Human rights abuses at a psychiatric hospital in KwaZulu-Natal

Members of the Committee The seven members of the Committee were as follows: Head of the Department of Psychiatry, Nelson Mandela School of Medicine, and Head of Mental Health Services KwaZulu-Natal (Chairman); Resident Commissioner KwaZulu-Natal, Public Service Commission (Deputy Chairperson); Member of Townhill Hospital Interim Board; Programme Manager Mental Health and Substance Abuse, KwaZulu-Natal; Head of the Department of Psychology, University of Limpopo (Medunsa Campus); Specialist Psychiatrist in private practice, President Elect of the Society of Psychiatrists of South Africa; and the Chief General Manager, Legal Services in KwaZulu-Natal.

Objectives.The terms of reference of the Committee of Enquiry were to investigate allegations of human rights abuses of psychiatric patients at the hospital, and to report their findings to the Minister, in line with the media reports.
Methods.The public was invited through notices in the print and electronic media to make submissions relating to the allegations.Interviews and site inspections were conducted.
Written submissions were received.Legislative and regulatory frameworks were studied.Reports of previous commissions as well as hospital records were analysed.Recommendations.The Committee recommended that remedial and preventive measures be undertaken as a matter of urgency to combat human rights abuses and address deficiencies in the system.The approach adopted by the Committee also included in loco inspection of the hospital wards and precincts.Further interviews were conducted on site with a random selection of patients and staff.
The methodology further included scrutiny of hospital records, with special emphasis on patient files, incident reports, human resources records, and sick leave and off-duty register to test the reported allegations.

Findings
The findings are presented in the order of the terms of reference.

Neglect of patients
There was overwhelming evidence of patients being neglected by staff.

Sexual abuse
There was evidence of patients being sexually abused by staff.

Physical abuse
The Committee of Enquiry received information substantiating the allegations of physical and verbal abuse of patients by staff and of staff by patients.

Theft of patients' food and belongings
There was ample evidence of staff stealing patients' food and belongings.

Patients sleeping on the floor
The committee's in loco inspection of the hospital revealed evidence of floor beds and patients sleeping on them.

Female patients not allowed access to underwear
The allegations were confirmed.Nurses agreed that female patients sometimes did not wear panties because of shortages and because of their psychotic state.

Abuse of staff members by patients
The Committee found evidence of verbal, physical and emotional abuse of staff members by patients.Patients abused staff members because of the nature of their illness.There were no trauma counselling services and no satisfactory Employee Assistance Programme

Staff reporting on duty under the influence of alcohol
There was overwhelming evidence from hospital records and interviews supporting allegations of staff coming to work under the influence of alcohol.

High rate of staff absenteeism
The Committee found evidence of a high rate of absenteeism.
A disturbing pattern was the escalation of absenteeism after the 15th and 30th of each month, these being paydays.

Poor patient management
During the in loco inspection the Committee found evidence of poor patient management by the doctors, with some patients prematurely transferred to the pre-discharge ward while they were

Inadequate recreational facilities
Patients were found to be spending most of their time in the wards, with little or no exercise and recreation: No reading material was supplied to stimulate those who were recovering.Television was usually provided.The beautiful and undulating hospital gardens were not used in the therapy of the patients.

Racism, nepotism and favouritism
There was overwhelming evidence of racism, nepotism and favouritism at the hospital on the part of middle management, and by doctors with regard to employment, work allocation and clinical management.Ward accommodation reflected a racial bias.

Staff shortage and poor work conditions
Staff shortage and poor work conditions were major problems in the hospital and were highlighted in almost all the interviews and confirmed during the inspection.The ratio of nursing staff to patients left much to be desired.There were 3 nurses to 26 patients -1 nursing sister, and 2 staff nurses/nursing assistants.
There were 2 psychiatrists to 250 patients.This was clearly inadequate as psychiatric patients need constant attention, particularly in the acute phase.Such patients are often restless and some may be aggressive.
Staff shortage was a major problem at all levels.On paper the hospital had a staff complement of 336.However, at the most, existing staff numbered 230 due to factors such as budgetary constraints and unavailability of registered psychiatric nurses, particularly males, as the majority of them go to the prison department or overseas.The current staff-patient ratio was 4 nurses to 30 patients.When the nurses and doctors compared themselves with their overseas counterparts there was a marked difference in staff-patient ratios.For example, in Australia there are usually 6 psychiatrists to 26 patients, and 1 psychiatric nurse to 2 patients.
This kind of patient load was causing frustration and demorali-sation among those staff members who were highly motivated.Generally, staff were of the opinion that they were doing a thankless job.The unions also complained about the hospital being short staffed, with volunteers coming in to assist having no certainty that they would be employed in the near future.This also contributed to low morale and lack of effectiveness on the part of the staff.
Because of staff shortage, staff members were not always available to supervise patients adequately.The Committee heard of an incident in which a young girl pushed her head through a broken window.Her head was trapped and she bled to death.

