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RISK-BASED INSPECTION
REPORT
HELEN JOSEPH TERTIARY HOSPITAL
GAUTENG PROVINCE

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Risk-Based Inspection Report - Helen Joseph Tertiary Hospital
11 to 13 September 2024 and 2 to 5 December 2024
 TABLE OF CONTENTS
ABBREVIATIONS 1
1 EXECUTIVE SUMMARY 3
2 BACKGROUND AND BRIEFING OF THE HOSPITAL MANAGEMENT 4
3 LEGISLATION AND OTHER PRESCRIPTS 4
4 METHODOLOGY 5

SECTION A 6

5 FACT FINDING REPORT ON THE ALLEGATIONS 7

5.1 Allegations of the dilapidated structure 7

5.2 Challenges encountered: Maintenance of the building, grounds and infrastructure 7
5.3 Allegations of the unattended corpse 10
5.4 Allegation of repeated radiological CT scan on the same day 11
5.5 Allegation of long stay in accident and emergency unit 13
5.6 Allegations of unprofessional behaviour by doctors 15

6 INSPECTION FINDINGS AND INTERVIEWS CONDUCTED IN MEDICAL WARD 8 16

6.1 Environment of care 16

6.2 Patient dignity 18
6.3 Interviews with staff in Ward 8 19
6.4 Interaction of nursing staff and doctors 19
6.5 Infrastructure maintenance department 20

7 HOSPITAL MANAGEMENT RESPONSE TO MR HOLMES ALLEGATIONS 21

7.1. User rights and clinical governance 22

7.2. Programme to prevent other complaints 22
7.3. Interview with the clinical manager - internal medicine department 23

8 ANALYSIS RELATED TO QUALITY OF CARE AND SAFETY IN HJTH 24

8.1. Quality of care 24
8.2 Safety 25

SECTION B 26

9 ADDITIONAL FINDINGS RELATED TO THE COMPLAINT 27

9.1 Cleanliness of the hospital and waste management 27

9.2 Findings on the hospital management 32
9.3 Human resources component 33

SECTION C 35

10 FOLLOW UP INSPECTION VISIT 36

11 FINDINGS AND ANALYSIS RELATED TO THE FOLLOW UP VISIT 38

11.1 Leadership and governance 38

11.2 Maintenance, facilities and infrastructure 41
11.3 Concerns with the relationship between doctors and nurses 44

12 RECOMMENDATIONS 45

11.1 Gauteng Provincial Department of Health 45

11.2 Management of Helen Joseph Tertiary Hospital 45

12 CONCLUSION 46
 LIST OF ACRONYMS AND ABBREVIATIONS

A&E - Accident and Emergency

ALOS - Average Length of Stay
CMJAH - Charlotte Maxeke Johannesburg Academic Hospital
CEO - Chief Executive Officer
CT - Computer Tomography
DID - Department of Infrastructure and Development
DPOS - Daily Patient Opinion Survey
ED - Emergency Department
ECG - Electrocardiogram
EWS - Early Warning System
EXCO - Executive Committee
HE - Health Establishment
HJTH - Helen Joseph Tertiary Hospital
HOD - Head of the Department
HPCSA - Health Professions Council of South Africa
IPC - Infection Prevention and Control
MANCO - Management Committee
MEC - Member of the Executive Council
MHCU - Mental Health Care User
M&M - Morbidity and Mortality
NHLS - National Health Laboratory Service
NQIP - National Quality Improvement Plan
NSM - Nursing Services Manager
OHSC - Office of Health Standards Compliance
OPT - Outpatient Department
PCV - Polyvinyl Chloride
PSI - Patient Safety Incidents
RHT - Refusal of Hospital Treatment
RWOPS - Remunerative Work Outside the Public Service
SAHPRA - South African Health Products Regulatory Authority
SOP - Standard Operating Procedure

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
 ANNEXURES

Annexure 1: Helen Joseph Hospital Maintenance Plan 2024/25

Annexure 2: Response Report on the Complainant’s Allegations

Annexure 3: Dr Edoo Statement

Annexure 4: Occupational Health and Safety Inspections

(July 2022, November 2022, August 2022 and April 2023)

Annexure 5: Infection Prevention and Control Hand Wash Facilities Audit

Annexure 6: Disaster Management Plan

Annexure 7: SOP on Management of Corpses

Annexure 8: Patient Safety Incidents or, Statistical Data

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1. EXECUTIVE SUMMARY

This report presents the findings of a risk-based inspection and a follow-up risk-based inspection visit
conducted by the Office of Health Standards Compliance (OHSC) at Helen Joseph Tertiary Hospital.
The inspection was initiated following a complaint published on social media by Mr Tom London, whose
real name is Mr Thomas Holmes, (hereinafter referred to as “the complainant”). Mr Holmes raised issues
related to inadequate infrastructure maintenance, poor environmental hygiene in the medical ward,
and the unprofessional behaviour of medical doctors toward healthcare service users.

Helen Joseph Tertiary Hospital is a 630-bed provincial tertiary hospital in Johannesburg, Gauteng
Province. An interim management structure currently manages the hospital. During the initial Risk-
Based Inspection (RBI) at Helen Joseph Hospital was under the interim management of an acting
Chief Executive Officer (CEO), Dr Arthur Manning, a Clinical Manager, Dr Rufus Thoka, and a Nursing
Service Manager, Ms Azwimbavhi Tshitereke. The Gauteng Provincial Health Department appointed
this interim management team for three months, beginning 1 August 2024; however at the time of
follow up inspections, all the senior managers were still in acting positions. Following media reports,
the OHSC inspection team conducted a risk-based inspection based on the allegations made by
the complainant. The inspectors initially conducted a three-day risk-based inspection from 11 to 13
September 2024 and a follow-up risk-based inspection visit from 2 to 5 December 2024.

The initial risk-based inspection findings confirmed the complainants’ account of details. The inspections
revealed serious contraventions of the prescribed norms and standards regulations for quality and
safety and various other applicable laws aimed at ensuring safe and quality healthcare services. The
hospital’s infrastructure was in poor condition, with leaking water from steam pipes, and a sagging
ceiling, which posed safety risks to patients and staff. Several toilets were out of order, forcing some
staff members to travel to a nearby shopping mall to relieve themselves.

It was also established that there were indeed delays in removing a patient’s mortal remains in the ward
due to inadequate mortuary attendants. The broken taps and electric plugs were held with sellotape
even on the patient’s bedside, close to the functional piped oxygen supply. The hospital management
team, interviewed during the inspection, confirmed the OHSC inspection findings.

This report identifies critical areas that require immediate attention, including infrastructure repairs,
cleanliness improvements, and enhanced training for hospital staff on professional conduct. Emphasis
is placed on the urgent need for systemic changes to ensure compliance with the prescribed norms
and standards regulations set forth under the National Health Act, 2003 (Act No 61 of 2003) and any
other laws applicable to provide safe, hygienic, and respectful healthcare services to all patients.

The inspection report captures the essence of OHSC’s inspection findings, including a detailed review
of the allegations, the hospital’s responses, and the OHSC’s recommendations to improve healthcare
services at Helen Joseph Tertiary Hospital.

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.2. BACKGROUND AND BRIEFING OF THE HOSPITAL MANAGEMENT

On 7 September 2024, a complaint by Mr Thomas Holmes about Helen Joseph Hospital (HJTH) surfaced
through a viral video shared across multiple social media platforms such as Facebook and WhatsApp.
In the video, Mr Holmes expressed dissatisfaction with his treatment from a doctor who took his file
without greeting him. He also highlighted the unprofessional behaviour of some medical staff during a
lumbar puncture procedure conducted on another patient during his third day in the Accident and
Emergency (A&E) unit while waiting for a bed. He criticised having to undergo a Computed Tomography
(CT) scan twice on the same day, citing negligence and wasting resources. Mr Holmes further pointed
out the delay in the handling of a deceased patient’s remains and noted poor conditions in the ward,
including the presence of flies and inadequate infrastructure.

The OHSC conducted an inspection to determine the veracity of the allegations in Mr Holmes’s viral
video recording. Upon arrival at HJTH, the OHSC team was received by the Personal Assistant to the
Acting Chief Executive Officer (CEO), Dr Arthur Manning. A briefing meeting was held with the senior
management team to outline the purpose of the OHSC visit. The briefing meeting was attended by Dr
Manning, Ms Tshitereke (Acting Nursing Director from Charlotte Maxeke Academic Hospital), Mr Xaba
(Quality Assurance Manager- HJTH), Dr Thoka (Acting Clinical Manager from Bertha Gxowa Hospital),
Ms Rirhandzu Kubayi (Deputy Director Human Resources-HJTH), and Ms Nomakhwezi Mjada (Personal
Assistant to the Office of the CEO-HJTH). Ms Catherine Mbuyane, the Director of Quality Assurance
at the National Department of Health, and Ms Vuyiswa Melk, the National Quality Improvement Plan
(NQIP), Dr Mariam Edoo Manam, the Clinical Manager of HJTH, and later Ms Nokhwezi Ndoda, the
Deputy Director of Support and Logistics, joined the session. A collaborative and exploratory interaction
was adopted to obtain the required information.

The OHSC team explained to the HJTH management team that the complainant’s viral video allegations
regarding HJTH informed the risk-based inspection. Based on these allegations, the OHSC identified
specific functional areas (where services are provided) for inspection. The executive management was
interviewed individually, and followed by visits to various service areas within the hospital.

3. LEGISLATION AND OTHER PRESCRIPTS

This report considers the provisions of the following pieces of legislation:

• The Constitution of the Republic of South Africa (Act No. 108 of 1996)
• Mental Health Care Act, 2002 (Act No. 17 of 2002)
• The National Health Act, 2003 (Act No. 61 of 2003) As amended.
• Norms and Standards Regulations Applicable to Different Categories of Heath Establishments, 2018.
• Procedural Regulations Pertaining to the Functioning of the Office of Health Standards Compliance
• And Ombud, 2016.
• Promotion of Administrative Justice Act, 2000 (Act No 3 of 2000).

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4. METHODOLOGY

The inspection was conducted using the following methodology:

• Observations;
• Patient record analysis;
• Documents analysis; and
• Staff and patients’ interviews.

The report is divided into three inter-related sections:

• Section A - Addresses Mr Holmes’s complaint/allegations.

• Section B - Addresses additional findings related to the complaints.
• Section C - Addresses findings of a follow-up risk-based inspection.

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 Mr Thomas Holmes
complaints/allegations

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5. FACT FINDING REPORT ON THE ALLEGATIONS

5.1 Allegations of the dilapidated structure

Allegation:
Mr Holmes alleged that the structure of the hospital with a focus on Ward 8 was dilapidated.

