When patient reported outcomes and experiences are far from satisfactory: The view of the Health Ombud

Key lessons from the Health Ombud

• Take patient complaints seriously – Adverse experiences signal the need for intervention.
  
• Commit to continuous improvement – Healthcare services must evolve to meet rising patient expectations.
  
• Stay updated on medical advances – Rapid innovations require ongoing staff training.
  
• Enforce professional accountability – Monitoring and enforcing ethical and professional conduct is essential.

Actions required for addressing unsatisfactory outcomes

• Analyse incidents and prevent recurrence.
  
• Implement corrective measures and monitor compliance.
  
• Hold staff and facilities accountable for systemic failures.
  
• Advocate for strategic health system reforms.

Role of the Health Ombud

Established under the National Health Amendment Act of 2013, the Health Ombud operates as an independent entity in the Office of Health Standards Compliance (OHSC). It considers, investigates, and disposes of complaints relating to non-compliance with prescribed norms and standards. The procedures it uses are required to be fair, economical, and expeditious to render improved quality of healthcare to South Africans.

Case Studies: Systemic Failures in Healthcare

Case 1: Communication Failure at Tembisa Hospital

A 34-year-old male patient with multiple comorbidities, including Covid-19, was placed on nil-per-mouth status and treated in isolation. The lack of communication about his treatment plan led him to believe he was being starved. This incident, occurring during the early Covid-19 pandemic, highlights the critical role of clear patient communication.

Case 2: Denial of Care at Motherwell Nu 11 Clinic

A teenage girl, allegedly sexually assaulted, was refused treatment under the mistaken belief that medical intervention would compromise forensic evidence. She was instead sent to a police station, where she collapsed and died. This case underscores the need for proper training in handling vulnerable patients and emphasising that patient care is primary, forensic evidence is secondary.

Case 3: Rahima Moosa Mother and Child Hospital Crisis

A 2023 Health Ombud report exposed severe mismanagement at Rahima Moosa Mother and Child Hospital (RMMCH), leading to unsatisfactory treatment of pregnant women and infants. Issues included aging infrastructure, a broken sewerage system, and patients forced to sleep on floors. Public outrage, fuelled by an open letter from Dr. Tim de Maayer, led to the Ombud investigation and mandated reforms, including:

• Urgent infrastructure upgrades.
  
• Overhaul of senior management.
  
• Reorganisation of human resources to match the hospital’s specialist role.
  
• Establishment of feeder hospitals to manage lower-tier cases.

Case 4: The Life Esidimeni tragedy

One of South Africa’s most devastating healthcare failures, the Life Esidimeni case resulted in 144 preventable deaths due to gross mismanagement of psychiatric patients. The Gauteng Department of Health was forced to close unlicensed NGOs and ensure proper oversight of mental health facilities. Legal action was taken against responsible officials.

Statistical Overview of Healthcare Complaints (2022–2025)

(*Data until January 2025)

Conclusion

The Health Ombud’s findings highlight systemic weaknesses in South Africa’s healthcare system. While some reforms have been implemented, urgent action is still needed to improve patient care, enforce professional accountability, and drive meaningful healthcare transformation.

“The key shortcoming is poorly skilled management teams,” said Professor Mokoena.