Health Minister, Ombud outraged after death of teen told by nurses to walk to police station after gang rape

Her name was Zenizole Vena. She was only 15 years old.

On the last day of her life, 22 September 2022, Zenizole was gang-raped, took an overdose of medication and then, when she sought help at the Motherwell NU 11 clinic, the nurses said she had to walk to the police station, two kilometres away. They said they were told “not to touch” rape victims. 

With no money for a taxi, Vena suffered a seizure on the way to the police station. A taxi driver stopped and drove her the rest of the way. When she arrived, the police made her wait for over an hour. When she had another seizure, nobody came to help her. She died on the floor of the Motherwell Police Station.

Up until yesterday, 14 months later, no action has been taken against the nurses.

Now, Health Ombud Professor Taole Mokoena, has asked that a disciplinary hearing be instituted and that the nurses be reported to the South African Nursing Council. 

He said their negligence had contributed to Vena’s death.

“It was evident that she was not attended to in a manner that was consistent with the nature and severity of her health condition,” he said.

Mokoena released his findings on Tuesday 12 December after a complaint was lodged by Health Minister Joe Phaahla and the Democratic Alliance’s Shadow Minister of Health, Michéle Clarke.

“What happened to this young girl is an atrocity of bad healthcare and bad training,” Clarke said on Monday. 

“A young girl’s life could have been saved if the nurses took proper action.”

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The Health Ombud deployed investigators to look into the matter but said he had also interviewed some of the witnesses.

“The healthcare workers who attended to Ms Vena at the clinic did not touch nor examine her with the belief that every sexual assault case should be referred to the South African Police Services (SAPS). She was instead instructed to go to the Motherwell Police Station Community Service Centre as nurses at the clinic erroneously believed that ‘nurses are not allowed to touch rape victims to avoid tampering with evidence.’ 

“Despite their belief, the two nurses did not arrange transport to take both the escort (an elderly lady) and victim to [the police station] nor call the police to come to Motherwell NU 11 Clinic to take over the case. 

“One of the nurses indicated that she only took the patient’s vital health data, which was written in a personal diary but not in the approved patient administration record. 

“Based on the verbal and documentary evidence gathered and considered, it can be concluded that both healthcare workers concerned failed to refer Vena to the next level of care needed.

“Based on the evidence obtained, it can be concluded that Vena was not attended to in a manner that was consistent with the nature and severity of her health condition at Motherwell NU 11 Clinic,” Mokoena continued. 

He found that the SAPS had also failed to assist her at the police station. 

“It is quite disturbing and mind-boggling,” Mokoena wrote, “that a basic human instinct to assist a person in distress, particularly a child, does not seem to exist within the South African Police Service in Nelson Mandela Bay district.

“Vena was told to wait ... they only attended to her after she waited for 90 minutes. During this time, she experienced seizures and was foaming at the mouth. She was found dead lying on the floor in the charge office,” he said.

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Mokoena has made 14 recommendations, including that disciplinary procedures should be instituted against the two nurses and that they must be reported to the South African Nursing Council. 

He also recommended that SAPS officials should be trained in first aid and what must be done in a medical emergency.

The evidence gathered by the investigators from the Office of Health Standards Compliance revealed shocking negligence by health officials.

The report states that, according to the Nelson Mandela Bay health department subdistrict coordinator, Nomathemba Qabaka, when a sexual assault patient arrives at a clinic, healthcare workers must assess the status of the patient. A full physical examination must be conducted.

The healthcare workers must also assess whether the patient is emotionally disturbed. If the patient needs an emergency referral to a doctor, they must provide HIV testing and counselling, and also pre-exposure prophylaxis. They should give an emergency morning after pill and explain the procedure of opening a case. The police will take the patient to the Thuthuzela Centre and the healthcare worker will report the case to the subdistrict.

‘Could no longer talk’

Vena and her escort, an elderly woman, were sent away from the clinic at 7.25am.

The report found that by the time Vena arrived at the police station, she could no longer walk or talk. 

“According to the district manager of Nelson Mandela Bay District, Sonia Lupondwana, there was no doctor at Motherwell NU 11 Clinic on the day Vena came. This explanation is not accepted because the absence of doctors does not absolve the nurses from providing the necessary care to the patients,” Mokoena’s report continues.

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The former head of the Eastern Cape Department of Health, Dr Rolene Wagner, told Mokoena they had written a letter of apology to the Vena family but that it was never delivered.

“It is not in dispute that Vena was sexually assaulted, hence she presented herself at the clinic on 21 September 2022 for medical services,” Mokoena continued. “This fact was also supported by the findings on the post-mortem examination conducted by Dr LJ Mostert on 6 October 2022.”

The report found that Vena had no visible injuries but toxicology results indicated that she had high levels of the antibiotic trimethoprim, used for urinary tract infections, in her blood. 

“These levels were much higher than the normal levels in people taking this medication. It appeared that Ms Z Vena ingested a lot of trimethoprim tablets. According to Dr LJ Mostert, ‘the toxicology results (indicating) the cause of death will be consistent with trimethoprim overdosage’,” the report continued.

Mokoena said the nurses’  conduct had violated Vena’s constitutional right of access to healthcare. 

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He said that despite an undertaking by the Eastern Cape Department of Health, no disciplinary action had been taken against the nurses. 

Mokoena said the clinic, built in 1996, can no longer cope with the number of patients trying to access care as it only has two consulting rooms and disabled patients have to be accommodated in the storeroom. 

It also has no functional landline and the official cellphone has been in the possession of a nurse who has been booked off for a prolonged period. 

He added that he wanted to see a security plan for the clinic in the next three months. 

Phaahla said the incident was indicative of “serious negligence”.

“It is unacceptable [what happened here],” he said “I don’t think there is any excuse for the attitude that nurses do not touch rape victims. It is completely unacceptable.”

“We should feel ashamed and apologise to the family.”

He said the matter would not end with the handing over of the report, and that the department was receiving “constant feedback” about the poor attitude of public sector health staff.

“This is a wake-up call,” he said. “The issue of supervision also must be key. The staff had an opportunity to be trained,” he said. 

Phaahla said they were also keeping a “close eye” on the Eastern Cape Health Department for “other issues”.

“This may be just the tip of the iceberg,” he added. 

The Vena family has not commented on the outcome of the report. DM