State of the Forensic Pathology & EMS in the province: Department of Health briefing

Meeting report

Forensic Pathology Services presentation

Dr Beth Engelbrecht, Head: Department of Health (DoH), said the presentation would cover both Forensic Pathology Services (FPS) and Emergency Medical Services (EMS), and would touch on matters that the Department felt were important for the Committee to know.

Ms Vonita Thompson, Director: Forensic Pathology Services, presented the mandate, background and situation within the FPS as at end of the 2018/2019 financial year, and provided details of the service pressures within the entity, the circumstances of death, and provincial homicides. 

The Committee was told that from 1 April 2018 to 31 March this year, 12,045 cases had been logged, resulting in 11 816 admissions -- an average of 985 cases a month. 8 417 (71,2%) of these admissions took place in the two FPS facilities Cape Town in Salt River and at Tygerberg. The average response time from receipt of call to arrival on the scene was 35 minutes, with 73% of cases attended within 40 minutes. The average turnaround time from admission to examination was 3.9 days, with 55% of cases being examined within three days. The average turnaround from admission to release was 7.33 days, with 58% of cases released within five days. The average number of days from admission to receipt of post-mortem reports was 66 days. Interim reports were released while laboratory results were awaited. The average number of days from admission to completion of the detective bundle was 93.2 days.

The service had experienced an increase in case admissions, as well as case complexity. The 2019/20 average case admission had been 1 062 per month, compared to 1 003 for same period in 2018/19 and 985 for 2017/18. Last year, there had been 4 170 homicides in the Western Cape, of which 49% (2 029) were the result of gunshots, 35% (1 483) from stabbings, and the balance through other circumstances.

Ms Thompson said the FPS had an approved staff complement of 287 posts, and as at 15 July 2019, 98.3% (282) were filled. The service had also received approval for the filling of two pathologist and six Forensic Pathology Officer (FPO) posts. The organisational development investigation (ODI) for the commissioning of the Observatory Forensic Pathology Institute (OFPI) was currently being concluded.

Mr Wayne Mitten, Manager: Salt River FPS presented a virtual walkthrough and 3D model of the OFPI facility, describing the services, components and design of the new building.

Discussion

Ms A Bans (ANC) asked what information FPS would be giving in its interim report.

Ms R Windvogel (ANC) asked whether the Salt River and Tygerberg facilities were also serving the rural areas.  In the light of staff reductions, did the establishment figures presented mean there was no shortage of staff?

Mr R Allen (DA) asked if the FPS was experiencing any backlogs.  Referring to the 49% of victims who had died from gunshots, he asked what the department’s relationship with the South African Police Service (SAPS) was like.

Ms L Botha (DA) asked if the OFPI facility the first of its kind in South Africa, or the African continent as a whole.

FPS’s response

Ms Thompson said the interim report would include the first written reports.  When interim reports were released, they were often ‘under investigation,’ or ‘pending further investigation’, meaning the cause of death was still under investigation.

The two service points in Salt River and Tygerberg were two of 17 facilities in the province.  There were facilities outside of Cape Town.  FPS was structured to have regional referral centres.  They provided support to the smaller communities in the rural areas.  Cases could travel to the facility, or FPS could travel to the case. There were challenges with the referral system, but this was how the Department could provide quality and accessible services.

Regarding staff accessibility, she said the Department could never have enough staff.  The presentation was reflective of staffing improvements, based upon budget availability.  There was an intern programme that could provide some administrative and forensic pathology support.

With regard to the OFPI facility, Gauteng was also building something similar.  However, the forensic pathology institute facility under construction in the province integrated academics, training, research, laboratory spaces and the mortuary in one single facility.  This was the first of its kind in the country.  There was international interest. At the moment, the facility was about 80% complete.  October was the proposed commissioning date. The cost was about R 280 million, excluding commission and associated fees.

The relationship with SAPS and the impact of investigations was an ongoing challenge that the Department needed to manage.  They were receiving support from the Department of Community Safety to try and assist in strengthening the relationship with SAPS.  There were priority committees that could help in dealing with case backlogs and relationship issues.