The visit was made to Ward 8, where Mr Holmes was admitted and the radiology department. It also
extended to other hospital areas such as laundry, maintenance department, and occupational health
and safety to assess health and safety issues including the building’s condition and maintenance issues.
The following findings were noted during the OHSC inspection:

Findings:
The hospital building is old, and there are ongoing challenges with the water supply to the outdated
and rusted galvanised pipes. Ms Belphia Avheani, the Facility Manager, reported that Helen Joseph’s
management is aware of the backlog in maintenance needs. Ms Avheani mentioned that she previously
recommended replacing these pipes with polyvinyl chloride (PVC) pipes throughout the hospital, but
this was never implemented.

The health establishment has a planned preventive maintenance schedule for buildings and grounds
for the financial year 2024/25; however, no specific dates were indicated when the services would be
provided (Annexure 1: Maintenance Plan 2024/25).

There was no evidence that planned preventive maintenance for buildings and grounds had been
conducted as scheduled. According to the facility manager, only the sewer line was upgraded.
Supporting documents were requested but not provided.

Analysis of findings:

The building was dilapidated and not maintained despite scheduled maintenance plans available. This
finding contravened norms and standard regulations 14.(1) which state that the health establishment
and its grounds must meet the requirements of building regulations.

5.2 Challenges encountered: Maintenance of the building, grounds and

infrastructure
Some areas of the building, such as the basement area where the water and sewage pipes were
located, were not maintained.

The identified items and areas that require immediate maintenance included the following:

• Damaged plinth (some parts had fallen off) on the walkway outside the reception area;
• Damaged doors of the medical storage area and asset room;
• Broken window pane in accident and emergency unit;
• Vinyl covering was coming off the medical stores’ walls, workshop, passages, and asset room;
• There was peeling paint on the walls and ceiling of the medical stores, mortuary, and oxygen bank;
• Watermarks and damaged ceilings were observed in the boardroom and the medical stores;
• The accessible toilet was not functional in the administrative block; and
• The glass door to the administrative block was damaged.

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The maintenance budget is centralised at the district office in the City of Johannesburg. The contractors
are appointed at the district level, but the health establishment lacks documentation proving where
the services were managed and how the hospital monitors contract engagements taking place on the
premises for these appointments.

The Facility Manager, Ms Avheani, reported that the health establishment received a budget allocation
of R20,000,000 (Twenty million rands) for maintenance. As of July 2024, the expenditure stood at 64.9%,
amounting to R12,980,000, (Twelve million nine hundred eighty thousand rands). Priority is given to
statutory maintenance, which includes essential systems such as oxygen supply, vacuum systems, chiller
plants (to ensure compliance with legislation), lifts and boilers. A spreadsheet detailing the expenditure
report was projected. However there was, no evidence provided to demonstrate progress on the
maintenance of day-to-day repairs of nonfunctional and blocked toilets completed to date.

The occupational health and safety annual management inspection report on safety hazards and
maintenance requirements was unavailable. Only a few reports of occupational health and safety
inspections for the seven units in the hospital, including Ward 8 were produced as evidence submitted
to hospital management and conducted by the environmental health unit. The findings in these reports
included but were not limited to leaking pipes, damaged ceilings, broken windows and toilets.

The health establishment used generators as a backup in case of power supply interruption. Records
showed that testing was done weekly, and the maintenance service was performed annually;
however, the manufacturer’s instructions were not available to verify whether testing and service were
conducted according to the manufacturer’s instructions. The Facility Manager, Ms Avheani reported
that the routine service for the generators was due, and the service provider was on site at the time of
inspection; however, the service provider’s appointment letter was not produced.

The hospital has four boilers, but only three are in operation, one is out of order. The facility manager
reported that the boilers are maintained every three years; however, no documents are available
to support the boiler maintenance schedule or the maintenance that has been conducted. The fire
safety compliance certificate is not available. The hospital has 18 lifts, of which four are not functioning.
The two of four lifts that were not functioning are situated on the side of the Emergency Department
(ED) and were used to transport patients to the radiology and specialist clinic. The other two lifts are
situated near the laundry area.

A new building project for nurses’ homes and retail stores has been completed; however, the buildings
have not yet been occupied. It is alleged that the contractor has not been paid. There is a legal
process regarding a non-payment dispute with the contractor.

It was reported that due to the insufficient budget, there was a need to prioritises essential maintenance
for the oxygen, vacuum, chiller plants and life-saving equipment like generators. The maintenance of
the building and grounds remains unaddressed.

Ms Vutomi Hlongwane, the Occupational Health and Safety Manager, reported that safety hazards
have been identified throughout the hospital. The buildings are poorly maintained, with broken taps
and leaking toilets. Although systems are in place to report these issues to the hospital management,
they have not been addressed or fixed.

Equipment maintenance was challenging, including servicing newly bought equipment, but not limited
to the non-functional air conditioner in the sonar room, C-Arm, and mobile X-ray units.

Infrastructure limitations affecting users and their families were identified. These issues were not limited
to the mortuary, which lacked a waiting area. As a result, relatives of the deceased had to sit in the
passage outside the mortuary. Additionally, the viewing area for the deceased was smaller in size,
making it difficult for families to gather and pay their last respects.

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Sewage system Leaking water pipes
Comment: Overflowing – non-functional sewage Comment: Poor maintenance
system posing a health risk

Broken wall vinyl in bathrooms Unmanned peeling ceiling paint

Comment: Poor maintenance and conducive Comment: Poor maintenance support
environment for breeding of microorganisms -IPC

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5.3 Allegations of the unattended corpse
Allegation
Mr Holmes alleged that a corpse in Ward 8 was not attended for several hours.

Findings:
Records show that the patient was certified dead at 6H30 and the body was registered at the mortuary
at 9H00. The SOP for HJTH stated that the body must be removed within two hours. It was established
that mortuary attendants were not employed in the hospital thus the services of removing corpses
from the wards were done by porters. The manager pointed out the challenges of staff shortages. The
inspection team could not verify the required mortuary attendants; Mr Milton Ngoasheng, the Logistics
Manager (Mortuary, Laundry, Kitchen, Transport, Portering and Cleaning Services) failed to produce an
approved organisational structure requested by the OHSC inspection team.

Mr Ngoasheng reported that nurses in the wards sometimes do not call the mortuary immediately after
a patient has died. Instead, they often contact the family first to come to the hospital to view and
identify the deceased before the body is taken to the mortuary.

Observation in mortuary
The total mortuary storage capacity for bodies is 114, which includes outside containers used as a
cold room, the internal storage for 67 bodies and cold room for 47 bodies. Two fridges, (numbers one
and six) have been non-functional for the past four months, and there are no maintenance records
for them. The hospital has only one trolley to transport corpses from the wards to the mortuary. The
inspector was informed that the hospital has two hydraulic jacks and one of them was non-functional
and has been condemned; however documentation was not available.

Broken mortuary fridge Mortuary waiting area in the passage

Comment: Poor maintenance of equipment Comment: Lack of privacy

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Analysis of findings
The findings show that the corpse in Ward 8 was within the requirements of the hospital SOP to remove
the corpse from the mortuary. The hospital has not appointed mortuary attendants; however, porters
provide services to move corpse from the ward to the mortuary.

Failure to have an appointed mortuary attendants compromises the movement of corps from the ward
to the mortuary. The findings indicate contravention of norms and standards regulations 19(1), (2)(a),
which state that the health establishments must ensure that they have systems in place to manage
health care personnel in line with relevant legislation, policies and guidelines.

5.4 Allegation of repeated radiological CT scan on the same day

Allegation
Mr Holmes alleged that he had done a chest CT scan twice on the same day without any explanation.

Findings:
On 06 September 2024, Mr Holmes was sent to radiology for a CT scan, and a high-resolution test was
done, which revealed a mass. Upon reviewing the CT scan results by Dr Pillay, (Registrar), a second CT
scan was requested, which will include a contrast solution to establish the type of mass identified.

According to the acting CEO, Dr Manning, and Clinical Manager of Internal Medicine, Dr Thoka
mentioned that the repeated CT scan was part of managing Mr Holmes’s condition to elicit more
information; this is part of the routine procedure and does not constitute negligence. Clinical Manager,
Dr Edoo and acting CEO, Dr Manning stated that Mr Holmes was fortunate that a second CT scan was
ordered and done on the same day due to an available appointment slot. Mr Holmes was provided
with reasons for the repeat of the CT scan.

Further assessment of the CT scan waiting area revealed that it did not have adequate space, and
inpatients were mixed with those from the Outpatient Department (OPD). There was no contingency
plan available for continuity of care in instances where there was a breakdown of CT scan machine.
There were two sonar rooms, and one in a makeshift room without an air conditioner. Adverse events of
the sonar equipment overheating were reported. Radiology staff had expired dosimeters, which had
not been sent for reading, increasing the risk of overexposure to radiation.

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Expired dosimeters
Comment: Overexposure to radiation posing a safety hazard

Broken C-Arm Broken mobile/portable X-ray machines

Comment: Poor maintenance of equipment Comment: Poor maintenance of equipment
leading to delay diagnosis leading to delay diagnosis

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Analysis of findings:
Mr Holmes received timeous treatment where the CT scan was done within a short duration without
having to secure the appointment. In this finding, the clinical management provided to Mr Holmes,
adhered to the norms and standard regulations 7(1) which state that the health establishment must
establish and maintain clinical management systems, structures and procedures that give effect to
national policies and guidelines.

5.5 Allegation of long stay in Accident and Emergency unit

Allegation:
Mr Holmes allegation was that he stayed in the Accident and Emergency unit for three days before he
was admitted to Ward 8. During his lengthy stay at A&E unit, he could not use the toilets as they were
not usable.

Findings:
The Accident and Emergency unit is equipped with seven resuscitation beds, five of the beds have
ventilators. During the inspection, all the resuscitation beds were occupied. To accommodate additional
patients in need of care, three extra stretchers were added to the section. The monthly patient count
in the Accident and Emergency unit typically averages between 3,800 and 4,500. For August 2024, the
total headcount was 4,229, with 2,144 patients remaining in the department for over 24 hours while
waiting for admission due to a lack of beds.

Overcrowding in unit due to unavailability of beds, patients on stretchers and lazy boys
Comment: Patients stay in the emergency department for up to 72 hours awaiting beds, and beds not having
linen

Other sections in the Accident and Emergency unit were designated for various disciplines. There was
an area for surgical patients, one for medical and another for psychiatric patients. All patients were
triaged on arrival in the area designated for triage.

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
Staff interviews in the Accident and Emergency unit
During interviews with two consultants, Dr Patricia Saffy, Emergency Medicine Specialist and HOD for
A&E and Dr Chadinha, (Emergency Medicine Specialist and second in charge) along with operational
manager, Ms Nortjie, it was revealed that a newly constructed unit intended for the 72-hour observation
of psychiatric patients was available. However, this unit could not be utilised due to a shortage of
nursing staff. As a result, overcrowding in the Accident and Emergency unit has become a significant
issue, compromising the suitability of the environment for patient care and violating privacy standards.
Additionally, the A&E unit used to accommodate 72-hour observation patients lacks bathrooms, forcing
patients to wash in overcrowded areas using basins.

