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Published by:
Ivey Publishing (2020)
Revision date:
16 pages
Data source:
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In 2015, the Department of Health for the province of Gauteng, South Africa, deinstitutionalized patients in need of long term health care in an effort to reduce costs. The residents were moved from an established health care facility experienced with providing the care these patients needed to non-governmental facilities. Many of these facilities were unlicensed and lacking the skills and resources needed to provide the necessary care. The project was poorly planned with inadequate notice and patients were transferred without identification, medication, or medical records. From March to June 2016, 1,712 patients were transferred; many of them were lost in the system and 144 died-most from malnutrition, abuse, or neglect. The health ombudsman investigated and released a report in February 2017, placing the blame for the tragedy on three senior leaders in the health care system. A new member of the executive council was appointed upon the release of the report. In 2018, her challenge was to determine what happened and plan changes to ensure such a tragedy would never be repeated.

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This item is suitable for postgraduate courses.


Accountability; Health care; Change management; Deinstitutionalization; General management/strategy; International
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