It took five months for the family of a mentally ill patient who was transferred from Life Esidimeni care centre to find out about his death.

According to a report by health ombudsman Professor Malegapuru Makgoba, Charity Ratsotso died on July 11 2016 and his family only became aware of his death on December 20 2016.

This was when a relative visited the Cullinan Care and Rehabilitation Centre where Ratsotso was living.

Makgoba released the damning "Circumstances Surrounding the Deaths of Mentally ill Patients in Gauteng Province" report following his investigation into the deaths of 94 mentally ill patients.

Ratsotso's body was found in a government mortuary together with other unidentified bodies. Makgoba described the deaths as "neglect and callousness" by some officials in the Gauteng department of health.

Another patient, Freddie Collitz, 61, died at Mosego Home in Krugersdorp. He had a wound to the head, blisters around the ankle and a sore on his nose.

His wife Marie, 58, saw him two hours before he was declared dead on August 7 2016. When she enquired about the injuries on his body, Marie was told Collitz had fallen on the lawn.

Most of the patients died because they were suffering from other illnesses when they were received into the care of non-governmental organisations (NGOs).

Some were suffering from tuberculosis while others had jaundice.

Patients at Precious Angels died of cold and hunger because there was no food to feed them. This is because the health department allegedly took three months to pay the NGOs.

Some of the patients were in an unhealthy state when they were admitted, some were without proper clothing, had no shoes, while others were malnourished, the report said.

According to Makgoba, the director of mental health Dr Makgabo Manamela - who Makgoba recommended be suspended, together with other senior officials in the department - could not tell the number of dead patients.

Makgoba said Manamela said there were 48 deaths while evading to respond to other questions. Manamela also sent some patients to Precious Angels because the NGO had the "experience and expertise".

Manamela signed licences for NGOs while she did not have the authority to do so.

Meanwhile, licensing for Precious Angels was due for amendment this year.

Under fire head from the department of health Dr Tieho Selebano, who is also implicated in the report and faces a disciplinary hearing and suspension, was also found wanting during the investigation. Selebano was evasive and contradicted himself and was not sure how many patients died, according to the report. He thought the number of dead patients was above 36 but later said the number was above 40. He apparently said the deaths were not as a result of poor planning.

When asked why licences were issued to NGOs where patients had been placed, Selebano said staff were under extreme pressure and errors happened as a result

He indicated there were no "evil intentions" in the project although unintended consequences happened.

Former Gauteng MEC of health Qedani Mahlangu, who resigned a day before the report was released, had earlier indicated that there were 36 deaths.

Mahlangu was found to "blow hot and cold when responding to questions". She said the reason she did not want to release the numbers of deaths was that it had become a political game.

Mahlangu, Selebano and Manamela were identified as decision-makers and implementers of the project and Mahlangu's evidence contradicted Selebano's.

The trio brought "pain and anguish" to the nation and "were not examples of good public servants. Their decisions and actions denied a group of vulnerable patients a right to health care". Mahlangu was alleged by many witnesses to have said her decision of moving patients from Esidimeni was final and non-negotiable and that the project had to be done, the report said.

ntwagaes@sowetan.co.za