Lack of discipline
The commission found that there was inconsistency in the way the hospital management addressed grievances and cases of misconduct.

Strained relations between management and unions
Evidence indicated that unions were perceived to be a stumbling block in the handling of misconduct.On the other hand, unions maintained that it was their duty to represent their members.

Media reports
The Committee expressed awareness of the fact that spectacular and startling headlines are used to sell newspapers.The Committee noted that the most publicised stories are about things that go wrong, with scant attention given to things that go right.These reports can be very damaging to institutions and the government as they serve to create inaccurate and misleading images in the mind of the public.People can be led to fear the institution and lose faith in the government's provision of health services.Such reportage also leads to low staff morale.
The Committee expressed the opinion that most of the above adverse findings were a result of poor management over a number of years and the absence of an effective hospital board.
Furthermore there was no Provincial Director of Mental Health and Substance Abuse to support the hospital management.
Lamentably, the National Department of Health also did not have a National Director of Mental Health and Substance Abuse to ensure a quality mental health care service at the hospital.
Therefore the Committee strongly recommended that hospital management should be strengthened by advertising and filling all the vacant management posts, and that the hospital board should be put in place without delay.

Recommendations
Recommendations were itemised as follows: Neglect of patients , MB ChB,DCH, MFGP,DFM, MMed (Psych) Department of Psychiatry, University of KwaZulu-Natal, Durban, and Head of Mental Health Services KwaZulu-Natal Background.Following allegations of human rights abuses at a psychiatric hospital in Pietermaritzburg, KwaZulu-Natal, that were reported in one of the local newspapers, the national and provincial Ministers of Health visited the hospital.Because of the seriousness of the allegations, the national Minister of Health established a Committee of Enquiry to investigate the allegations.The 7 committee members included experts in mental health care services, legal services, public service sector, a hospital board member, and a representative of the community.

Findings.
The findings of the Committee confirmed all media allegations of human rights abuses as appearing in the terms of reference.In addition, the Committee identified the following systemic defects: (i) weak management over a long period of time; (ii) absence of a hospital board; (iii) inadequacies in the physical layout and quality of facilities; (iv) abuse of staff by patients; (v) staff reporting on duty under the influence of alcohol; (vi) high rate of absenteeism; (viii) shortage of staff; (viii) lack of discipline; (ix) evidence of racism, nepotism and favouritism; and (x) strained relations between the management and unions.
of the enquiry was posted in the local media inviting interested or affected parties to participate.The notice in the print media was complemented by announcements on local radio stations where members of the public were invited to submit personal experiences of human rights abuses at the hospital to the Committee.The following documents were studied: media reports; the Constitution of the Republic of South Africa Act No. 108 of 1996; the National Health Act of 2004; the Mental Health Care Act No. 17 of 2002; the Norms Manual for Severe Psychiatric Conditions; the Strategic and Implementation Plan for Delivery of Mental Health Services in KwaZulu-Natal of 2003; the Batho Pele Principles; the Patients Rights Charter; the Public Service Act of 1994; Health is a Human Right; the KwaZulu-Natal Minister of Health Budget Speech 2005; and the International Council of Nurses Code of Ethics for Nurses of 1953.The following reports of previous commissions were reviewed: the Retief Commission of 1996/1997, the Manzi/Cassimjee Commission of 2002, and the Human Rights Commission of 2005.Over a period of 6 weeks the Commission met once a week to listen to oral submissions, conduct interviews and analyse written submissions.Members of the public, union representatives, patients and hospital staff were interviewed.A professional stenographer recorded all interviews and made hard-copy transcripts of the interviews.
1.The Patients Rights Charter should be supported, implemented and monitored, and every morning these principles should be read and internalised by the staff on duty.Further, the Charter Volume 13 No. 4 December 2007 -SAJP