They also highlighted a shortage of linen, which resulted in patients having to use their blankets or
occasionally lying on beds without sheets. They faced challenges in transporting patients to the X-ray
department when the lifts were broken, as the unit was located on the first floor while the accident and
emergency unit was in the basement. Moreover, two emergency X-ray rooms within the unit were non-
functional.

They further pointed out issues with water shortages, particularly during times when the city experienced
a lack of water. Due to the hospital’s location, it is often the first to run out of water and the last to
receive water from the tank.

Analysis of the findings:

The complainant’s concern about his long stay in casualty before being allocated a bed in the ward
was proven true, as records showed that he stayed in casualty for three days. The matter was further
confirmed through a review of three patients who were in Accident and Emergency unit at the time of
inspection, and the following was established:

• Two of the three patients who came to the Accident and Emergency unit the previous day were
still in the unit and awaiting beds;
• Some patients were lying on uncovered mattresses;
• Lack of clean linen in the linen room;
• The psychiatric section was overcrowded with patients on 24 and 72-hour observations;
• There were no beds for the MHCU; hence some patients were using reclining lazy boy’s chairs as
beds ; and
• Three toilets of which one staff toilet and two of the male toilets in the unit were non-functional, and
a broken sink was noted in the sluice room.

Non-functional toilet Non-functional toilet

Comment: Poor maintenance of infrastructure Comment: Poor maintenance of infrastructure

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
A&E unit was overcrowded, with users awaiting beds in the wards, including the MHCU who were placed
under 72-hour observation. During the users’ stay in A&E unit they had no access to beds and bathing
facilities. Cleaning of the area was also a challenge thus infection prevention was compromised.

The overcrowded casualty compromised users’ privacy. Users stayed for prolonged periods in the
casualty area without proper bathing facilities.

The above findings confirm contravention of norms and standards regulations 8 (1) and 2(b),(c) which
state that the health establishment must maintain an environment which minimizes the risk of disease
outbreaks, the transmission of infection to users, health care personnel and visitors.

5.6 Allegations of unprofessional behaviour by doctors

Allegation:
Mr Holmes alleged that doctors did not behave in a professional manner when coming into the ward
and treating the patients. The doctors would come in the ward without greeting anyone, including
nurses and patients. Even when at the bedside of the patient they never talked to the patient but only
write in the patient’s file without asking anything from the patient.

Staff interviews
The staff in the unit stated that they were surprised by the sudden change in mood by Mr Thomas
Holmes, who they described as friendly and respectful. The staff stated that Mr Holmes had never raised
complaints since his admission in the ward on 1 September 2024 until the eruption of the incident on
Saturday morning. The staff attributed Mr Holmes’s sudden unhappiness to changes in the doctors,
particularly Dr Pillay, who had been his primary doctor since admission. The staff in the ward confirmed
the change of Dr Pillay, who had to handle some less complicated patients’ workloads while also
preparing to write exams in two weeks.

The staff members in the unit experienced the doctors (the registrars) as “curt,” but interns (doctors)
were the opposite due to possibly more reliance on the nurses to do their duties. One senior staff
member said there are no multi-disciplinary rounds in the unit, and doctors (the registrars) sometimes
do not conduct physical assessments of patients; “they hardly touch patients”.

The intern, described as “blonde,” never greeted Mr Holmes on the first day of taking him over. The
team could not interview her because she was given days off. She was allowed to be off because the
situation and influx of staff from provincial and national offices were overwhelming, as she felt it was
due to her. However, the clinical manager (Dr Edoo) availed her statement outlining the sequence of
events.

Observations
While conducting interviews with the ward manager, three medical students arrived and without
introductions, requested an ECG machine, which was in her office. The manager was aware of their
visit but relied on the name tags that they were students from University of Witwatersrand, but again,
she was not privy to their visit.

Findings
The nursing staff bemoaned the lack of communication when new interns, students, or registrars were
allocated to the ward. They stated that new faces would just come to the ward without a warning.

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Analysis of findings
The finding confirmed that the communication between doctors and nurses as well as patient was a
great concern affecting the safety and quality of health services to the users. There was no proper
communication between new interns or registrars, and even when they were in the wards, nobody
introduced them to the nursing personnel.

6. INSPECTION FINDINGS AND INTERVIEWS CONDUCTED IN MEDICAL WARD 8

Allegation: Presence of flies in Ward 8

Ward 8 is located on the 4th floor and serves as an admission ward for internal medicine. It has a
capacity of 32 beds and is primarily designated for female patients. However, it also functions as an
overflow accommodation for the adjacent male medical ward. Mr Holmes was admitted in Ward 8
due to the full capacity of the male medical ward, Ward 9.

6.1 Environment of care

Observations in Ward 8:
There were flies in the cubicles hovering on the curtain rails; however, the cause of the infestation
could not be determined. Environmental officers were called in to assess the situation and fumigate the
areas, but they were reluctant to do so while parts of the ward were occupied. Even after the curtains
were stripped and changed, flies were still visible during a subsequent visit on 12 September 2024. It was
noted that the fly-repellent machines in Ward 8 were not functional and did not have electrical cords.

The ward had a very strong offensive odour, which was attributed to mattresses that had been soaked
in urine for an extended period. Patients were using their personal blankets due to a lack of sufficient
linen. The linen room in the ward was disorganised, and clean linen contained in one bag was still
unpacked and lying on the floor. Staff stated that the cleaning team was short-staffed and unable to
properly store the clean linen on shelves as required.

Findings:
Numerous flies gathered on the screening curtain rails and the environmental health officers classified
the situation as an “infestation.”

Ward 8 floor Loose electrical cables

Comment: Rotting of the scatting Comment: Posing a danger

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 Loose hanging cables Gaping electrical socket
Comment: Health hazard Comment: Health hazard

The drip room was also in disarray, with boxes of intravenous fluids left on the floor rather than being
packed onto the shelves as necessary. Electrical plugs in the wards generally showed signs of poor
maintenance, including those beside the beds in every cubicle in Ward 8. Some plugs were mounted
on the wall and held up with tape due to a lack of support from the maintenance unit.

Loose electrical plug held with sellotape Loose electrical plug held with sellotape
Comment: Poor maintenance support, risk of Comment: Poor maintenance support, risk of
electrical shock electrical shock

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The bedside plugs posed a safety risk, potentially leading to electric shocks for patients. The Ward
8 operational manager indicated that many repair requests were not being addressed by the
maintenance department due to the alleged lack of materials needed for repairs.

The door hinges of the staff toilet in Ward 8 were broken and supported by a rope tied to another door
in the hallway. Both the toilet seats and covers were also damaged. Additionally, the vinyl wall covering
was broken, creating a potential breeding ground for micro-organisms. The water taps on the basin,
which had three sets of elbow taps, were not synchronised properly; when the middle tap was opened,
water flowed from the leftmost tap, and the centre tap did not have running water.

Leaking water pipes Water taps

Comment: Poor maintenance Comment: Poorly connected taps. Water comes
out from the extreme taps when the middle taps
are opened. Similarly, when extreme taps are
opened, no water comes out.

The paint on the ceiling was peeling, although the cause could not be established. A broken window in
the isolation room had been temporarily covered with a box because maintenance had not yet made
the necessary repairs. The centre tap did not have running water.

6.2 Patient dignity

Ward 8 has 32 beds, but only two bathtubs are available for shared use between male and female
patients. Due to a shortage of linen, some patients have resorted to using blankets brought from home.
The curtains around the beds, intended to provide privacy during examinations or procedures, were not
replaced for two days after being cleaned. The manager responsible for cleaning and laundry explained
that the curtains could not be replaced because the male cleaners were off duty, compromising the
patients’ dignity. However, the ward manager noted that the attitude of the departments affects how
requests are handled and expressed gratitude that some previously rejected requests were fulfilled
due to the involvement of the OHSC. The manager felt there was a lack of accountability in addressing
these issues.

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6.3 Interviews with staff in Ward 8
Inspectors conducted interviews with staff in Ward 8. The staff in the unit expressed surprise at the
sudden change in mood of Mr Holmes, whom they described as friendly and respectful. They noted
that Mr Holmes had never raised any complaints since his admission to the ward on 1 September
2024 until the incident on Saturday morning. The staff attributed Mr Holmes’s sudden unhappiness to
changes in his medical team, particularly the departure of Dr Pillay, who had been his primary doctor
since his admission. They confirmed that Dr Pillay was moved to manage less complicated patients and
lighten her workload as she prepared for exams in the next two weeks.

The staff members in Ward 8 characterised the doctors (registrars) as “curt,” exhibiting a rudely brief
and abrupt manner when interacting with ward staff during rounds. In contrast, the interns (doctors)
were described as polite, likely due to their greater reliance on nurses to assist with the execution of
their duties.

While interviewing the manager in Ward 8, three medical students arrived. None of them greeted or
introduced themselves to her; instead, they went straight to request an ECG machine from the ward
manager’s office. The manager was unaware of their visit or presence in the ward, stating that she
relied on their name tags to identify them as students from University of Witwatersrand but she had not
been informed about their arrival.

The staff member mentioned that simple things like doctors greeting and talking to patients could be
done. Increase the supervision of doctors to foster a culture of customer care. Nurse managers should
be included during the orientation of new doctors and interns to emphasise the expectations when in
the wards.

6.4 Interaction of nursing staff and doctors

Although the relationships between nurses and doctors were generally described as collegial, some
staff members expressed concerns regarding doctors’ disregard for nurses’ skills. They felt doctors
often did not accept or consider nurses’ advice in patient care. The nursing staff lamented the lack of
communication when new interns, students, or registrars were assigned to the ward, noting that these
new healthcare workers would often arrive without prior notice. One senior staff member mentioned
that there are no multidisciplinary rounds in the unit and doctors (registrars) sometimes fail to conduct
physical assessments of patients, stating, “They hardly touch patients.”

Regarding the allegation that doctors talked about holidays, cars, and houses while busy attending
to patients. The nurse assisting the interns stated that the conversation did not occur during the
lumbar puncture procedure. The other staff member said that she had overheard in the corridors the
conversation about holidays, cars and houses.

The intern, described by Mr Holmes as “blonde,” never greeted him on the first day of taking him over
as a patient. The inspectors could not interview the intern doctor because she was given days off at
the time of inspection. She was allowed to take time off because the situation and influx of staff from
provincial and national offices post the circulation of Mr Holmes video clip were overwhelming, as she
felt it was due to her. However, the Clinical Manager, Dr Edoo, availed her statement outlining the
sequence of events (Annexure 3). In summary, the intern in her statement acknowledged that it was
true she did not greet Mr Holmes when she took his file/ record. The reason given for not greeting was
because of the training that was taking place in the same cubicle and was avoiding disturbance. The
acting Chief Executive Officer (CEO), Dr Manning, who had previously held a meeting with doctors,
confirmed in his written response on the day of the briefing meeting on 11 September 2024.

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The intern doctor took the file to familiarise herself with Mr Holmes’s progress. Once the training was
completed, the intern returned to see Mr Holmes, who expressed unhappiness that his file/records were
taken, and the intern did not even greet him. According to the statement provided, the intern doctor
apologised to Mr Holmes.

