Media Statement: Health Ombud releases findings on psychiatric case death by burns at Dr George Mukhari Academic and neonatal death at Netcare Femina hospitals.

Monday 23rd March , 2026

For Immediate Release

23 MARCH 2026
To All Editors and Health Journalists

Health Ombud releases findings on psychiatric case death by burns at Dr George Mukhari
Academic and neonatal death at Netcare Femina hospitals.

Pretoria. The Health Ombud, Professor Taole Mokoena, has released findings from two
investigations. The first investigation examined the care and death of a mental health care
user by burns at Dr George Mukhari Academic Hospital (DGMAH), the second investigated
the neonatal death at Netcare Femina Hospital (NFH).

PSYCHIATRIC CARE FAILURES AT DGMAH
The investigation into the death of Ms L. Mohlamme, a 35-year-old psychiatric patient who
died from burn injuries on 24 June 2024, revealed serious systemic and clinical failures,
including:
• Unlawful admission procedures,
• Improper restraint practices,
• Not reporting a prior sexual assault disclosure,
• Punitive withholding of prescribed medication,
• Unsafe seclusion compounded by fire safety failures such as locked exits,
inaccessible extinguishers,
• Assault by Staff,
• Absent disaster plans, and
• Inadequate infrastructure, inadequate staffing, and poor oversight compromise
patient safety and dignity.

The Health Ombud confirmed that Ms Mohlamme was alive during the fire and died from
severe burn injuries. The investigation highlighted broader patterns of abusive care,
insufficient staff knowledge of mental health legislation, and systemic lapses of governance.

Recommendations
The Health Ombud calls on the Gauteng Department of Health and DGMAH management
to urgently address compliance and safety failures, strengthen oversight, and ensure
protective measures for vulnerable mental health users. Professional regulatory bodies have
been urged to consider disciplinary action against the implicated staff members.

NEONATAL DEATH AT NETCARE FEMINA HOSPITAL
The Ombud’s investigation into baby Moatlegi Masoka’s death found that while the
prescribed medication was correct, a clinical error occurred when adrenaline was
administered intravenously instead of by nebulisation, due to an incorrect route
prescription. Communication failures resulted in the unnatural death of the infant. The report
also substantiated that NFH failed to refer the death for a forensic post-mortem. Additional
findings identified outdated medication protocols, inadequate Neonatal Intensive Care
Unit (NICU) shift handovers, and irregular electronic medical record access controls.

Recommendations
The Health Ombud directed NFH and the Netcare Group to establish a task team to oversee
remediation measures and report progress quarterly; strengthen medication safety, such as
pause and combination of electronic prescription before proceeding and dual-verification
systems; update clinical protocols and shift handover procedures; improve electronic
medical record controls and staff access; and engage in further mediation with the Masoka
family. Some of the implicated healthcare professionals will also be referred to regulatory
bodies for further inquiry.

These investigations underscore the importance of robust clinical leadership, clear
communication channels and procedures, and stringent safety systems to prevent
avoidable harm and strengthen public confidence in healthcare services.

The complete detailed reports are available for public access on the Health Ombud
website at www.healthombud.org.za.

End.

Issued by the Health Ombud.

Media Enquiries
Ricardo Mahlakanya
Cell: 066 473 8666

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