Friday 25 September

Life Esidimeni

Contents

Introduction

Here we detail the tragic history and outcomes of the Life Esidimeni case. Due to the cruel and inhumane decisions of the Gauteng Department of Health, 141 patients with mental health problems died in undignified conditions. Over 1,400 surviving patients were exposed to torture, trauma and severe violations of their human rights. The whereabouts of 44 of the mental healthcare users transferred from Life Esidimeni remain uncertain to this day.
Warning: This page contains descriptions of gross human rights violations.

Timeline

18 February 2016
Gauteng Department of Health (GDOH) extends its contract with Life Esidimeni for 3 months, announcing all patients will be transferred out by end of June.

March – August 2016
Mass transfer of mental healthcare users begins.

  • Patients moved in chaotic, unsafe conditions
  • Families not informed of whereabouts
  • Many NGOs unlicensed and unprepared
  • Patients experience neglect, abuse, and lack of basic care

August 2016
Christine Nxumalo discovers her sister, Virginia, has died after being transferred to Precious Angels NGO. At least 8 others die at the same NGO. Calls for an inquest begin.

September 2016

  • Government reports 36 deaths (later revealed to be far higher)
  • 15 Sept: Health Ombud Prof. Malegapuru Makgoba tasked to investigate
  • 16 Sept: Families request police inquests into deaths

1 February 2017
Health Ombud releases report: “No Guns: 94+ Silent Deaths and Still Counting”

  • Confirms at least 94 deaths
  • Finds constitutional rights violations and systemic failure

March 2017
Government begins moving surviving patients from unsafe NGOs to proper facilities.

June 2017
Justice Dikgang Moseneke appointed to lead arbitration between government and families.

9 October – December 2017
Arbitration hearings take place over 45 days with 60 witnesses, including senior government officials.

19 March 2018
Arbitration ruling delivered:

  • Government condemned for reckless decisions
  • Families awarded compensation, including R1 million constitutional damages each
  • State ordered to implement recovery plan and memorialise victims

18 April 2018
SAPS opens 46 inquest dockets into the deaths.

19 July 2021
Formal inquest hearings begin at Pretoria High Court, presided by Judge Mmonoa Teffo

10 July 2024
Inquest judgment finds that former Gauteng Health MEC, Qedani Mahlangu, and former Director of Mental Health in Gauteng, Dr Makgabo Manamela negligently caused the deaths of nine mental healthcare users: Virginia Machpelah, Deborah Phehla, Frans Dekker, Charity Ratsotso, Koketso Mogoerane, Terrence Chaba, Daniel Josiah, Matlakala Motsoahae, and Lucky Maseko. 

    29 October 2024
    Families and advocacy groups protest, demanding prosecutions from the NPA.

    18 August 2025
    NPA informs families of a final decision pending further review as a legal opinion recommends prosecution of Mahlangu and Manamela, with charges currently limited to 2 victims.

    13 April 2026

    The NPA announces that it has decided to proceed with the decision to prosecute individuals implicated in the Life Esidimeni tragedy. 

    The transfer to NGOs

    On 18 Feb 2016, the GDOH extended the contract with Life Esidimeni for another three months but stated that all mental healthcare users would be transferred out of the facilities by the end of June that year. Between March and August 2016, mental health care users with varying diagnoses and needs were discharged from Life Esidimeni and transferred to NGOs and hospitals around the province. The process was completely haphazard, with patients being loaded onto the back of trucks, confidential patient records being lost and chaos characterising the process.

    The families of patients were not informed where their loved ones were being sent. Some patients were moved multiple times before their families found them. NGOs were not licensed properly, and lacked the facilities to take proper care of patients.

    In August 2016, Christine Nxumalo discovered that her sister Virginia had passed away after being transferred without her knowledge to Precious Angels NGO. After learning that a further 8 other patients had died at the same NGO, Christine demanded an inquest into her sister’s death.

    Mental healthcare users were tortured, abused, punished and in some cases deprived of food, water and adequate shelter and sanitation at the (often overcrowded) unlicensed NGOs. Mental healthcare users were not provided with the medicine or treatments that they needed for their mental health. In dire and squalid conditions, many developed dehydration, secondary infections like pneumonia or had uncontrolled seizures. NGOs were not staffed with trained healthcare professionals, lacked appropriate medicine and equipment, and in some case even basic infrastructure like beds, bedding and sanitation.