While Mr Holmes wanted to discharge himself, the intern could not let him sign the Refusal of Hospital
Treatment (RHT) because it did not fall under her competency. Dr Pillay was called to address the
patient’s concern; however, he did not manage to change the patient’s mind about refusing hospital
treatment. Finally, Mr Holmes signed the RHT and was given the referral letter to seek treatment
elsewhere.

The floors in Ward 8 looked clean at first glance, but were greasy around the skirting. When the
inspectors arrived, some cubicles were emptied to allow the cleaners to strip the floors, change the
screen curtains, and clean the curtain rails. The floor stripping seemed to be an effort to clean the ward
thoroughly to eliminate the dirt observed in the cubicles and to address the ongoing fly problem in
the ward, which contradicted Dr Manning’s statement who mentioned during the briefing session that
there were no flies.

Analysis of the findings:

The inspection confirmed Mr Holmes’s complaint about the presence of flies in the ward. Mr Xaba, the
quality manager, and the environmental officers acknowledged that flies are a problem in other wards
as well.

The above findings confirm the contravention of norms and standards regulations 8 (1) and 2(b),(c)
which state that the health establishment must maintain an environment which minimizes the risk of
disease outbreaks, the transmission of infection to users, health care personnel and visitors.

6.5 Infrastructure maintenance department

The ward manager stated that requesting repairs from the maintenance department is always delayed
due to a lack of material from the maintenance department. On review of the ward works order request,
several works order requests dating back to 2021 that have not been attended to were noted. The
senior artisan was interviewed and requested to provide reconciled works orders from 2021 to August
2024. This evidence was not provided even though it was said it would take just an hour to produce.
The senior artisan stated that the Department of Infrastructure Development (DID) has not provided him
with materials for the past three years. He could only fix minor things, such as leaking water taps, that
did not require buying additional or new materials. The poor state of infrastructure maintenance was
evident in several places during the walkabout in the hospital, where leaking water and steam pipes
were noted in the central medical supply storage area.

The senior artisan stated that, in most instances, he would see contractors coming into the hospitals to
conduct maintenance of electrical power back up systems (generators) without his prior knowledge
or inclusion in the development of service specifications. There was no clarity from the management
team on which department between Health Infrastructure and DID should provide materials for the
maintenance department to be fully functional.

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7. HOSPITAL MANAGEMENT RESPONSE TO MR HOLMES ALLEGATIONS

Mr Holmes, the complainant, was admitted to HJTH in Medical Ward 8. He expressed concerns about
healthcare users being taken for granted by healthcare workers, stating that they were not assisted
when seeking help. He described patients as being treated like guinea pigs and reported feeling
disrespected by medical doctors who did not greet them, and exhibited unprofessional and rude
behaviour. Additionally, he criticised the hospital’s dilapidated infrastructure and mentioned spending
several days in the casualty department before his admission. Mr Holmes also noted that he underwent
a CT scan procedure twice on the same day.

The Acting CEO, Dr Manning, prepared an unsigned report regarding the complainant’s allegations
against HJTH (Annexure 2) and provided it to the inspectors. However, Dr Manning was not present
for a one-on-one interview between 11 and 13 September 2024, during the pre-inspection briefing
meeting where he supplied the OHSC team with his written report.

The first paragraph of the unsigned report discusses Mr Holmes medical condition, noting that he
remained in the Accident and Emergency until he was assigned to an appropriate bed in Ward 8. The
report states that the management team investigated Mr Holmes’ complaint and concluded that the
medical management was appropriate. However, it does not explain the basis for this conclusion.

The report acknowledges existing infrastructure problems but fails to outline any concrete plans to
address these issues. It also mentions the need to investigate the attitudes of medical doctors.

Management was collectively interviewed during the briefing meeting, and Dr Manning, in his written
response, stated the following regarding the video allegations:

• The clinical care provided to Mr Holmes was said to have been excellent, as stated by the
management team. The management team further stated that it is important to note that Mr Holmes
did not express any complaints about his clinical care, except that he underwent CT scans twice on
the same day. Dr Manning mentioned that the provincial office advised that expert services could
be acquired to assess Mr Holmes’s clinical care if needed. Dr Manning confirmed that Mr Holmes
signed a Refusal of Hospital Treatment (RHT) and refused to speak with hospital management after
leaving the facility.

• The management team met the doctors who treated Mr Holmes after the allegations made by
him. The doctors admitted that they generally do not greet patients and used Mr Holmes complaint
experience to reflect on customer care. In the pre inspection briefing meeting, Mr Xaba the Quality
Manager stated that similar complaints were raised in 2022 in surgical wards.

• Dr Manning and the management team mentioned during the briefing meeting that Infrastructure
analysis was done, and the report promised to be furnished to the inspection team was not
produced. Dr Manning was not available on the subsequent days of inspection. He further raised
concerns about the one unreliable theatre that was non-functional during inspection.

• The back-up water supply from the 3rd floor was raised as a challenge. The water pump lacked
the capacity to pump water beyond the 3rd floor, making it difficult to provide services when the
municipal water supply is closed or cut off.

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• Dr Manning stated that there were only a “few” flies in Ward 8 and would not have been attracted
by the corpse not moved to the mortuary. He also said that the origin of the flies could not be
established because the windows in the ward were kept closed.

• Dr Manning informed the inspection team that the interim management was brought in to stabilise
and turnaround the services in HJTH. This interim team includes an Acting CEO, Acting Nursing
Service Manager, and Acting Clinical Manager. They have been deployed from different hospitals.

7.1 User rights and clinical governance

The quality manager, Mr Xaba, was interviewed to establish how the hospital manages complaints
and patient incidents. The quality manager stated that they encouraged users to raise their concerns
or dissatisfaction, the hospital has implemented a system called the Daily Patient Opinion Survey
(DPOS). This system encourages early detection of dissatisfaction, and investigation, and resolution of
complaints. The units are encouraged to conduct the survey twice daily (morning and afternoon) and
submit the forms to the quality unit for analysis. Users are also provided with the mobile contact numbers
of the quality managers so they can contact them directly if they are not comfortable writing. The usual
complaints procedure was also continued.

It could not be verified whether the DPOS was conducted during Mr Holmes’s hospital admission stay
or the morning of the video incident because Mr Xaba (QA Manager) could not provide evidence as
requested.

Another system implemented to reduce the escalation of complaints was Acknowledge, Introduce,
Duration, Explanation, Thank you (AIDET). This process is said to enhance communication between
patients and clinicians, and the hospital experienced a reduction in complaints about doctors in
2023/24, which were said to be high during the 2022/23 financial year. About 70 doctors were trained
in the system, but there was insufficient attendance from the doctors in internal medicine. There was no
impact analysis of the AIDET program that could assist in consistent implementation.

Mr Xaba stated that he previously requested a slot to present the AIDET program to doctors during the
Morbidity and Mortality (M&M) meetings, but Dr Bayat denied the request. The reason for rejecting the
request advanced by the responsible Head of Department (HoD), Dr Bayat internal medicine, was that
doctors were uncomfortable talking in the presence of Mr Xaba. The doctors advanced for the same
reason doctors were uncomfortable having discussions in the presence of Mr Xaba when Mr Xaba
was gathering information after Mr Holmes’s video came out. Dr Bayat was unhappy that the quality
manager directly requested information from the affected doctors.

The morbidity and mortality meetings are exclusive to doctors to the extent that the quality manager
is sidelined, and even when he requested to attend, his request was denied. The chairperson of the
morbidity and mortality meetings has failed to provide the quality unit with minutes, seeing that he
could not attend the meetings. Clinical managers did not support the quality manager to remove the
exclusivity barrier to allow the quality manager to address quality-related matters in the management
of patients. Mr Xaba did not provide the terms of reference for the morbidity and mortality forum to
establish its composition or membership.

7.2 Programme to prevent other complaints

Mr Xaba and the quality team (champions) tried to identify infrastructural issues and requested
intervention from the maintenance department. However, due to a lack of materials, the maintenance
unit could not attend to the repair requests from different units. The infrastructure complaints raised by
Mr Holmes were previously reported by managers in the hospital but were not addressed.

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Findings:
The Occupational Health and Safety Manager, Mr Vutomi Hlogwane conducted inspections and
identified non-compliant issues in the wards, such as exposed electrical wires and leaking pipes in the
basement. Mr Hlogwane mentioned that reports for the periods July, August, November 2022, and April
2023 were furnished to management (Annexure).

Analysis of the findings:

Despite the inspections conducted by the occupational health and safety manager in HJTH and
reports furnished to management, no enforcement action was taken, and thus the state of the building
remained dilapidated.

This finding contravened norms and standard regulations 14.(1)—which state that the health establishment
and their grounds must meet the requirements of building regulations.

7.3 Interview with the clinical manager- internal medicine department

The Clinical Manager, Dr Edoo, outlined the chronology of events leading to Mr Holmes’s signing a
refusal of hospital treatment. Dr Edoo obtained a statement from the affected intern doctor and stated
that she had to give her days off to recuperate from the mental effects Mr Holmes incident. She said
that Mr Holmes’s record was analysed, and Dr Edoo concluded that the patient received the best
care they could provide. She clarified the matter relating to the CT scan repeated twice, which was a
normal procedure.

Dr Edoo raised concerns that the institution lacked stable leadership, which could contribute to poor
outcomes. For the past six years, the hospital has changed CEOs five times. The hospital struggled to
retain some sub-specialists because the posts did not exist in the Helen Joseph Hospital’s organogram.
Staff morale is low, precipitated by the daily conditions that staff members must work in. However, she
also appreciated the interim management deployed in the hospital for three months. She found the
interim management to be supportive and quick to act. It was, however, unclear what would happen
at the end of the three-month period given to the interim management Acting CEO, Acting Clinical
Manager-surgery, and Acting Nursing Services Manager.

Interviewed managers complained about the staff shortages nurses, doctors, etc., which management
attributed to the non-alignment of hospital classification and organogram. The facility was gazetted
as a tertiary hospital in 2012 but has never had an approved organogram and budget aligned to the
level of care. The problem was said to be general to all tertiary hospitals in Gauteng. It was noted that
there was no typical tertiary hospital in the province with both structure and budget properly aligned
as gazetted.

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8. ANALYSIS RELATED TO QUALITY OF CARE AND SAFETY IN HJTH

The OHSC inspection revealed sufficient evidence to substantiate and confirm most of the allegations
made by Mr Holmes’s in the viral video clip circulated in the media related to the following: doctors not
greeting patients; flies’ infestation in Ward 8; demised patient mortal remains not being moved to the
mortuary timely, and poor state of infrastructure.

However, the OHSC was satisfied with the reasons given in the explanation in relation to the CT scan.

8.1 Quality of care

8.1.1 Staff attitude

The allegation of doctors not greeting patients, which refers to the core of healthcare worker attitudes
towards patients and treating patients with dignity, was found to be true and confirmed by management.
This attitude of doctors was not only limited to the patients but also to interactions between nurses and
doctors. This allegation further played itself out during the OHSC inspection, where three undergraduate
student doctors walked into the office of Ward 8 manager during an interview with OHSC inspectors,
and did not greet let alone greet the ward manager and proceeded to ask about an ECG machine.

