The Ombud established that:
- A total of ninety-one (94+) and not thirty-six (36) mentally ill patients (as initially and commonly reported publicly in the media) died between the 23rd March 2016 and 19th December 2016 in Gauteng Province.
- All the 27 NGOs to which patients were transferred operated under invalid licenses.
- All patients who died in these NGOs died under unlawful circumstances.
- On the date, 13th September 2016, when the MEC made the public announcement of 36 deaths, 77 patients had already died.
- Between May and September 2016, 77 MCHUs died.
- The OHSC inspectors and Ombud identified and confirmed 73 deaths, while the Ministerial Advisory Committee on Mental Health identified and confirmed 66 deaths during the course of their investigations.
- At the time of writing the Report, 94 patients had died in 16 out of 27 Non-Governmental Organisations (NGOs) and 3 hospitals.
- 75 (79.78%) patients died from 5 NGO complexes (Precious Angels 20, CCRC/Siyabadinga/Anchor 25, Mosego/Takalani 15, Tshepong 10 and Hephzibah 5).
- There were 11 NGOs with no deaths, 8 NGOs with average deaths and 8 NGOs with ‘higher or excess’ death.
- Only 4 MCHUs died in hospitals compared to 77 MCHUs deaths at NGOs; in absolute numbers for every 1 death at the hospitals there were 19 deaths at the NGOs but correcting for the total base population the ratio is 1:7. This ratio is very high. This finding is consistent with the interpretation that the problem was in the NGOs.
- 95.1% Deaths occurred at the NGOs from those MCHUs directly transferred from Life Healthcare Esidimeni (LE).
- 81 deaths were LE-associated while 13 deaths were not.
- The Gauteng Directorate of Mental Health (GDMH) could only identify 48 deaths. These differing numbers are symptomatic and pathognomonic of an institution with poor data integrity (lack of accuracy and lack of consistency) and the lack of reliable and quality information systems found during the investigation.