The death of 118 mental patients was as a result of gross incompetence coupled with former Gauteng Health MEC Qedani Mahlangu “being clueless” about what she was doing, Ombudsman Malegapuru Makgoba told the arbitrary hearing on Tuesday.

In May 2016 Mahlangu ordered the transfer of the patients from Life Esidimeni to 27 other non-government organisations.

”I think there was just general incompetence across the system. Warning signals were there, but the department was not ready in a proper way,” said Makgoba.

The health ombudsman was under cross examination from lawyer Dirk Groenewald, who represented three families who’s relatives died in the Esidimeni saga.

Retired Justice Dikgang Moseneke asked Makgoba what could have driven Mahlangu to go ahead with moving patients that led to to deaths of so many patients, while she was warned of dangers of her actions.

”What was she doing? What drove her in the face of all warnings by experts, clinical departments, families, even by project managers she appointed … and she still pushed through when the risks appeared so ominous. What was it? Did she tell you what drove her so hard to want to do this that turned out so fatal?” asked Moseneke.

Makgoba said MahIangu never understood the magnitude of the problem.

”I do not think she knew how big this matter was, I do not think she understood either, I tried to find out from her what actually happened and controls she set up, all I could gather was that this whole thing was not planned properly. There were no proper processes,” said Makgoba.

Makgoba testified about how families went for months without knowing where their relatives were.

The department never bothered to inform families where patients were being transferred to. Those who found out about the transfers and requested information about the whereabouts of their loved ones were ignored.

One parent, a reverend, found out a year later about his son’s location only because the patient called him to wish him a happy birthday, he said.

“For over a year Reverend Mabuya did not know where his son was transferred to, until, by coincidence, Billy called him on his birthday, and that was when he knew where he was. He then went to see him and bought him KFC, and as I testified yesterday, Billy was so much hungry he ate the KFC and the paper bag covering it. This was a serious human rights violation.”

One patient died and his sister did not know for three weeks until she received a call from the NGO.

”They asked her if they should bury the brother or whether the family would come collect his body … from this you can see that the families were not treated with common courtesy, human dignity and respect.

“Importantly, these are embedded in our Constitution – to treat people with respect, it is one of the pillars of our Constitution, and that did not occur in relation to the relatives and families.”

The health ombudsman described as “horror” the stories that emanated from the Esidimeni saga.

"One heard stories about how patients were transported in inappropriate transport where some of them had to be tied to the vehicles because the transportation was not appropriate. Some patients were transferred, for example, from Cullinan, and then to somewhere else almost against the decision of the team that assessed them as to where they fit," said Makgoba.

”It is a requirement in mental health that assessment on capability of patient, intellectually and physically, be done before the transfer. Then you identify a suitable place that would befit their requirements. The opposite was done, which went against what is required in mental health.”

Some patients were transferred several times from one NGO to another.

Makgoba said every time a mental patient is transferred, they are affected by that process and take a long time to recover from the experience.

”Some of them are not even aware as to where they were going, they do not protest….occassionally they do but generally they do not protest. You are basically doing something against people who are vulnerable and quiet, and I just thought that that was cruelty,” he said.

Groenewald asked Makgoba if the government had lied to patients’ relatives when the department said the patients would be looked after properly when they were transferred from Esidimeni.

Makgoba said: ”I am not a lawyer and I find usage of that word very difficult and complex there’s big difference between lying. Incompetence is a often subconscious and not deliberate, lying is deliberate intentional process, I do not think there could have been such intention…to say they lied is too strong a word.”

He said he could use a friendly term and say the state was "were economical with the truth."

Moseneke earlier started the proceedings by reminding everyone that Tuesday was World Mental Health Day, adding that it was important to protect the rights of mentally ill patients.