Ms Thompson said admission and release, and what was impacting release time, was a complex issue.  Sometimes the delay was due to difficulties with identification.  Sometimes the release was hindered by the number of pathologists admitting those cases.  Case investigations also took time and affected release times.  Cases were allocated in terms of the availability of information.  Cases could also be prioritised for several reasons.  It was a balancing act, and a number of factors could delay the release time -- it was a challenge the Department faced.

She noted the backlog process.  The Department was examining as many cases as they were receiving.  Challenges specifically were in the fact the Department was examining more cases than in the past.

Further discussion

Ms Botha asked if the construction company was still on site to hand the OFPI facility over.  

Mr M Xego (EFF) asked for clarity on the geographic location of FPS facilities, and wanted to know why there was one in Oudtshoorn.

Ms Thompson said there were about 300 unidentified cases.  This was because it was a prolonged process that could include DNA and facial reconstruction.

Mr Mitten said that the Department was dependent on the police, availability of resources and databases.  It could take up to three months.

Ms Thompson referred to Laingsburg and the surrounding municipal areas, and the use of the Oudtshoorn facility.  Both Beaufort West and Laingsburg had been contructed to have a doctor and pathologist based there.  The challenge was retaining people.  Pathologists could handle cases at both locations if this was needed, and could travel to cover the full geographic area.

Ms Windvogel asked the Department why it took so long for it to come and pick up a body, citing an example where it had taken three hours.

Dr Engelbrecht explained that the police must first respond to the crime scene.  FPS was a secondary response.

Ms Windvogel responded that according to the police, they had been waiting for FPS.

Ms Thompson said that in the specific example, services had been dispatched from Worcester. There could be a further delay when cases were diverted, or delays for other reasons.  It was an issue that the Department had looked at.

Dr Engelbrecht briefly addressed the Department’s measurement of the average response time.  She said it was a quality marker, and something the Department paid attention to.

Emergency Medical Services presentation

Mr Shaheem de Vries, Director: Emergency Medical Services (EMS), gave details of the 2019 trauma statistics for Cape Town. The top ten areas for trauma incidents were Khayelitsha (865 incidents), Delft (735), Philippi (703), Strand (692), Mfuleni (562), Macassar (518), Mbekwini (503), Nomzamo (477), Lwandle (466) and Du Noon (402). Of these 5 923 cases, just over 32% had been responded to in less than 15 minutes.

The top ten areas for gunshot incidents were Delft (131), Khayelitsha (63), Philippi (52), Manenbeg (50), Hanover Park (42), Lentegeur (40), Tafelsig (38), Bonteheuwel (37), Wesbank (34) and Eastridge (33). The average response time for 22% of these incidents was under 15 minutes.

The following “red zone” areas had been identified, but were not limited to: Browns Farm Phillipi, Tafelsig, Beacon Valley, Hayden Park, Nyanga, Gugulethu, New Crossroads, Manenburg, Hanover Park, Kalksteenfontein, Chicargo (Paarl), Site C Khayelitsha and J Section Lingelethu.

Part of the protocol for servicing an incident in a red zone area was:

• Confirm that the area is safe to enter;
• SAPS should accompany all resources when entering a red zone;
• Staff should wait at a police station until a police escort becomes available.

The strategy being employed to deal with the challenges it faced included strengthening the senior EMS leadership; creating comprehensive staff health services; reassessing “resource cost” constraints; implementing a health services platform design; and promoting greater community engagement through a “whole of society approach” (WOSA).

Discussion

Mr Allen asked for background on how protocols were established.  Was there anything that prohibited them from ensuring that the protocols included checking in with the metro or traffic police? He would like more information on the length of calls, citing a personal example of a red zone call that had taken 32 minutes. He commented that staff were being pushed to their limit, and wanted to know what the absenteeism rate was.