8.1.2 Delays in removal and transportation of a corpse

The delay in transporting the corpse to the mortuary was confirmed by staff and attributed to a shortage
of porters and family members who get called to identify their deceased relatives. The porter allocated
to the internal medicine department was also responsible for assisting other departments. There are
three dedicated porters, servicing the entire hospital in the collection of corpses.

8.1.3 Infestation by flies

The complaint about flies in the ward was found to be true. Ward 8 was infested with flies, as reported
by Mr Holmes, and other hospital wards were also affected. Although there were attempts for deep
cleaning exercises during the OHSC inspection, the flies infestation seemed resistant and were still
hovering around even a day later after the cleaning. Cleanliness is expected in any setting where
health services are provided and poses a threat of further nosocomial infections.

8.1.4 Poor infrastructure

There was substantive evidence on the alleged poor state of infrastructure in the ward and across
the entire health establishment. There was still a lot of outstanding maintenance in the hospital such
as loose electric wires in Ward 8 and broken windows. The other units also were experiencing poor
infrastructure due to lack of maintenance. In Poly clinic there were missing taps, pealing vinyl walls,
gaping ceiling and blocked toilets.

The challenges of poor infrastructure were said to be attributed to lack of contract management at the
hospital level as all contractual agreements including the deployment of contractors was managed by
the provincial office.

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8.1.5 Leadership
It was notable that the hospital was managed by deployed interim management, who were given
three months, ending in October 2024. There was no documented evidence on the rationale for having
interim management in HJTH, and it was alleged that the provincial department brought in interim
management. The former CEO got a post at the national level and the acting CEO, Dr Manning
was appointed in August 2024. While the Clinical Manager, Dr Thoka was seconded from Bertha
Gxowa hospital for interim as the former clinical manager was on suspension. The Nursing Manager,
Mr Mayekiyeso was seconded to CMJAH for operational reasons with Ms Tshitereke appointed to act
as nursing manager on interim bases. The district would know why interim management was deployed
and why they have not advertised.

8.2 Safety
8.2.1 Clinical: Repeat CT scan procedure
It was also established that Mr Holmes went to the radiology department twice for a CT scan, but there
was no clinical negligence as was alleged, whilst he has gone twice this was in keeping with proper
and adequate management

As is alleged, Mr Holmes spent three days in the Accident and Emergency unit. The unit has a space
challenge, resulting in overcrowding.

The hospital cannot accommodate all patients who require admission due to the lack of district or
regional hospitals in the surrounding area. The Accident and Emergency unit has high volumes of
patients daily. Furthermore, the overcrowding challenge was often caused by dysfunctional lifts and
posing delays in moving patients, which has a negative impact early treatment due to delays of
reaching the wards. Similarly, the delay to access diagnosis due to X-ray machines in a poor state of
repair in the Accident and Emergency unit

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Additional inspection
findings

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9. ADDITIONAL FINDINGS RELATED TO THE COMPLAINT

9.1 Cleanliness of the hospital and waste management.

9.1.1 Availability of cleaning equipment
Equipment such as scrubbing and polishing machines were not serviced for a period of more than a
year, and requisitions for repairs sent to the technical department were not attended to. Work orders
or requisitions for some of the equipment were not provided by the manager responsible for cleaning
services, Ms Mathe. The reference numbers for the requisitions were documented in a notebook instead
of recorded in works order requisitions.

Observations
The corridor towards the laundry was dirty, and the staircase next to the laundry was barricaded with
a door.

Clean linen left on the floor and was insufficient Mops hanging through the window, unmarked for
Comment: Poor housekeeping different areas
Comment: Poor housekeeping

Flies were observed hovering in the wards, compromising infection prevention and control. Baths,
basins, and floors in wards 22 and 23 had stains.

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The hospital grounds were not clean, and there was littering of waste, papers, and boxes scattered
over the grounds.

Dumping in the grounds

Comment: Poor ground maintenance

9.1.2 Infection Prevention and Control principles

An Infection Prevention and Control Committee (IPC) was appointed and had clear terms of reference
however the hospital did not have an appointed IPC Coordinator. The attached report (Annexure 5)
named Infection Prevention and Control Handwash Facilities Audit dated 31 March 2024 indicates
the non-functional toilets and taps. The 14 February 2024 minutes of the committee address the same
challenge of non-functional toilets and taps. There was no evidence of any action taken to address the
identified challenge in the IPC report.

Waste management practices including storage were not adhered to as general waste accumulated
in several areas of the health establishment. For instance, at the entrance towards the nursing college,
outside the Accident and Emergency unit, and next to the National Health Laboratory Service (NHLS)
building. The general waste containers were overflowing and used gloves were observed to be mixed
with general waste. Empty alcohol bottles and lots of cigarette buds were scattered everywhere. The
grounds were unkept and the designated smoking area was not used.

Findings:
Despite HJTH having an IPC committee appointed, there was no appointed focal person or strategy for
managing IPC-related incidents.

Analysis of the findings:

Failure to have an appointed IPC focal person in HJTH compromised IPC principles. The finding
indicates contravention of norms and standards regulations 19(1), (2)(a), which state that the health
establishment must ensure that they have systems in place to manage health care personnel in line
with relevant legislation, policies and guidelines.

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Management of sewerage system
The challenges noted with the sewerage system include blocked drains and leaking pipes outside the
NHLS building. The sewer was flowing from the drain outside the linen bank and water puddles were
observed in several parts of the premises, such as the records storage area, the surgical supplies stores
in the basement area and the budget office. Lack of sewer system maintenance will contribute to the
development and spreading of water-borne diseases.

Laundry services
Observations:
The hand wash basin in the dirty linen area was not functional, promoting the spread of nosocomial
infections, particularly as the country is still recovering from the COVID-19 pandemic. The non -functional
hand washing basin compromises the principles of hand hygiene.

Broken trolleys and basin in the laundry

Comment: Poor maintenance of infrastructure and equipment

The linen was insufficient to cater for health establishment users. There were many broken trolleys in the
laundry. There were newly procured trolleys which were never used as they could not fit in the lifts. There
were two non-functional laundry machines and only one small machine was working, A sterile sealed
eyewash kit was not available in the laundry.

There was no system to manage linen sent or received from central laundry, leading to unaccounted
shortages. Linen stock sheets were not reconciled monthly to identify losses and shortages. Linen
delivered to the wards was insufficient for the number of beds.

Laundry manager interview:

Five laundry staff members serviced 24 wards and eight areas daily, including the Theatre, Intensive
Care Unit, Ophthalmology ward, Accident and Emergency, Breast clinic, X-ray, and Renal unit.

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The daily duties of laundry staff include:

• Collection of linen from the wards;

• Sorting of the linen and placing it in bags for collection;
• Receive linen from the truck and sort it for dispatch;
• Deliver linen to the wards; and
• Pack the remaining linen in the storage area.

The Laundry Supervisor, Ms Simba, raised a concern about the shortage of laundry attendants which
impacted negatively on laundry services.

Findings:
Linen availability:
• There is no schedule for the delivery of linen between the wards and the laundry department, as
verified in the inspected wards.
• Laundry staff collects dirty linen from wards and delivers clean linen, not according to the needs
identified by the wards but according to the quantity of linen available in the laundry.
• There was no standard operating procedure for the management of linen in the units.
• Patients in the casualty did not change clothes for days due to the unavailability of clean hospital
clothes.
• Particularly psychiatric patients, who stay longer due to unavailability of admission beds.

Analysis of findings
The laundry findings align with the observations made in the wards, where little or no linen was found in
the linen rooms. This impacted patient dignity and privacy.

The above findings confirm contravention of norms and standards regulations 8 (1) and 2(b),(c) which
state that The health establishment must maintain an environment which minimizes the risk of disease
outbreaks, the transmission of infection to users, health care personnel and visitors.

9.1.3 Asset management

Old furniture (Disused wheelchairs and broken chairs) was found lying indiscriminately in the hospital
near the areas such as Accident and Emergency, Renal unit and NHLS building. Most of the old furniture
and equipment scattered in different places of the hospitals could have been disposed of or put in a
designated storage area.

Findings:
Asset management procedures such as condemning, and disposal were not implemented.

Analysis of the findings:

The broken items lying around the hospital pose a health and safety hazard to the users and staff which
is indicative of poor asset management within the hospital.

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9.1.4 Surgical supplies stores
The surgical supplies stores were found to be inadequate in terms of size. Some areas of the unit were
not meant to be used as storage space as plumbing pipes from other service areas such as the kitchen
and theatre, were running through and inside them. The pipes ran through the storage area were
meant to be used for drainage in cases of blockages.

Leaking water and steam pipes were observed in the medical supply storage areas and were damaging
supplies. The surgical supplies store was moist and damp, and the moisture damaged boxes carrying
supplies.

The budget office which is housed in the surgical supplies’ stores had water damages and sagging
ceiling predisposing staff to occupational health and safety risks.

9.1.5 Records management

The space in the records management area was insufficient, with files stacked on the floor against the
wall. Finding patient records in the stack of files is a nightmare for the administrative staff resulting in
the inability to find the patient file. The inability to find the patient files occurs frequently and leads to
delays in health users accessing services, causing loss of clinical records, and thus compromising the
continuity of patient care and treatment. The clerks are forced to create duplicate patient files with
each visit, impacting on the continuity of patient care and frustrations to the patients. Staff shortages
were highlighted in the patient records unit. The unit manager raised the concern of inability to update
patient demographic data in the files by clerks as doctors demand that all files be preretrieved a day
before patient visit. Failure to update the patient files for any demographic changes predisposes the
hospital to not having accurate patient information.

Interviews
Administrative clerks complained about the offensive smell, such as sewage in the record keeping area
and water leaking from the roof. This environmental condition is unfavourable to their well-being and
compromising to their health.

The state of the records storage area and intervention

The interview with Ms Vutomi Hlongwane, a Health and Safety Manager, confirmed the following
findings:

The Disaster Management Plan for HJTH, (Annexure 6) was developed and has not been approved.
Ms Hlongwane, further mentioned that there are various reasons why the City of Johannesburg has
refused to approve the HJTH Disaster Management Plan and Fire Drill Activities under their supervision.
The reasons are mainly infrastructure-related, such as lack of ramps on floors, lack of a functional Fire
Detection System, hospital floor plans, dilapidated basement pipes, and housekeeping issues related
to discarded equipment.

The Department of Infrastructure Development (DID,) conducted a building condition structural

assessment survey for blocks housing in wards 18 and 19 in 2020. The structural visual inspection, referred
to as the Preliminary Structural Condition Assessment Survey, found the following:

Water leaks were observed on the floor in wards 18 and 19. Inefficient drainage in the area may
damage and /or compromise the use of areas below the two ward floors. The assessment survey report
identified a remedial action required to improve the condition relating to the building which was to
repair water leaks observed at the services floor level.

