A Doctor Becomes a Patient, and the System Fails Him

Dr. Edward Mabubula was a man who understood the inner workings of medicine. A 64-year-old specialist physician and nephrologist, he had spent his career navigating the complexities of the human body. Yet, when he became the patient, the system he was part of failed him in the most fundamental way. Four years after his death, a damning report by Health Ombud Professor Taole Mokoena has revealed a chilling omission: there was no documented record of his basic clinical assessment before a routine procedure that ended his life.

On 27 March 2021, Dr. Mabubula, who was living with metastatic colon cancer, drove himself to the Wits Gordon Oncology ward to have an ambulatory chemotherapy pump disconnected. It should have been a quick, routine visit. According to the ombud’s findings, a nurse flushed his chemotherapy port while he was seated. The only pre-procedure note was a temperature reading. There was no documented baseline examinationno record of his blood pressure, heart rate, or lung sounds, despite his complex history of lung surgery and tuberculosis.

The Collapse and the Cause

Minutes after the flush, as he stood to put on his shirt, he collapsed. An urgent scan revealed the cause: a right frontal cerebral air embolismair trapped in the blood vessels of his brain. Independent experts confirmed the port flushing procedure caused this rare but known complication. The report concluded that performing the flush while he was seated, followed by standing, likely allowed air to travel retrograde into his venous system.

Dr. Mabubula never recovered. He died on 3 June 2021 after weeks in intensive care. The certified cause was natural, citing respiratory failure. But the ombud’s investigation pointed to a preventable tragedy rooted in systemic neglect.

A Widow’s Quest and a System’s Broken Protocol

His widow, Irene Tebogo Mabubula, lodged a formal complaint, seeking R20 million in compensation and, more importantly, accountability. The ombud’s report vindicates her pursuit. It found the Wits Donald Gordon Medical Centre breached the National Health Act by failing to maintain proper health records. There was no dedicated patient file opened or retrieved for his visita stunning lapse for a major private facility.

“The investigation uncovered a complex case… aggravated by the medical centre’s undocumented practice of failing to open or retrieve patient files and failing to record critical baseline clinical assessments,” Mokoena stated.

Orders for Change, But Grief Remains

The ombud has issued binding recommendations: the centre must develop formal protocols for port procedures, ensure proper documentation for every patient, and provide psychological support to Irene Mabubula and her family. The centre must also participate in mediation to resolve the dispute.

The ombud has declared the matter closed, but for Irene Mabubula, closure is a distant concept. The report provides answers but cannot restore what was lost. For the public, it serves as a harrowing case study. If a specialist doctor, savvy to the ways of hospitals, can fall victim to such a basic documentation failure, what hope is there for the most vulnerable patients? The death of Dr. Mabubula is a stark testament that in healthcare, the simplest oversighta missing file, an unwritten notecan carry the highest possible cost.