    Against all expert advice, and contrary to their constitutional obligations, the GDOH went ahead with a plan that resulted in the deaths, trauma and torture of some of the most vulnerable members of society.

    The Health Ombud’s Report

    By September, the MEC, in answering parliamentary questions, said that 36 former residents of Life Esidimeni had died since the transfer out of the facility. Evidence later showed that at the time, more than double that number of patients had passed away because of the rushed and inhuman move from Life Esidimeni to other NGOs. By 15 September the Health Ombud Prof. Malegapuru Makgoba was requested by the Minister of Health to investigate the deaths of patients, and then on 16 September 2016, family members asked the police to launch inquests into all of the deaths of deceased mental healthcare users. SECTION27 provided relevant evidence to the Ombud and the police.

    The Health Ombud investigated the transfer of patients in more detail, and invited the MEC to make submissions on their report, which they only did after some delay. The Ombud’s report entitled: ‘NO GUNS: 94+ SILENT DEATHS AND STILL COUNTING’ – which you can read here – was published on 1 February 2017. It detailed the 94 known deaths of mental healthcare users and inhumane treatment of others, stating that:

    ‘There is prima facie evidence, that certain officials and certain NGOs and some activities within the Gauteng Marathon Project violated the Constitution … [and] have shown a total disregard of the rights of the patients and their families, including but not limited to the Right to Human dignity; Right to life; Right to freedom and security of person; Right to privacy, Right to protection from an environment that is not harmful to their health or well-being, Right to access to quality health care services, sufficient food and water and Right to an administrative action that is lawful, reasonable and procedurally fair.’

    Ombud’s report, p.2
    The Ombud’s report

    Several deceased had died from illnesses that questioned the conditions/circumstances under which and the quality of care patients received at NGOs e.g. fits, dehydration, aspiration pneumonia, acquired pneumonia, cardiac arrest, ‘being found dead in the morning without night observations’ etc. (Ombud, Expert Panel and MAC); So in short, nothing could be that simply ‘natural’; the conditions and circumstances at NGOs made these deaths other than ‘natural’

    Ombud’s report, p.43.

    Alternative Dispute Resolution

    A month after the publication of the Ombud’s report, the GDOH began moving surviving mental healthcare users from the unlicensed NGOs to safer facilities. We gathered evidence on behalf of the families and delivered it to SAPS, calling for officials involved to be prosecuted, and unlawful burials be investigated further.

    In June 2017, in line with recommendations made by the Ombud’s report, former Deputy Chief Justice Dikgang Moseneke was appointed to arbitrate an Alternative Dispute Resolution between the government and the families of the Life Esidimeni deceased (legally represented by SECTION27) and survivors (represented by Legal Aid South Africa). The arbitration began on 9 October 2017. Originally estimated to take three days, the arbitration spanned 45 days, with 60 witnesses testifying and two days’ worth of legal arguments brought before the arbitrator. Of the 60 witnesses, 12 were senior government officials including the Minister of Health, the Gauteng Premier, the Members of the Executive Council for Finance, Health and the former Health MEC Qedani Mahlangu, whose fingerprints were found to be “peppered” all over the Life Esidimeni tragedy.

    SECTION27 represented 63 bereaved families in the process.

    The arbitration award

    Justice Moseneke read out a searing indictment of the government on 19 March 2018, where he ordered that the state pay various costs and damages to the families of deceased mental healthcare users. Pulling no punches, Justice Moseneke condemned senior state officials for the “wanton, arbitrary and unaccounted decision” to discharge patients from Life Esidimeni into the care of unlicensed NGOS – a decision which “caused so much pain and suffering, stress, trauma and morbidity, and in [his] view, is a very serious breach of the constitutional obligations by the State and its servants”.

    In terms of common law damages, DCJ Moseneke ordered the state to:

    • Pay claimants R180,000 for psychological injury and trauma
    • Pay claimants R20,000 towards funeral costs
    • Erect a memorial for the victims of the Life Esidimeni Marathon Project
    • Pay for counselling for up to three family members of the deceased

    Constitutional damages

    But the arbitration award went beyond common law damages orders alone. Justice Moseneke also ordered the state to pay R1 million in constitutional damages to each claimant for the gross violation of various rights enshrined in the Constitution, including the rights to life, dignity, equality, freedom and security of the person from torture, access to healthcare and sufficient food and water, and the rules surrounding public administration.