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Analysis of the findings:
Water pipes were leaking in the records storage area. Patient records were soaked in water, damaged
with possible loss of critical patient information. Despite the occupational health and safety report with
recommendations (Annexure 9) furnished by DID, the situation was never attended to at HJTH and has
since worsened. This finding contravened norms and standard regulations: 14.(1), which state that the
health establishment and their grounds must meet the requirements of building regulations and 6(1)(2)
(a), which state that the Health establishment must ensure that the records of the health care users are
protected, managed and kept confidential in line with section 14, 15 and 17 of Act.

Records room Records room

Comment: Area very dirty possible breeding area Comment: Dark passage with leaking sewage health
for rodents hazard

9.2 Findings on the hospital management

9.2.1 Leadership and governance
The hospital board members were reported to be seven, however two appointment letters from
the MEC’s office were produced which was not proportional to the category of the hospital. Sub-
committees of the hospital board were also not available.

Findings:
The hospital board file produced did not have evidence that the board members had attended the
induction instead, unsigned minutes of an introductory meeting held on 16 April 2024 were produced.
The unsigned minutes indicated the proposed dates of induction as 30 April or 07 May 2024 (Refer to
POE-HJTH Hospital Board Q1 Introductory Meeting). The next date of the meeting was indicated as 18
June 2024 but there was no evidence that the meeting took place. Terms of reference and the code
of conduct for the governance structure were not produced.

The terms of reference for the Executive Committee (EXCO) were not approved and indicated the
frequency of meetings as weekly (every Wednesday); however, the last unsigned minutes produced
were for the meeting held on 08 July 2024. There were draft minutes of the meeting held on 22 August
2024. There were no minutes for May and June 2024. MANCO was reported to have not been functional
since COVID-19 pandemic.

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The terms of reference for the cluster forum to which HJTH and CMJAH were reported to belong, were
not available. The submitted minutes for the cluster forum were not signed.

Analysis of findings
The management and hospital board were not functional resulting in a lack of oversight, provision of
strategic direction as well as lack of accountability. There were no processes for developing systems
of internal controls, effective and efficient risk management process as well as dealing with ethical
matters. This finding indicate contravention with norms and standards regulations 18 which state that
the health establishment must have a functional governance structure with written terms of reference.

9.3 Human resources component

The CEO position at HJTH has not been filled and different officials have been in acting appointments
dating back to 2019 as per (Annexure 10). The critical vacant posts are that of the CEO and two clinical
managers.

Findings
The lack of stability in the health establishment results in poor leadership, oversight, governance and
accountability. There is no transparency on the appointment of contractors allocated to the health
establishment and no systems and processes in place for the entire contract management thereof.

Organogram and staffing plan:

The total “approved” posts for the medical component was indicated as 289 and the filled posts as 349
yet the vacancy rate was reflected as six instead of +60 since the health establishment was over what
was allocated based on the 2007 organogram. The vacancy rate reflected as 100% instead of above.

The numbers for all categories (clinical, nursing, allied and support services) reflected on the human
resources (HR) monthly reports were not tallying to inform the reflected vacancy rates and was verbally
explained by the HR manager which was not easily understandable. It was cited that the reports were
packaged according to the preferences of the different CEOs that were coming to the hospital on an
acting basis. There is a Clinical Manager (Dr Modisane) that is reported to be on suspension since 24
February 2024 to date without an official suspension letter as the matter was handled at the provincial
office. Staff shortage was reported to be a problem in the hospital even though the report may show
that the posts are filled. The unfunded posts are never catered for the persal system but find expression
on the 2007 organisational structure. The limited budget allocation from Treasury is also used for the
“Out of Adjustment” posts which deplete the structure.

The EXCO organogram for the HJTH was not approved, and it included the clinical manager who
was dismissed on 14 August 2024 on charges of misconduct. The regional organisational structure was
reported to have been in the process of approval since 2016.

Public Service Co-ordinating Bargaining Council (PSCBC) Resolution 1 of 2003 addresses the disciplinary
code, and procedures did not reflect the maximum period of suspension. Section 65 (7) of the Public
Service Regulations for the turnaround time for filling of posts stated that a funded vacant post shall
be advertised within six months and be filled within 12 months after becoming vacant. The unsigned
amended version of the regulations state that appointments should not be over three months following
advertisements.

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The requested evidence of the process for the recruitment and appointment of doctors in the health
establishment was not produced during the inspection.

There was no report produced on RWOPS and commuted overtime. The requested information on the
RWOPS and commuted overtime as well as their monitoring were not submitted during the inspection.
There was no evidence of staffing ratios in relation to acuity and activity levels for the different units and
it was said not to be implemented in the health establishment

Human resource administration

Minutes of an ad HOC meeting held on 24 July 2024 between management of HJTH, organised labour and
GDOH HOD delegate highlighted concerns around the overflow of patients in emergency department
(ED), shortage of staff including the vacant CEO post and infrastructural challenges. Management was
given until 1 August 2024 to come up with resolutions. The minutes reflected that the MEC Health has
signed the organisational structures for tertiary, regional and district hospitals where HJTH falls in the
category of tertiary hospitals. There is an indication of bullying by managers on the minutes which was
said to result in the high attrition rate indicated on the exit interviews conducted. The exit interviews
requested were from the previous six months as at the time of inspection. The appointments of Ms
Azwimbavhi Tshitereke (Acting Nursing Director) and Dr Rufus Thoka (Clinical Manager) from the Office
of the HOD Health in Gauteng to assist at Helen Joseph Hospital was stated to be for the period of three
months however, the exact commencement date was not indicated. The turnaround strategy that
gave birth to the reported secondment and swapping of executive officials (Acting Nursing Director
and Clinical Manager) within the cluster (HJTH, CMJAH, Bertha Gxowa and Ekurhuleni District Office)
was not available. The Nursing Service Manager for HJTH was reported to be stationed at CMJAH on
an interim basis.

The produced documents governing and guiding human resources operations and activities such as
employment equity, retention and resettlement policies among others, were outdated. The policies
were signed between 2011and 2015 against the stipulated review period of three years.

Analysis of findings
There is no transparency in relation to human resources matters affecting the health establishment by
the Gauteng Health provincial office as evidenced by lack of supporting documentation for the HR
circumstances involving senior management at hospital level. Cases of suspended senior members
(two Clinical Managers) were left to be pending for prolonged periods which impacts negatively on
service delivery and progressive leadership in HJTH. There are no systems in place to monitor RWOPS. The
monthly HR reports that are tailored to suit different acting CEOs’ preferences are not self-explanatory
and persuasive to inform adequate decision making. Human Resources operations are not guided by
valid policies.

The finding indicates contravention of norms and standards regulations 19(1), (2)(a), which state that
the health establishment must ensure that they have systems in place to manage health care personnel
in line with relevant legislation, policies and guidelines.

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Follow-up inspection

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10. FOLLOW UP /RISK-BASED INSPECTION

Post risk inspection conducted in 11 to 13 September 2024, the OHSC conducted a follow-up risk-based
inspection on 2 to 5 December 2024 to determine the improvement from the initial inspections

Allegations of dilapidated structure and poor maintenance:

Focusing on Ward 8 (where the complainant Mr Holmes was previously admitted). The condition and
state of Ward 8 had considerable improvements compared to the previous inspection visit in September
2024.

Cleanliness: It was observed that the cubicles, toilets, bathrooms and showers in Ward 8 were generally
clean. All the curtains in the ward were clean. There were no flies observed during the follow-up visit.

Flies’ infestation: There was no longer any evidence of the fly infestation that had been claimed and
seen during the previous inspection findings.

Maintenance: The curtain rails were fixed, and others were replaced with new ones. The shower was
working and had hot water which was centrally regulated by the maintenance department. All toilets
in the unit were functional and the leaking was fixed, the two patients’ toilets which were previously not
working were replaced with new ones.

Staff interview
Ms Khanyisile Ramatshoba, Ward 8-Unit Operational Manager, indicated that deep cleaning was
conducted and the areas that had flies were cleaned, dirty curtains were replaced with clean ones.
The maintenance department fixed patients’ toilets and showers. She further indicated that the hospital
has a plan to renovate the ward and temporally move patients to one of the wards. There would not
be a plan as it sounds like work is in progress.

Findings (in Ward 8):

There were still maintenance issues that had been reported and noted at the last inspection.

The rusting of the skirting boards under the hand washing basins, hanging electrical wires and the
exposed electrical point were not fixed. This finding contravened norms and standard regulations
14.(1)—which state that the health establishment and their grounds must meet the requirements of
building regulations.

Allegations of long stay in the overcrowded A&E unit

The users were still staying much longer in the A&E unit compared to the previous inspection and the
unit was still overcrowded.

Staff interviews
The purpose of the interview was to find out if the overcrowding in A&E unit was still occurring.

Interviews were conducted with four staff members, Dr Chandina (Consultant), Ms Norkee (Operational
Manager), Ms Masimula (Professional Nurse) and Dr Icely (Medical Officer), who were all working in the
A&E unit.

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Observations in the A&E unit:
On 03 December 2024 the resuscitation area had 13 patients who were critically ill. A newly built unit
meant for 72-hour observation of mental health care users was not yet utilised. There was still a mix
of genders (males and females) healthcare users in the mental health care cubicles. The medical
high care area had eight patients who were sleeping on stretchers with six patients waiting for beds
allocation in the medical wards.

Findings:
The beds in the resuscitation area and 72-hour area for the mental health care users were full during the
follow-up visit. Overcrowding in A&E unit is still the same as it was discovered in the previous inspection.
Previously Mr Holmes alleged himself to have stayed in A&E unit for three days. Trauma patients and
mental healthcare users were staying for more than three days in A&E.

Medical casualty is always full due to the unavailability of beds in wards resulting in patients sleeping
on stretchers. Trauma patients stay long due to the unavailability of ICU beds as Helen Joseph Hospital
ICU has 10 beds. There was a newly built 72-hour observation unit that was not utilised, with allegations
of shortage of skilled psychiatric nurses, hence psychiatric patients awaiting 72-hour observation are
managed in casualty.

Analysis of findings
One of the causes of overcrowding was the unavailability of beds in the wards.

Infection prevention and control was compromised as the patients stayed for long in A&E unit without
having a bath as the unit has no dedicated bathrooms for bathing.

Due to overcrowding it was not easy to clean the area and shortage of linen is still a challenge in the
A&E unit.

Inability to utilise the newly built 72-hour observation unit for mental health care users and lack of beds
for admission of users contribute to violation of human rights and compromised privacy.

The above findings still confirm contravention of norms and standards regulations 8(1) and 2(b),(c)
which state that The health establishment must maintain an environment which minimizes the risk of
disease outbreaks, the transmission of infection to users, health care personnel and visitors.

