Gauteng Fixes Psychiatric Unit After Patient Dies in Hospital Fire

On March 23, 2026, the Gauteng provincial government announced steps to fix problems at the psychiatric unit in Dr George Mukhari Academic Hospital. This came after a patient died in a fire, as detailed in a Health Ombud report. Gauteng Premier Panyaza Lesufi shared the updates during a media briefing in Pretoria. The government implements measures to improve operations in psychiatric unit, including more staff, better security, and safety upgrades. These changes aim to protect mental health patients and prevent future tragedies.

Ms L Mohlamme, a 35-year-old mental health care user, died in that fire. Her brother-in-law brought her to the hospital on June 19, 2024. The Health Ombud launched an investigation to check if her care followed the Mental Health Care Act. That law demands humane, dignified, and least restrictive treatment for all mental health patients.

The probe revealed bigger problems across the system. It found punitive practices, poor infrastructure, low staffing levels, and staff who did not know the Mental Health Care Act well. Governance and oversight also failed in key ways. Professor Taole Mokoena, the Health Ombud, stated, “More broadly, the investigation uncovered systemic violations of the rights of mental health care users.” These issues led straight to failures in Mohlamme’s case.

Here are the main problems found in her treatment:

• Her admission broke rules. Two doctors did not examine her separately or use the right forms, making it invalid.
• Staff used mechanical restraints too much. This went against national guidelines.
• She reported a possible sexual assault. No one checked it, wrote it down, or told the police as required.
• Doctors withheld her medicine on purpose as punishment. They faked records to show it was given.
• Staff denied her food during seclusion as punishment.
• Seclusion safety steps were ignored.
• The seclusion room sat far from the nurses’ station. It had no good monitoring tools.
• Another patient warned about fire risks. Staff brushed it off.
• No one searched her fully before seclusion. She had a cigarette lighter, likely used to start the fire.
• Emergency exits stayed locked. Keys were lost or hidden.
• The hospital lacked solid disaster plans.
• Mattresses were not fireproof. They caught fire fast and spread it.
• A postmortem showed she was alive in the fire. She died from severe burns.

Professional groups will now review these issues. The Health Professions Council of South Africa (HPCSA) and the South African Nursing Council (SANC) will look into the actions of involved staff. They may start conduct inquiries.

The Gauteng government acted fast after getting the draft report. They hired 12 more nurses, raising the total to 105. Nine permanent security guards now work on-site. They respond first to problems. The province trained 21 nurses and two social workers on their duties. New CCTV cameras let security watch in real time. Fire fixes are underway. The hospital got a fire compliance certificate on February 19. Some work remains, like buying fireproof mattresses. Plans also call for better recreation and rehab areas. Premier Lesufi said, “When the draft report on the matter was presented to us, we immediately undertook an overhaul to rectify the situation and to ensure that this kind of incident does not occur within our institution again.”

The Health Ombud called for a full redesign and fix-up of the psychiatric unit. It must meet all laws on security and safety. The Ombud will keep watching the changes. They plan to team up with others to stop such events. Mokoena stressed, “Protecting the dignity, safety, and rights of mental health care users is not optional; it’s a constitutional and legislative imperative.”