At least 143 psychiatric patients died when they were taken out of a licensed care facility and placed with facilities that did not have the means to care for them.
It was a mental health tragedy on a scale that South Africa had never seen before.
The head of the country's health service in the country's most populous province of Gauteng made the 2015 decision to transfer mentally ill patients from a registered licensed facility to several private mental health facilities that were not licensed and did not have the means to look ofter the patents. The outcome of Qedani Mahlangu's fateful decision was that 143 of them died from neglect.
Starting February 2016, more than 1,700 patients were rapidly relocated from the Life Esidimeni hospital in Johannesburg to 27 privately run clinics that were unable to care for them.
The Gauteng provincial health department cancelled its contract with Esidimeni as a cost-cutting measure.
At the Life Esidimeni arbitration hearing in Johannesburg where Mahlangu testified, a sea of protesters, consisting of the loved ones of the dead patients converged on the hearings to demand answers.
TRT World's Adeshewa Josh reports from Johannesburg.