A 35-year-old mental health care user, Ms L Mohlamme, died from severe burn injuries in a fire at the psychiatric unit of Dr George Mukhari Academic Hospital after her admission on June 19, 2024. Mental health patients, hospital staff, and the Gauteng provincial government face impacts from this incident, as the government announced measures on March 23, 2026, to fix inefficiencies flagged in a Health Ombud report and prevent future deaths, according to SAnews.gov.za.
Ms L Mohlamme was brought to the hospital by her brother-in-law. She died in a fire likely started by a cigarette lighter she had on her. An autopsy confirmed she was alive during the fire.
The Health Ombud report listed key procedural failures:
- Admission did not follow legal rules, as two doctors did not examine her properly.
- Staff used too much mechanical restraint, against national guidelines.
- They withheld her prescribed medication and food as punishment, then falsified records to show they gave it.
- The seclusion room was far from the nurses’ station with no good monitoring.
- Staff ignored another patient’s fire safety concerns.
- Emergency exits were locked with keys hidden or lost.
- Mattresses were not fireproof, letting the fire spread fast.
Gauteng Premier Panyaza Lesufi said the government acted fast on the draft report. They added 12 nurses, for a total of 105. Nine permanent security staff now work on-site. They trained 21 nurses and two social workers. New CCTV cameras help monitor in real time. Fire fixes earned a compliance certificate on February 19, but more work continues, like buying fireproof mattresses.
The Health Ombud probed if care met the Mental Health Care Act, which calls for humane and dignified treatment. The probe found wider problems. These included punitive practices, poor infrastructure, low staffing, weak staff training on the Act, and bad oversight.
This was one of two probes. The other looked at a neonatal death at Netcare Femina Hospital. Lesufi noted, “When the draft report… was presented to us, we immediately undertook an overhaul.” Prof Taole Mokoena, the Ombud, said the findings show “systemic violations of the rights of mental health care users.” The Health Professions Council of South Africa and South African Nursing Council will review staff actions.
The case showed failures in legal steps for admission, restraint use, and reporting an alleged sexual assault. Staff did not assess, document, or tell police about it. Safety rules broke down in seclusion and fire response.
The Ombud urged redesigning the unit for better security and safety. They also called for upgrades to recreation and rehab areas. Mokoena stressed that protecting dignity and safety is a “constitutional and legislative imperative.” Professional reviews “will be requested,” per the report.
Fire projects continue, including procurement of fireproof mattresses for full compliance. Reporting, security, and supervision have strengthened. More training ensures staff know their duties.
The Ombud will track these fixes with stakeholders to stop repeats. Lesufi pointed to “outstanding matters requiring urgent attention.”
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