Death was already in the air in Ward 23, where Shonisani Lethole met his demise at Tembisa Provincial Tertiary Hospital on June 29 last year.
He lay in the ward, starving and sick, surrounded by Covid-positive patients and corpses that had not yet been removed.
Outside, his frantic family stood laden with buns, Kentucky Fried Chicken and Nando's for him. But they were not allowed in, and the food - which they gave to cleaners to deliver - never found its way to their dying son.
Even the staff at the Ekurhuleni, Gauteng, hospital, when asked to rate Lethole's care, said "they would not like any of their relatives to be cared for in this way".
These details are contained in a harrowing 204-page report on the circumstances surrounding Lethole's death, released by health ombudsman professor Malegapuru Makgoba this week.
The findings include missing doctors' notes, contradictory versions of events by staff, no attempt at resuscitation. The report recommends that 19 staff members, including CEO Lekopane Mogaladi, face disciplinary inquiries. It also found that Letholewas given only one meal in more than 100 hours.
Makgoba called Lethole's treatment "negligent, callous and uncaring … This uncaring attitude represented gross medical negligence."
But Mogaladi - who said the hospital will appeal against the findings - denied that Lethole received no food before he was intubated and claimed he sent investigators the names of five other patients who witnessed Lethole receiving meals.
On Friday, the CEO declined to share with the Sunday Times the details of the patients he claims were excluded from the report.
"We are appealing and we have given the information to the tribunal," he said.
The health ombudsman's spokesperson, Ricardo Mahlakanya, said no witnesses were ignored in the investigation. "All the witnesses were interviewed. People will try to come up with stories to run away from murder."
Lethole, 34, was referred to the Tembisa hospital from a Kempton Park clinic on Tuesday, June 23, complaining of chest pain and difficulty breathing. He was accompanied by his worried father, Albert Lethole.
He was evaluated by an unsupervised intern, according to the ombudsman's report.
At 12.36pm he was admitted to the casualty Covid isolation ward by an unsupervised clinical associate trained to assess patients, make diagnoses and prescribe treatment under the supervision of a physician.
The hospital described him as an "athletic patient" with "no history of comorbidities".
Lethole's results showed he had damage to his kidneys, liver, lungs and skeletal muscles and had inflammation throughout his body - consistent with a Covid infection. But these results were never seen or acted on by senior doctors caring for him.
The ombudsman said proper management could have yielded a different outcome.
When Lethole's tests came back positive for Covid-19 pneumonia on Friday, June 26, he was transferred to Ward 23.
Evidence shows Lethole was not offered any meals from his admission until 8am on Friday - 43 hours and 24 minutes later.
The ombudsman noted that before Lethole was admitted his last meal was at 4am at home, which added eight hours and 36 minutes to the time he spent without food.
Hospital caterers were on strike "over [personal protective equipment] and salaries", so no food was served to patients.
Wilfred Ntebogang Mothwane, deputy director of nursing, told the ombudsman he observed food lying at the doors of casualty as staff without PPE refused to enter the area to distribute food to patients for fear of contracting Covid.
He said that "all staff were on strike and it was worst on these three days. Many patients were not even seen, patients' clinical records were mixed up and corpses were left lying all over the place."
Friday's breakfast would be Lethole's last as the report showed he did not eat on Saturday before he was sedated and intubated at 1pm. No feeding tube was inserted.
At 8.31pm on Friday night Lethole tagged health minister Zweli Mkhize about the "deplorable" conditions at the hospital, in a tweet that quickly went viral.
Lethole died on Monday, June 29 at 10.30pm.
The report said the doctor who intubated him initially said he also inserted a feeding tube. However, she later said she had asked a nurse to do this. There is no record of this.
"So, for another 57 hours, 30 minutes, Lethole was to endure not being fed … This took place when he was most vulnerable and sedated," Makgoba said.
The ombudsman also found that after Lethole spoke to his family, they bought him meals on several occasions. But - as Covid protocol dictated - only patients and staff are permitted into the hospital. His family relied on the hospital's cleaning staff to pass the food along, which they did not do.
It took about 69 hours and 19 minutes after admission at casualty before two registered medical practitioners, a Dr Bangala and a Dr Shabangu, assessed Lethole's condition for the first time.
The ombudsman said that even finding the date of Lethole's death "necessitated a rigorous verification process . due to these incongruities and inexplicable conflicting evidence obtained from the two clinical teams, caring for the same patient, in the same ward".
Albert Lethole initially thought his son had died on the Saturday. A clinical team swore he died on the Sunday and another clinical team said it was on Monday.
Having him declared dead took a further 10 hours and 15 minutes. At 8am on Tuesday he was declared dead, his body already in rigor mortis.
When he died he did not even know he had Covid and his family were only notified later, after receiving guests to commiserate on his death.
Lethole's family indicated last year they will take legal action against the hospital.
"It is overwhelming. The report confirms many, many failures in management, governance and medical care at Tembisa Hospital. From what we have read so far, it also confirms that Shonisani's account of what happened was true," Albert Lethole said this week.
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