“Oh my goodness!” This was how former deputy chief justice Dikgang Moseneke reacted to news that the number of former Life Esidimeni patients who had died by the end of last month had increased from 118 to 141.Hearing that 23 more mentally ill-patients had died in the aftermath of their bungled transfer to several unlicensed NGOs, under former Gauteng health MEC Qedani Mahlangu’s watch, clearly shocked him.He asked acting Gauteng health department head, Ernest Kenoshi, to repeat the number, probably wanting to ascertain if he had heard correctly.Moseneke is heading the arbitration hearing between the state and families of the former Life Esidimeni patients who died.Kenoshi conceded that the figure could probably increase because the department was not certain if it was the ultimate figure. It had planned to have the list audited.The additional 23 patients died since February, when health ombudsman Professor Malegapuru Makgoba released his findings into the deaths of former Life Esidimeni patients who were transferred to the NGOs. Families of the deceased patients gasped in disbelief as Kenoshi read through his documents.It was heard that patients continued to be exposed to sub-standard care at some of the NGOs, even after news broke that over 90 had died.Makgoba found that the transfer, which became known as the Gauteng mental health marathon project, was done in a “hurry/rush; with chaotic execution; in an environment with no developed, no tradition of and no culture of primary mental healthcare community-based services framework and infrastructure.“The NGOs were lured into what appeared to be a business opportunity not to be missed. They received patients knowing that they neither had the capacity and expertise, nor the requisite infrastructure to care for mentally-ill patients.“Our finding is that the Gauteng department of health overlooked and/or failed to properly anticipate the consequences that may arise from the rushed transfer of patients."The negligent conduct led to making unsound decisions that did not seek to prioritise the healthcare and safety of patients, thereby putting the lives of patients at risk,” he concluded.At Friday’s hearing, it emerged how at least three mentally-ill patients were buried as paupers. In one case, an owner of the facilities signed off permission for a burial as “a relative” of the deceased.Seven other paupers’ burials were stopped. Their bodies are still in a mortuary while the department is trying to find their relatives.Kenoshi said when he was appointed in February, to join new Health MEC Gwen Ramokgopa, their priority was to save lives.Mahlangu resigned in the wake of the scandal over the deaths. Kenoshi replaced Barney Selebano, who was suspended.After finding patients still living in unsuitable conditions, they made sure they were transferred to better facilities. At least 850 patients were moved out of NGOs over three months, starting in February.“Punishing those responsible was not an immediate impulse, the focus was more on saving people’s lives,” he said. Police and other organs of state had been brought in to probe the matter. The investigation would seek to understand why the patients were transferred. “They can now start looking into who was responsible and for what,” he explained.The hearings continue tomorrow and are expected to be concluded by the end of next week.