Good morning to all of you members of the media, and welcome to this press briefing. We called you here today to publicly account for the findings of the investigation into the circumstances surrounding the death of a Mental Health Care User, Mr Quinton DuPlessis, at Witrand Specialised Hospital in Potchefstroom. We are also here to report on progress made by the North West Department of Health in implementing recommendations arising from the investigation. The death of a patient in our care is a matter of the utmost seriousness. When a person is admitted to a public health facility, particularly a specialized mental health institution, that person is placed in our care, and we have a profound responsibility to protect their dignity, safety and wellbeing. As the Department, we therefore have a duty to investigate allegations thoroughly, establish the facts, acknowledge shortcomings where they exist, and take corrective action.

BRIEF BACKGROUND

Mr Quiton DuPlessis was a long-term Mental Health Care User at Witrand Specialised Hospital. He was diagnosed with intellectual disability disorder (moderate) at a young age, Prader-willi syndrome and underlying chronic conditions. He was previously admitted at Bophelong Psychiatric Hospital (BPH) and was discharged on 10 June 2013 and then taken to a placement centre. Since his admission at Witrand he has had leave of absences in 2014, 2015 and the last one in 2021. His death subsequently became the subject of public concern and allegations of possible abuse and assault, including allegations circulated on social media.

Following these reports, I visited Witrand Specialised Hospital on 21 June 2025 as part of my “Re Bona Ka Matlho” oversight programme. Re Bona Ka Matlho is about government seeing, hearing and responding to problems on the ground rather than waiting for communities to escalate their concerns repeatedly. Given the seriousness of the concerns raised, I appointed an investigation team to establish the circumstances surrounding the incident and to examine the broader conditions under which patients were being cared for at the hospital. The investigation team constituted various managers and experts including, specialist psychiatrist, Advocate, Director: Mental health, Director: Communications, Forensic nurse, Labour relations expert and chaired by one of our experienced Clinical managers in the department. Following these reports, I visited Witrand Specialised Hospital on 21 June 2025 as part of my “Re Bona Ka Matlho” oversight programme. Re Bona Ka Matlho is about government seeing, hearing and responding to problems on the ground rather than waiting for communities to escalate their concerns repeatedly. Given the seriousness of the concerns raised, I appointed an investigation team to establish the circumstances surrounding the incident and to examine the broader conditions under which patients were being cared for at the hospital. The investigation team constituted various managers and experts including, specialist psychiatrist, Advocate, Director: Mental health, Director: Communications, Forensic nurse, Labour relations expert and chaired by one of our experienced Clinical managers in the department.

The investigation report has now been finalised, and I am releasing it today because the people of the North West have a right to know what was found and what action is being taken.

KEY FINDINGS AND RECOMMENDATIONS The investigation was commissioned to establish the circumstances surrounding the patient’s care and death, assess allegations of abuse or negligence, determine compliance with clinical and operational protocols, and identify systemic factors that may have affected patient safety and quality of care. It is important to indicate from the onset that regarding the allegation of sexual assault, that the interviews conducted and documentation reviewed were inconclusive. The investigation therefore did not establish sufficient evidence to make a conclusive finding on the allegation.

Importantly, the post-mortem report was still outstanding when the investigation report was finalized. The matter relating to the allegation of sexual assault also remains part of the South Africa Police Services (SAPS) investigation process, and the Department will await the finalization of that process and consider any additional evidence arising through this lawful investigative processes. We must therefore be cautious and allow the relevant investigative and legal processes to reach their conclusion.

Allegation of possible assault is also immediately ruled out by the investigation. The investigation established that, what seemed like bruises can be attributed to complications of his medical conditions. While the investigation did not find evidence to substantiate allegations of physical abuse, it did identify some management gaps in patient care, inadequate communication and escalation of patient concerns, staff shortages, weaknesses in infrastructure and security, inadequate maintenance of equipment, challenges with laundry and other support services, and weaknesses in management and governance. Failures relating to adherence to established protocols and the need to strengthen the assessment, monitoring and escalation of patients whose clinical condition deteriorates, were also identified.