    Justice Moseneke also found the State contravened the National Health Act, 2003 and the Mental Health Care Act, 2002 and ordered that the new MEC Dr Gwen Ramokgopa present a recovery plan to the Health Ombud and claimants within 6 months of the award and every subsequent 6 months until the recovery plan is concluded.

    The Award

    “This is a harrowing account of the death, torture and disappearance of utterly vulnerable mental health care users in the care of an admittedly delinquent provincial government. It is also a story of the searing and public anguish of the families of the affected mental health care users and of the collective shock and pain of many other caring people in our land and elsewhere in the world. These inhuman narratives were rehearsed before me, the Arbitrator, in arbitral proceedings I am about to describe.”

    — Justice Moseneke, Award, p.2

    Inquest, the Mental Health Recovery Plan and remembrance

    To this day, high ranking officials in the GDOH, including Qedani Mahlangu, Dr Makgabo Manamela and Dr Barney Selebano have not been prosecuted. However, they did face disciplinary inquiries by their professional bodies, such as the Health Professions Council of South Africa.

    On 18 April 2018, SAPS officially opened 46 inquest dockets into the Life Esidimeni tragedy. Pieter Luyt from the National Prosecuting Authority is the evidence leader at the inquest hearing presided over by Judge Mmonoa Teffo at the Pretoria High Court. SECTION27 is representing 44 bereaved families and will provide evidence to the joint inquest, and hopes that those responsible for the deaths of 141 mental healthcare users and the torture and trauma of over 1,400 others are brought to justice. You can watch the Inquest on the Judiciary’s YouTube channel.

    The Inquest into the deaths during the Life Esidimeni tragedy began virtually on 19 July 2021. You can read our factsheet about the inquest here:

    DOWNLOAD FACTSHEET

    Life Esidimeni Inquest: Judgement (10 July 2024)

    On 10 July 2024, Judge Mmonoa Teffo found that former Gauteng MEC for Health, Qedani Mahlangu, and the former Director of the Mental Health Directorate in Gauteng, Dr Makgabo Manamela negligently caused the deaths of nine mental healthcare users: Virginia Machpelah, Deborah Phehla, Frans Dekker, Charity Ratsotso, Koketso Mogoerane, Terrence Chaba, Daniel Josiah, Matlakala Motsoahae, and Lucky Maseko.

    Judge Teffo noted that Ms Mahlangu negligently terminated the Life Esidimeni contract despite expert advice and warnings, resulting in mental healthcare users being moved to NGOs that were ill-equipped and insufficiently experienced to care for them. This conduct, Judge Teffo stated, led to deaths that could have been avoided.

    Read the full judgment below:

    LIFE-ESIDIMENI-INQUEST-JUDGMENT.2024Download

    Memorandum Handover to the National Prosecuting Authority (NPA)

    The Life Esidimeni families, joined by members of the disability sector, the South African Depression and Anxiety Group (SADAG), SECTION27 and other interested parties, held a picket on 29 October 2024 to hand over a memorandum to the National Prosecuting Authority (NPA) offices in Pretoria. The interest groups demanded that the NPA prioritise the prosecution of Qedani Mahlangu (the former Gauteng Health MEC) and Dr. Makgabo Manamela (the former Director of Mental Health in Gauteng) for their roles in the Life Esidimeni tragedy.

    Final_Memorandum of Demand for Justice and Accountability for the Life Esidimeni Victims_28Oct2024Download

    NPA updates families on decision to prosecute

    The Life Esidimeni Families met on 18 August 2025 with the National Prosecuting Authority (NPA), represented by Acting Director of Public Prosecutions, Adv. Marika Jansen Van Vuuren. The meeting follows years of delays in the decision to prosecute those responsible for the deaths of 144 mental health care users.


    At the meeting, the NPA informed the families that it has received a legal opinion that recommends prosecution of former Gauteng MEC for Health, Qedani Mahlangu, and former Director of Mental Health, Dr. Makgabo Manamela. However, the legal opinion recommends prosecutions for the deaths of only two people: Mr. Terence Chaba and Ms. Virginia Machpelah. The NPA informed the families that a team of prosecutors has now been formed to assess both the legal opinion and the extensive evidence already presented at the Inquest to make a final decision on prosecution.

    Full statement accessible here.

    WDA