‘€œThe epidemic and its tragic consequences have drawn attention to the extreme pressure on the neonatal unit from crowding and insufficient space, equipment and staff. Breakdowns have occurred in the application of standard operating procedures and quality control. These increase the risk for similar tragedies happening again,’€ the investigative panel found.

The Gauteng health department yesterday released the four-page report, months after former health MEC Qedani Mahlangu consistently declined to release it, opting to make available a two-page statement.

However, the current MEC Ntombi Mekgwe sent, what is being touted as the full investigation report, to the Democratic Alliance’€™s Jack Bloom.

Mahlangu refused Bloom access to the full report despite his application for it through the Promotion of Access to Information Act.

The report identifies a number of deficiencies including a lack of basic supplies such as roller towels and antiseptic sprays, as well as a shortage of equipment such as thermometers, which could lead to cross-infection if shared between babies.

The conclusion, which is the same as that contained in the two-page report, is that ‘€œThe deaths of the babies occurred as a consequence of a norovirus (gastro) epidemic in the neonatal wards ‘€¦ No specific acts of negligence in relation to the care or treatment of individual patients were identified.’€

The investigation also found that all the babies were ‘€œhigh risk’€ cases with a birth weight of less than 1 500 grams, although most of them appeared to be progressing well before the outbreak.

Records kept by medical and nursing staff were found to be excellent.

Seventeen neonates had been affected by the outbreak that caused severe diarrhea and vomiting. The outbreak was later linked to norovirus, a relatively common gastrointestinal virus that is spread not only by contaminated hands, water or food, but also through breathing in of droplets from vomit or stools.

The report found a neonatal unit facing severe pressure of overcrowding for a long time. The unit was described as a prime environment for cross infection.

It identified the preparation and distribution of formula feeds in the unit being an example of an area needing urgent attention.

Bloom said he was aware that five of the babies’€™ mothers were being assisted by a major law firm to sue the hospital adding that he would ensure that they get this report.

 ‘€œIt is essential that there is accountability for these deaths even if no specific individual can be directly blamed.

 Things like hand washing and basic infection control do not cost money and need to be rigorously enforced at all times at all hospitals,’€ said Bloom.

 ‘€œMeasures should be taken to address management, staff, equipment and overcrowding issues to ensure that no baby ever dies again from rectifiable deficiencies.

A legal case would be good if it reinforces this basic principle,’€ he added.