During a regular visit, Sophie Mangena was shocked to find that her mother with dementia had been transferred from the psychiatric facility without so much as a phone call to the family, and the nurse on duty didn't know exactly where she was.
Desperate for information, the daughter heard from a security guard that her mother might have been taken to Takalani, a little-known facility in Johannesburg's Soweto township.
When the family finally found their mother, the 56-year-old matriarch had lost so much weight she was barely recognizable. Shivering and hungry, she was in dirty clothes and barefoot. Days later, she died.
Mangena was one of at least 144 psychiatric patients who died after South Africa's Gauteng provincial government hastily transferred 1,711 state-funded psychiatric patients in 2015 and 2016 from Life Esidimeni, a private health care provider, to other facilities, dozens of which were not properly licensed.
The death toll is expected to be higher: Two years later, the whereabouts of 44 patients are still unknown.
The experience is "a terrible tale of death and torture of mental health care users," ruled former Deputy Chief Justice Dikgang Moseneke, who last week issued a report awarding Mangena's family and 134 other relatives of victims USD 101,000 each.
The award sets an important precedent for human rights abuses in South Africa, observers say.
"It was emotionally overwhelming," said Boitumelo Mangena, Sophie's sister. "We've come to the end, but we still don't have the answers we're looking for. We still don't know why this happened." The revelations of gross mistreatment have shocked South Africans and raised troubling questions about the government's commitment to its most vulnerable citizens more than 20 years after the end of apartheid.
"This is the biggest mass death since democracy," said Sasha Stevenson, an attorney with Section 27, a public interest law center that represented Mangena and more than 60 other patients' family members. "This is a huge system failure."
For reasons that remain unclear, the government made the transfers between October 2015 and June 2016 in a rushed process that family members and Life Esidimeni staff have repeatedly described as "chaotic."
Some patients were tied up with bed sheets and loaded into trucks or were relocated without their identification or medical records. Others were moved multiple times between facilities. A health ombudsman's report released in February 2017 called the process "negligent and reckless and showed a total lack of respect for human dignity."
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