Ms Botha asked about employee assistance programme.  How many staff were on the programme now?  Who was the Department seeking collaboration with?  How did they communicate to make communities understand the challenges faced by the emergency services?  She wanted to take the presentation document to the communities she served so that they would have a better understanding of these challenges.

The Chairperson asked how private service delivery complemented the existing EMS, and wanted more clarity on community participation.

Mr Allen asked whether inter-facility transfers (IFTs) would be feasible in order to help deal with backlogs. 

EMS’s response

Mr De Vries referred to the challenges surrounding red zones, saying they posed an ethical dilemma.  No one should be denied medical care.  There were historical reasons as to why certain people were being disenfranchised based upon where they stayed.  The only way to resolve that issue was with transport, and the only way to do that was with ambulances.  He felt the burden on the EMS to solve the transportation issue was disproportionate.  The ethical issue with red zones was that they were unconstitutional.  The Department had participated in a safety symposium where it had been agreed that red zones could not be the only way communities were responded to.  They should not be indefinite. Red zones were temporary, and there was a push to get rid of them.  There had been issues in the past over red-zones, with staff refusing to go into communities due to their personal safety.  He saw this as an indication of the wrongness of red zones. The implementation of escorts into dangerous communities would enable people to be served. The Department was now providing a better service because of the changes in how they supported red zones. 

He discussed safety alternatives, including a neighbourhood watch response.  This might be a more effective and safer solution than EMS entering communities with SAPS.  Rent-a-cop had been suggested as an option as well.

Staff absenteeism rates were lower than before.  Since January 2016, there had been 103 work-related post-traumatic stress disorder (PTSD) cases amongst staff.  There was awareness in the Department of staff PTSD, and there were measures to report and attend to these cases as they happened.  Staff could come back to work, and the Department would ensure that they were placed in different positions if this was necessary.  The Department was aware of the high level of staff trauma, so they employed a strong Employee Assistance Programme (EAP).

With red zones, community engagement and sharing both sides of the issue was important. The only people who could perform this engagement were the staff, so the Department had started training them.  This included sending them into the communities.

Ambulances came from four different bases.  They were in these bases only at the beginning and end of shifts.  They were constantly moving, so ambulances came from everywhere.

He commented that private service was failing.  The Department had not engaged with them yet, and it was difficult to do so, as the business models were different.  However, in discussions around shared responses, they had been accommodating and welcoming.  He had observed some ways in which the two could collaborate.

He feels that the patient did not benefit from IFTs.  There was an inter-facility service and a public service.  The Department was looking at creating a different response that benefited the patient.

Dr Engelbrecht explained that ambulances tracked where the most calls came from, and positioned the vehicles accordingly.

The Department was meeting the public and private interface issue as part of the universal health coverage approach.  It wanted to explore an approach where the public and private sector could collaborate.

Further discussion

Ms Botha asked about the potential of community radio.  She also asked about awards to recognise achievements by EMS personnel.

Mr Xego asked about the ‘peak season,’ and what its impact was on the EMS?  With the two sectors, what would the impact be if there was one service that was nationalised?

Dr Engelbrecht agreed that community radio was good.  Language within communities may be an issue.  The principle of triage still served as an obstacle with communities.  The Department consistently needed to get the message across, and community engagement, communication and understanding needed to improve.

She recognised the importance of a departmental improvement in staff recognition.

She said that EMS it was a provincial competency.  Within a province, nationalisation may have potential.

Mr De Vries supported the importance of recognition of staff performance.  There were examples where the Department recognised employees’ decision to come to work.

Staff had to be diligent in requesting off time during the festive “peak season.”  At this time, there was not a peak in incidents, but a shift in the type of cases.  The Department could predict and expect this change, so they planned accordingly.

The Chairperson commented that Members of the Committee had a responsibility to support the Department within their own communities.

Committee matters

Ms Botha moved for the adoption of the minutes of the Committee’s 31 July meeting. Ms Bans seconded.

The Chairperson went through the draft Committee programme.

The meeting was adjourned