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11. FINDINGS AND ANALYSIS OF THE FOLLOW UP RBI

11.1 Leadership and governance

The follow-up risk-based inspection revealed that HJTH lacks a functional governing structure and
continues to be under the leadership of an interim management appointed and deployed by the
HOD of Gauteng Health, Mr Malotana however, it was established that a vacant position of a clinical
manager has since been filled by Dr Thoka, who was initially appointed to HJTH on an interim basis
in August 2024 after being transferred from Bertha Gxowa Tertiary Hospital. The CEO and the nursing
services manager positions (NSM) were still not filled. Despite the management team in acting positions
at HJTH, it was established further that Mr Mzuvukile Mayekiso, who is appointed in a permanent position
as a nurse service manager at HJTH has been seconded for mentorship by the HOD of Gauteng Health
to Charlotte Maxeke Academic Hospital, leaving a vacuum at HJTH.

The Human Resources Department at HJTH was allegedly not involved in the secondment of the nurse
service manager as informed by the HR Manager Ms Rirhandzu Kubayi

The follow-up RBI revealed further that the NSM from CMJAH, Ms Tshitereke, who was deployed to HJTH
by the provincial office on an interim basis, has since left on 31 October 2024. She gave Ms Baloyi a
letter to act as NSM while Ms Tshitereke will do remote oversight. However Ms Baloyi had not received
any formal handover.

Analysis of findings:
The secondment of the NSM, Mr Mzuyukile Mayekiso, from HJTH to CMAJH did not take patient-
centeredness into account, as there is now an adverse vacuum at HJTH following the departure of
another NSM, Ms Tshitereke, who has since returned to CMAJH on 31 of October 2024. The position of
the CEO was still not filled as the interim CEO Dr. A Manning previously appointed on an interim basis
was continuing with acting.

The finding indicates contravention of norms and standards regulations 19(1), (2)(a), which state that
the health establishment must ensure that they have systems in place to manage health care personnel
in line with relevant legislation, policies and guidelines.

Management and leadership system

There were no action plans on extended length of stay, adverse events, to monitor nursing care given
to users with decreased mobility. There was no explicit procedure on collaboration with internal stake
holders on user care.

Clinical governance
In HJTH, clinical governance was deficient and lack of management of PSIs exemplify. There were
no patient safety incidents (PSIs) meetings held internally in the health establishment and reporting to
the relevant structures. HOD’s did not collaborate on user care issues, and did not discuss them after
holding their departmental M&M meetings and only one unit which is surgery extends the invitation for
attending M&M meetings to nurses including the Quality Assurance Manager, Mr Xaba.

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Interview with the Acting CEO Dr Manning
Doctor Manning confirmed that the appointment of the interim structure for three months from August
to October 2024, that included himself as the Acting CEO, the Clinical Manager, Dr Thoka and the
Nursing Service Manager, Ms Tshitereke at HJTH was done by the HOD of Health, Mr Arnold Malotana
The appointment was as a result of the challenges concerning the nursing practices, which was
circulating in the media platforms, regarding patients that were staying for too long at the Accident
and Emergency unit and the overcrowding at HJTH. Dr Manning confirmed further that upon resuming
his duties as the Acting CEO at HJTH, a risk analysis was done which revealed and confirmed that the
overcrowding challenges was as a result of poor bed management as patients were not rotated and
shifted in beds when they were stable or even ready for discharge but still occupied beds such as cot
beds that need to be utilised for vulnerable users.

He further mentioned that some of the challenges with unavailability of beds was that when nursing
department counted the beds in use, they also included the ones that were broken which had a
negative effect on asset management.

It was noted that staff were consistently absent from the health establishment and their duties. He
indicated that internal medicine personnel were one of the staff who knocked off during midday to go
and do RWORPS.

Status quo regarding complainant’s complaint to date:

It was established during the follow-up risk-based inspection that HJTH management proceeded to
identify infrastructure issues and worked with Gauteng Department of Health to appoint contractors to
address the following identified infrastructure challenges such as electrical cables in Ward 8 and the
leaking pipes in the basement.

They also worked on training doctors only regarding customer care services. Since the release of
Mr Holmes video clip, HJTH has provided training doctors on customer service. Mr Xaba, the Quality
Manager, is leading the customer care service training program to the staff.

It was mentioned that a management team consisting of the head of the department, consultants and
intern doctors conduct rounds when there is congestion in A&E unit to clear the backlog.

Mortuary was not investigated as there were allegations that Mr Holmes opened curtains to get access
to the corpse in the ward. The corpse was kept for a long in the ward whilst trying to find the family before
sending the corpse to the mortuary, as it was a requirement of the SOP. The SOP on the management
of corpses has since been reviewed and the aspect of the nursing staff trying to find the family has since
been removed and the SOP was approved (Annexure 7).

Dr Manning cited that the Gauteng Health Department has concluded the disciplinary case involving
the suspended clinical manager at HJTH, which has been pending for over two years and six months
and the clinical manager has now resumed duties on 1 November 2024, however, no document has
been produced in support thereof.

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
Interview with the Acting NSM Ms Tshitereke from CMAJH
Ms Tshitereke confirmed that her appointment by the HOD to assist in HJTH was because of the challenges
that were experienced within the nursing discipline and endorsed by reports from South African Nursing
Council and complaints of overcrowding and unavailability of beds in HJTH. Ms Tshitereke further
confirmed that the challenges of overcrowding were aggravated by lack of systems to manage bed
allocation, and that during her period she managed to implement a system of bed management for
the wards in HJTH.

Ms Tshitereke also indicated that the other challenge was lack of good working relationships
amongst the nursing manager of HJTH Mr Mayekiso and his assistant nurse managers thus the strained
relationships had a huge impact on patients as operations such as bed management were not done.
She also confirmed that there was lack of desire to work by managers who did not visit nursing care
areas and only stayed in their offices. Ms Tshitereke also confirmed that she made a finding that the
assistant managers were more than is required for the tertiary hospital as there were 19 of which four
was allocated on night duty and that each NSM manages two wards; whereas, at CMAJH, which is a
central hospital, had only four assistant managers in the structure.

Ms Tshitereke confirmed that the bed management system is now utilised by all managers in the hospital
and that collaborative meetings were happening amongst nursing managers. It was also confirmed that
Mr Xaba, quality assurance manager, has started attending mortality and morbidity (M&M) meetings in
one unit where he presented the role of the quality assurance department.

Interview with the clinical manager Dr Thoka

Dr Thoka indicated that Mr Xaba, the quality assurance manager, was barred from attending M&M for
reasons that are not known. He then indicated that the role of quality assurance was crucial and thus
he invited Mr Xaba to the M&M meeting for the surgical unit to present the role of quality assurance
and that the plan was that he should sit in all M&M meetings.

Interview with the quality assurance manager Mr Xaba

Mr Xaba indicated that after the complaint by Mr Holmes, the HJTH quality assurance department
presented the challenges encountered by Dr Thoka which included patient safety incidents (PSIs) and
not taking part in M&M meetings as it is for the doctors only. He indicated that Dr Thoka invited him to
the surgery M&M meeting on 9 October 2024 where he presented quality assurance indicators and
PSIs. To date he has not attended any of the M&Ms for other departments like Internal Medicine led by
Dr Edoo and the one for the Emergency Department.

Management of PSIs

It was established that the hospital was not reporting PSIs, (see Annexure 8) in the following PSIs:

• Abscondment of users in general;

• Abscondment of users under 72-hour observation;
• Falls bedside; and
• Missing patients.

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
Analysis of findings:
There was a huge safety and clinical risk to the users due to the non-reporting of the PSIs to the relevant
structures such as OHSC by the hospital and failure of the nursing and quality assurance manager to
attend all departments M&M but Surgery only.

This finding still indicate contravention with norms and standards regulations 7 (1) (2)(b), which state
that the Health establishment must establish and maintain clinical management systems, structures and
procedures that give effect to national policies and guidelines

Interview with facility and infrastructure manager Ms Avheani

Ms Belphia Avheani, the Facility Manager mentioned that the Department of Infrastructure Development
(DID) is no longer doing maintenance in HJTH since 1 April 2024. The service has since been taken
over by the Gauteng Provincial Department of Health. She indicated that contract management is
done in the Gauteng Health Department. Since the Gauteng Department of Health monitors contract
management, most of the time she does not have full details and specifications of the appointed
contractors, she is therefore not able to monitor what contractors need to do or what needs to be
done.

Ms Avheani indicated a lack of transparency in contract management citing reference to the new
stores that has not been handed over by the contractor. She also mentioned that there is no policy
that governs contract management and that HJTH does not have the SOP on contract management.

11.2. Maintenance facilities and Infrastructure

Maintenance support
The OHSC Inspectorate team visited some areas to verify whether there was maintenance activities
performed following the previous inspection conducted from 11 to 13 of September 2024.

Surgical supplies stores:

There was no evidence of maintenance activities conducted in the surgical supplies area.

Findings:
The surgical supplies stores which are in the basement has leakage from the sewer pipes with water and
debris coming from these sewage pipes making the area to be unhygienic and causing cockroach
infestation.

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
 Surgical stores
Comment:Leaking sewage

Analysis of findings:
The surgical supply stock was still stored in the same area, which was found to be inadequate. The
newly built storage which was completed but not occupied was still not utilised. The leaking sewage’s
pipes had an unbearably strong offensive smell which was posing health risk to health care workers. This
finding contravened norms and standard regulations 14.(1)—which state that the health establishment
and their grounds must meet the requirements of building regulations.

Mortuary department:
The two fridges which were not functional during the previous inspection were fixed and operational.
A total of seven fridges were functional as opposed to the last visit where five fridges were functional.

Findings:
It was noted that fridge number seven, although functional, was missing seventeen pans. The mortuary
was still operating with one trolley which covered the entire hospital for the collection of the deceased
from the wards.

Records storage room

The state of the records room area was worse compared to the previous inspection.

Findings:
The storage area for patients X-ray films and health records was in a terrible state. There was leaking
water everywhere and a strong offensive smell from the leaking sewerage pipes.

The files of the users were damaged by the water. The corridor leading to the area was dark with no lights.
It was reported that employees who were working in the storage area were moved to another health
records storage area but when previous X-ray films are needed by the doctors, they should access the
smelling record area to fetch them. This finding contravened norms and standard regulations: 14.(1),
which state that the health establishment and their grounds must meet the requirements of building
regulations; and

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
6(1)(2)(a), which state that the Health establishment must ensure that the records of the health care
users are protected, managed and kept confidential in line with section 14, 15 and 17 of Act.

Poly clinic
The area had missing taps and handles, piling vinyl walls, gaping ceiling, blocked toilets. There is a delay
in repairing broken equipment as the maintenance department always report lack of repair material.
Maintenance was still not done in areas of the hospital which were noted in the previous inspection visit.

Accident and Emergency unit

There were two broken sinks in the sluice room covered with red plastic which were not fixed. One of
the exit doors had broken glass and one window in the mental health care user’s area was broken and
a toilet seat for the disabled users toilet was missing.

Ms Norkee (Operational Manager for A&E) produced a maintenance request book (Job card) showing
that all the above areas requiring maintenance were reported and no response from the maintenance
department to fix broken toilets as the fixing material was not available.

