For a full year, Lucy Ramphele has barely slept. Each night the face of her son returns, a young man she believes was failed by the very health system meant to save him. He would have turned 27 on December 1, a milestone she now marks not with celebration but with unbearable grief.
On Wednesday she sat quietly in a Pretoria auditorium as health ombud Prof Taole Mokoena released two investigation reports:
- one into the death of Pitsi Eliphuz Ramphele at Pietersburg Provincial Tertiary Hospital in Polokwane, Limpopo;
- the other over the death of 64-year-old physician Dr Edward Mabubula at Wits Donald Gordon Medical Centre in Johannesburg.
Both deaths, Mokoena said, reveal deep systemic failures that continue to endanger patients across South Africa’s strained health system.
Lucy, who travelled from Turfloop to attend Wednesday’s briefing, said she felt a measure of relief that the failures that contributed to her son’s death had been acknowledged.
“It has not been easy. I was there during my son’s last days. I still remember his last words: ‘Mama, I am coming home on Friday.’ That Friday … he died, just days before his birthday,” she said.
Pitsi, she said, was a twin, a dedicated student preparing for his final two modules before graduating with a Bachelor of Business Administration and Juris Doctor qualification.
A journey before his death
Lucy said her son’s health problems began in early 2023.
“He was in Polokwane just after 7pm when he was stabbed with a screwdriver during a cellphone robbery. He stayed in the hospital the whole of February. Doctors operated and used staples, and one doctor mentioned that a staple had touched his intestine, but said it should not be a problem.”
For months afterwards, Lucy said, Pitsi recovered well — until November 26, when he suddenly experienced severe stomach pains. “Ngwana ka [my child], I could see he was deteriorating and not getting help,” she said.
He was my child. We trusted the hospitals and they failed us
— Lucy Ramphele, mother of Pitsi Eliphuz Ramphele
She rushed him to Rethabile Hospital, where they waited four hours for a file to be opened. He was never seen by a doctor; they had already left for the day. “The security told us to ‘go home and come back tomorrow’. But my son was very sick,” she said.
The next day, they went to Pietersburg Provincial Tertiary Hospital. “The treatment was the same,” she said.
On November 28, while still awaiting surgical intervention for acute small bowel obstruction, Pitsi died.
To make matters worse, the hospital told the family they could not perform a postmortem, forcing them to seek services privately.
Health ombud investigation
Mokoena launched an investigation after Pitsi’s aunt, veteran activist and academic Dr Mamphela Ramphele, lodged a formal complaint on March 27. The complaint cited:
- delays;
- lack of prioritisation;
- absence of medical assessment; and
- ultimate failure to provide the surgical care he urgently needed.
Mokoena said investigators identified seven key allegations, all substantiated by evidence:
- Administrative delays: Nearly four hours to open a file at Rethabile Hospital.
- Failure to triage: Unqualified staff assigned to critical areas; essential triage equipment missing.
- No triage at Pietersburg hospital: Records did not support claims that triage occurred on arrival.
- No doctor seen: Doctors at Rethabile left before attending to all patients, including Pitsi.
- Negligent monitoring: More than 21 hours without a medical review at Pietersburg hospital, despite signs of deterioration.
- Missed surgery: Pietersburg hospital failed to provide timely surgical intervention, which “could have prevented his death”.
- No postmortem services: Family denied postmortem to determine cause of death.
Additional systemic failures were also noted:
- falsification of medical records at Rethabile to conceal procedural failures;
- poor supervision of interns and registrars, who made independent decisions without oversight;
- leadership instability, with prolonged acting appointments and low morale; and
- resource shortages, including:
- missing equipment;
- inadequate waiting areas; and
- medication stockouts.
“The investigation concluded that misallocated human resources, failure to follow triage protocols and inadequate supervision were major contributors to the systemic dysfunction,” Mokoena said.
This is far from an ordinary occasion. These findings compel us to look beyond the statistics. They remind us of our duty to ensure that every patient receives safe, effective, compassionate care
— Dr Ernest Kenoshi, Office of Health Standards Compliance chair
He added that poor leadership further eroded accountability, placing patients at unacceptable risk.
The ombud issued binding recommendations, including:
- a task team to be established within one month to monitor implementation;
- more administrative staff and equipment at Rethabile within six months;
- mandatory retraining of nursing staff on triage protocols within one month;
- biometric logging systems for doctors within three months to ensure accountability;
- referral of implicated staff, including those involved in falsifying records, to the Health Professions Council of South Africa and South African Nursing Council for disciplinary action; and
- proper induction of doctors on postmortem services across the province.
A system under strain
Dr Ernest Kenoshi, chairperson of the Office of Health Standards Compliance, said Wednesday’s briefing was a sobering moment.
“This is far from an ordinary occasion. These findings compel us to look beyond the statistics. They remind us of our duty to ensure that every patient receives safe, effective, compassionate care,” he said.
For Lucy, the findings may bring accountability, but not peace. “He was my child,” she said. “We trusted the hospitals and they failed us.”
Mokoena said the CEO of Pietersburg Provincial Tertiary Hospital and its quality assurance officials should reach out to the Ramphele family to apologise for failing to arrange a postmortem when the family requested one.
“They should acknowledge the lapses by both nursing and medical teams in adequately monitoring Mr Ramphele and responding appropriately to clinical and investigative findings that clearly indicated an acute abdomen — express regret and remorse for the fatal outcome that resulted from the shortcomings in the hospital’s management of his case,” he said.
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