Health Ombud releases findings on Zenizole Vena case

South Africa – The Health Ombud, Professor Taole Mokoena, on Tuesday released the findings of the investigation into the allegations of a patient denied provision of care at the Motherwell NU 11 Clinic in the Eastern Cape .

Mokoena said his office was requested by the Minister of Health, Joe Phaahla, to investigate potential negligence and suboptimal care at the clinic .

The complaint alleged that the clinic denied provision of healthcare to Zenizole Vena, a 15-year-old, which resulted in her death .

Vena had gone to the clinic, accompanied by an elderly woman, seeking healthcare after being sexually assaulted .

The investigation established that Vena was turned away by healthcare workers at the clinic and that she later died at the Motherwell Police Station Community Service Centre (MPSCSC) where she had sought assistance .

The allegation that Vena was denied provision of care at Motherwell NU 11 Clinic was substantiated and confirmed based on the information gathered during the investigation, said Mokoena .

It was also established that two nurses did not arrange transport to take both the elderly escort and the victim to MPSCSC or call the police to come to Motherwell NU11 clinic to take over the case .

The investigation further revealed additional findings, such as the failure of the Motherwell Police Station Community Service Centre to assist Vena upon her arrival at the charge office .

At the station, she was told to wait and was attended to her after she waited for one hour and 30 minutes .

During this time, she experienced seizures and was foaming at the mouth .

She was later found dead on the floor in the charge office .

“The investigation was conducted through analysis and triangulation of information and documentary evidence received from Motherwell NU 11 Clinic, the Eastern Cape Provincial Department of Health (ECDoH), Nelson Mandela Bay District Health (NMBDH), onsite visits and interviews with relevant personnel,” Mokeona said .

Interviews were conducted with 13 witnesses between 28 February 2023 to 27 March 2023 by the investigation team from the Office of the Health Ombud .

“A further 10 interviews were conducted by the Ombud and the investigation team from 15 to 19 May 2023 .

This included eight witnesses, who were re-interviewed and they did not contradict themselves .

Statements from three witnesses were also received from the Motherwell Police Station .

“It is important to mention that before the Office of the Health Ombud investigation, the Eastern Cape Provincial Department of Health had conducted an internal investigation in November 2022 and shared their report with the Office of the Health Ombud,” Mokoena said .

He said it was quite disturbing that a basic human instinct to assist a person in distress, particularly a child, does not seem to exist within the South African Police Service (SAPS) at Motherwell Police Station .

“The allegation that Motherwell NU 11 Clinic failed to refer Ms Z Vena to the next level of care was substantiated and confirmed .

“Based on the evidence obtained, it can be concluded that Ms Z Vena was not attended to in a manner that is consistent with the nature and severity of her health condition at Motherwell NU 11 Clinic,” Mokoena said .

The complaint was lodged by the Democratic Alliance’s Shadow Minister of Health, Michéle Clarke, in September 2022 against the Motherwell NU 11 Clinic .

In his remarks, Minister Phaahla said it is totally unacceptable for someone to be denied healthcare .

Recommendations include, among others, that the District Manager of the NMBDH should institute a disciplinary inquiry within one month against various personnel; the District Manager must, within two months, ensure that mentoring is provided to the healthcare workers to ensure that all the nurses are kept abreast of the new developments in the management of sexual assault cases; the District Manager of NMBDH and the Head of Department must, within six months, procure a service provider to install the Service/Notice Board at the Motherwell Clinic that indicates the health care services provided by the clinic and indication of working times at the clinic; the District Manager must within one month ensure the Standard Operating Procedure for the management of sexual assault cases is developed and in-service training is provided to the staff at Motherwell NU 11 Clinic .

The report with findings and recommendations was handed over to Health Minister for further analysis .

It can be found on www .

healthombud .

org .

za .

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