The Lodox machine, which is a full body scanner or imaging device, was reported to be not working
since May 2024 due to some of its wires been damaged by the contractor which was doing the
renovations in the A&E unit.

Analysis of findings:
Having personnel working in the basement area of the hospital with no ventilation is a violation of
occupational health and safety. This finding contravened norms and standard regulations:14.(1) (2)
d, which state that the health establishment and their grounds must meet the requirements of building
regulations

Alleged mismanagement and irregularities in contracts:

Since the previous inspections, contractors have been sent to Ward 8 for possible renovations. It was
cited by Ms Avheani, the Facility Manager, that there were three contractors who were sent by the
province to Ward 8. The contractors were sent to assess the requirements of the possible renovations that
would be required in Ward 8. The contractors did not leave any documentation after their assessment,
and they never came back to HJTH.

Ms Avheani, the Facility Manager mentioned issues of potential contractual irregularities were cited
with reference to contractors that came to the hospital on 17 of September 2024, to assess Ward 8
for possible renovations and no plans and records are available in the hospital. The contractor, who
did not leave any record of identification, came to do the measurements in Word 8 regarding the
renovations but there was no information on when the project would commence.

Reference was also made to the two residential buildings, a cretche and the new store building that
were built in 2017 with the allegations that the contractor was never paid and has never been handed
to the hospital to date. It was alleged that the matter on the alleged contractual irregularities was
managed by the Gauteng Provincial Health Office and that matter was with the South African Courts.

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11.3 Concerns with the relationship between doctors and nurses

Interviews by nurses alluded that there were challenges experienced with the relationships between
doctors and nurses. Doctors were said not to announce their arrival to nurses when entering the ward
in instances where they were not seen, hence thus some of the doctors do ward rounds by themselves
without involving nursing personnel and do not inform patients about their diagnosis and the progress
thereof.

Ms Khanyisile Ramatshoba, operational manager in Ward 8, indicated that patients were still complaining
that doctors do not inform them about their diagnosis or prognosis, and they often do rounds without
involving nurses.

The were allegations of a shortage of nursing personnel thus at times nurses were not able to accompany
doctors when they are to examine patients.

Findings:
The working relationship between nurses and doctors was strained.

Analysis of findings:
Doctor Chandina, consultant in A&E unit indicated that doctors attended training on Acknowledge,
Introduce, Duration, Explanation, Thank you (AIDET) which assist in promoting doctor- patient relationship.
One of the medical doctors, Dr Icely from the A&E unit, confirmed that she attended training, and it
was beneficial as it reminded them of how to interact better with patients and to sustain the relationship
thereof.

It was also indicated that since the OHSC team visited the hospital in September 2024, the Hospital
Clinical Manager, Dr Edoo, heads of departments and the A&E consultants have been visiting the A&E
unit to observe the situation and provide guidance in managing patients which was the practice that
was never done before.

X-Ray department
Some improvements were observed in the X-ray Department. Employees dosimeters were replaced
with new ones which were not expired.

Findings:
The monthly radiation tests reports for dosimeters were not available. The eight X-ray machines which
were not functioning in the previous inspection were still in the corridor awaiting withdrawal of the
license and disposal certificate from South African Health Products Regulatory Authority.

One of the X-ray machines, Techmed Unit, was not maintained since 2022 and as a result it was
malfunctioning. This finding contravened norms and standard regulations 13(1) which state the health
establishment must ensure that medical equipment is available and functional in compliance with the
law.

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
12. RECOMMENDATIONS

The following recommendations are made for the GDoH and Helen Joseph Tertiary Hospital management
to implement. The GDoH and hospital management will be required to provide a progress report on
implementing these recommendations to OHSC.

12.1 Gauteng Provincial Department of Health (GDoH)

The Gauteng Provincial Department of Health must take the following actions:

• Conclude the disciplinary case involving the suspended clinical manager at Helen Joseph Tertiary
Hospital, which has been pending for over two years and six months. This case should be resolved
within 60 working days of receiving this report.
• Expedite the filling of CEO position within 60 working days to ensure service delivery and stability at
the hospital.
• Develop a staffing structure aligned with tertiary services for Helen Joseph Tertiary Hospital within 12
months of receiving this report.
• Facilitate the appointment of a governance structure (Hospital board) for the hospital within 90
working days of receiving this report.
• Finalise payment of the service provider that built the new stores for proper handover and
occupancy.

• Intervene and facilitate the opening of the designated Mental Healthcare User unit to resolve
overcrowding in the Accident and Emergency unit within 60 working days and report to the OHSC
within 14 days of implementing

12.2 Management of Helen Joseph Tertiary Hospital

It is recommended that hospital management must implement the following:

• Fast track the opening of the designated Mental Healthcare User unit to resolve overcrowding in
the Accident and Emergency unit within 60 working days and report to the OHSC within 14 days of
implementing
• Conduct a risk assessment of Accident and Emergency and formulate Quality Improvement Plans
(QIPs) within 30 working days.
• Develop and share with the OHSC a plan to protect the health and safety of users housed in the
same areas as mental healthcare users within 60 days
• Appoint the Occupational Health and Safety Committee within 60 working days.
• Develop and implement a culture change management programme to improve employee
relations among doctors, nurses, and administrative staff within 60 days.
• Train all clinical staff in the Standard Operating Procedures (SOPs) for user management including
management of mental health care users, within 30 days.
• Develop and implement a waste management plan to clear waste scattered throughout the
hospital within 60 working days, as specified in the report.
• Service medical equipment such as the Lodox in A&E unit within 30 days.
• Develop and implement a SOP for management of contracts within 90 days.
• Develop a maintenance plan and implement with reasonable timelines. This plan must be submitted
to the OHSC within 90 working days.
• Provide training, streamline systems and processes with focus on the Patient Safety Incidents,
adverse events and complaints management within 90 working days.

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
13. CONCLUSION

The OHSC’s inspection confirmed the existence of the allegations made against the Helen Joseph
Tertiary hospital. The inspection found that Helen Joseph Hospital was in a state of despair, which did
not align with regulatory standards, ultimately compromising the quality of services and the safety of
patients and healthcare workers. The risk-based inspection report confirmed that Helen Joseph Tertiary
Hospital contravened regulations 6, 7, 8, 13, 14, 18, 19 and 20 of the norms and standards applicable
to different categories of health establishments, 2018.

In order to address the contraventions stated above, the GDoH must take responsibility of addressing
the issues of governance and leadership as the report shows that, the Helen Joseph Tertiary Hospital is
operating without a permanent senior management Chief Executive Officer, Deputy Manager Nursing
and Clinical Manager which resulted in the lack of oversight and accountability including completion
of the disciplinary case involving the suspended clinical manager. Furthermore, the GDoH must monitor
the implementation of the Department of Infrastructure and Development preliminary structural
condition assessment report (2020) which identified remedial actions required to improve the condition
of the Helen Joseph Tertiary Hospital building.

The inspection report further confirmed the lack of contract management, resulted in overcrowding in
the Accident and Emergency unit due to the non-commissioning of the newly build Mental Healthcare
User Unit. The Helen Joseph Tertiary Hospital management must fast tracking the opening of the
designated Mental Healthcare user unit to resolve overcrowding in the Accident and Emergency unit.
To protect the health and safety of users. The strengthening and implementation of risk management
policies must be adhered to. Maintenance of medical equipment must be scheduled as per the
recommendations service provider. The waste management plan must be implemented. The clinical
governance structure functionality is critical in ensuring patient safety and provision of quality health
care services.

The OHSC will continue to monitor adherence to norms and standards procedures in Helen Joseph
Tertiary Hospital. Upholding these standards, benefit patients and healthcare providers and create an
environment where risks are minimised.

The OHSC will continue to monitor the implementation of norms and standards regulations to contribute
towards high-quality, safe, and reliable healthcare services through working with all stakeholders in
health care sector.

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
Additional Picture Evidence

EMERGENCY DEPARTMENT

Patient Records
Comment: Patient records without identity of patients, can lead to wrong treatment and management to patients.

RECORDS MANAGEMENT DEPARTMENT

Overflowing record management area Overflowing record management area

Comment: Infrastructure limitations, not able to retrieve Comment: Infrastructure limitations, not able to retrieve
files timeously thus compromising patient care files timeously thus compromising patient care

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
WARD 22 AND 23

Unsecured sharp container and no provision of waste bins next to the basin
Comment: Inadequate infection prevention and control measures

WARD 22 AND 23

Camera in security control room

Comment: Most of the cameras are non-functional posing a security threat (Only 36 out of 167 functional)

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
 Helen Joseph Tertiary Hospital - Picture Evidence

EMERGENCY DEPARTMENT

Broken sink in ED sluice room Empty shelves in ED linen room

Comment: Poor maintenance of infrastructure Comment: Unavailability of linen

MAINTENANCE SUPPORT REQUESTS FOR REPAIRS

Unattended requests for repairs dating back to 2021 Unattended requests for repairs
Comment: Poor maintenance support Comment: Poor maintenance support

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
ASSET MANAGEMENT

Dumping in the grounds

Comment: Poor ground maintenance

RECORDS MANAGEMENT DEPARTMENT

Leaking sewage
Comment: Poor maintenance of infrastructure posing a health hazard

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
 Helen Joseph Tertiary Hospital - Picture Evidence

RADIOLOGY DEPARTMENT

No 41: Broken toilet in radiology department Gaping ceiling in radiology department

Comment: Poor maintenance of infrastructure Comment: Poor maintenance of infrastructure

RADIOLOGY DEPARTMENT

Portable X ray machine

Comment: Non-functional redundant portable X ray machine

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
EMERGENCY EXITS

Emergency exits
Comment: Obstructed and kept locked with a chain and posing a safety risk

CLEANING

Dirty staircase opposite entrance to laundry Area barricaded with door and unsafe
Comment: Poor housekeeping Comment: Area posing hazard to staff and users

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
 Helen Joseph Tertiary Hospital - Picture Evidence

CLEANING

A room full of broken cleaning machines

Comment: Poor maintenance of equipment

WARD 22 AND 23

Broken toilet in ward Overflowing linen canvas trolley

Comment: Poor maintenance of infrastructure Comment: Poor housekeeping

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
 Helen Joseph Tertiary Hospital - Picture Evidence

LAUNDRY

Empty linen shelves in the laundry Tall trolleys which do not fit in elevators
Comment: Unavailability of linen for users Comment: Inadequate specifications leading to
wasteful expenditure

STAFF AND PATIENT DIGNITY

Broken staff toilet door and was supported by a Broken toilet seat, making it uncomfortable for
rope seating on the toilet
Comment: Staff dignity was compromised as a Comment: Patient dignity was compromised as a
result of poor maintenance result of poor maintenance.

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Risk-based Inspection Report - Helen Joseph Tertiary Hospital
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Office of Health Standards Compliance

79 Steve Biko Road | Prinshof

PRETORIA | SOUTH AFRICA
Private Bag X 21 ARCADIA | 0007

www.ohsc.org.za