gauteng Department of Health and Sadag, whereby it was agreed that if patients have to be moved, they will be moved to facilities that do not offer an inferior service to the one they were receiving at Life Esidimeni.
"As it emerged later, Gauteng Department of Health unfortunately breached this agreement in every conceivable manner."
He said the national health department only learned about the province's misdemeanours when it was summoned to court for a second time, having thought the matter settled.
The agreement, an out-of-court settlement, included that the parties prepare a detailed plan by the end of January 2016. Sadag thus withdrew its court case, which was due in court on December 22, 2015.
The Gauteng health department, however, failed to provide a plan for the patient transfers.
In March 2016, Section 27 rushed to court to interdict the Gauteng Department of Health from moving the patients, but did not cite him as a respondent. He was therefore unaware of it. Section 27 lost the bid for an interdict.
He only learned about the deaths of the mentally-ill patients when then Gauteng health MEC Qedani Mahlangu told the provincial legislature that 36 had died, he said.
"I was completely shocked and could not comprehend the whole thing. I immediately contacted the Health Ombudsperson Professor Malegapuru Makgoba to investigate."
Over 100 patients died as a result of being transferred to facilities not equipped to look after them, Makgoba said in a report released in February. Many more were still at risk.
Democratic Alliance MP Wilmot James on Monday said Motsoaledi's reply should move him to support the call for a judicial commission of inquiry into the tragedy as further details of gross negligence, misconduct and misleading actions emerged.
DA leader Mmusi Maimane wrote to President Jacob Zuma in January asking him to establish the commission.
"There are still too many unanswered questions, and the DA believes that the Gauteng government must be held to account for their reckless decision that cost more than 100 mental health patients their lives," James said.