These findings demonstrate that, irrespective of the outcome of the outstanding inquest and post-mortem processes, there are important lessons that the Department must act upon to strengthen the quality of care at Witrand hospital. The report therefore recommends interventions that include strengthening clinical management protocols, improving staffing, addressing infrastructure and equipment deficiencies, strengthening security systems, improving infection prevention and support services, and enhancing management and clinical governance. It further recommends a dedicated Witrand Intervention Task Team to oversee and monitor implementation of the recommendations over a six-month period.

PROGRESS ON IMPLEMENTATION OF THE RECOMMENDATIONS

The Department has already made progress in several key areas identified by the investigation. Staffing: Staff appointments have reached 79%, with 43 of the 55 approved nursing positions filled. This comprises five Professional Nurses, eight Enrolled Nurses and 30 Enrolled Nursing Assistants.

Heating system: The heating system has been substantially addressed, with 26 new air-conditioners installed. This is important because it provides a more appropriate and stable environment for Mental Health Care Users, particularly vulnerable patients who require protection from cold conditions.

Lighting: All identified lighting problems have been addressed, including the replacement of faulty lighting and the installation of additional external floodlights. This improves visibility and contributes to a safer environment for both patients and staff. Windows and doors: The repair and replacement of broken windows and doors has been attended to, with 41 broken windows replaced on 23 August 2026 and an order placed for 14 steel exit doors. The Department will continue addressing windows and doors where damage occurs, while recognizing the need for ongoing maintenance in the specialized psychiatric environment.

Boilers: Of the two boilers, one is currently operational, following repair work completed on 11 September 2026. The operational boiler improves the hospital’s capacity to provide hot water and support essential services. The Department is continuing the work to address the second boiler so that the hospital has greater reliability and resilience in its hot-water supply.

CCTV and security: CCTV installation currently stands at 35%, with 16 of the required 46 cameras installed. The remaining security challenges, including physical security and completion of the CCTV installation, are being addressed.

Laundry: Laundry capacity remains a challenge. Currently, three of eight laundry machines are functional, representing approximately 36% functionality. The existing machines are between 30 and 40 years old and require replacement. This will require appropriate budgeting and procurement planning. The Department is therefore working towards replacing the ageing equipment to improve laundry capacity and ensure that patients have adequate access to clean linen and clothing.



LATEST CASE OF A FEMALE The Department has already responded through a media statement regarding a separate incident involving a female patient who allegedly absconded from Witrand Specialised Hospital and was subsequently found deceased on 26 August 2026. The deceased was a long-term, well-known patient who had been admitted to the hospital’s Female Ward 3 since 22 June 2023. Hospital management was alerted that a person matching the description of the missing patient had been found lying on Promosa Road, near the graveyard. Upon arrival, the person was confirmed to be the missing patient, and the family was immediately notified. Given the circumstances, the Department has initiated an investigation to establish the events leading to the patient’s death.

CONCLUSION AND WAY FORWARD Ladies and gentlemen, the findings of this investigation require us to be both honest and cautious. The investigation did not substantiate allegations of physical abuse, while the allegation of sexual assault remains inconclusive pending the outstanding postmortem and the finalisation of the SAPS investigations. We will allow those processes to run their course and will consider any additional evidence that emerges. At the same time, the investigation identified serious weaknesses in patient care, staffing, infrastructure, security and clinical and management systems at Witrand. These are matters within the Department’s responsibility, and we must address them. Progress has already been made, particularly in staffing, heating, lighting and windows and doors. Work continues on security, CCTV, the second boiler and the replacement of ageing laundry equipment. Our objective is clear: to strengthen patient safety, improve the quality of care and ensure that Mental Health Care Users at Witrand are treated with dignity, compassion and professionalism. We will continue monitoring the implementation of the recommendations and hold the relevant structures accountable for progress.

We extend our condolences to the family of the late Mr Quiton DuPlessis. While we cannot undo the loss of a life, we can ensure that the lessons arising from this matter are acted upon with seriousness and determination. The North West Department of Health remains committed to strengthening Witrand Specialised Hospital and ensuring that it provides safe, quality and patient-centred specialized mental healthcare.

I thank you