Accused number one in the Cat Matlala case, Musa Kekana, was admitted to hospital after what medical records described as an overdose involving alcohol and cocaine weeks before he later told a doctor that he had been suffocated at a police station, the Gauteng High Court in Johannesburg heard on Monday.
Dr Pooja Panicker, who examined Kekana at Edenvale Hospital on 17 April 2024, was referred during her testimony before Judge Cassim Moosa to medical records from an earlier hospital admission in March 2024.
Panicker confirmed that the earlier records were not her notes.
Reading from the hospital records, she told the court that on 4 March 2024 Kekana had been admitted for:
“Acute alcohol ingestion and cocaine use.”
Another entry recorded:
“Patient intubated for respiratory acidosis and decreased GCS.”
Panicker was then referred to a further entry dated 5 March 2024.
She read the record as:
“Alcohol and cocaine overdose, intubated for decreased level of consciousness and respiratory failure.”
The medical records also reflected that doctors were querying aspiration pneumonia.
Panicker explained that aspiration pneumonia could occur when a patient vomited and the vomit entered the airway and lungs.
“So aspiration pneumonia is usually when the patient vomits, and that vomitus then goes into your airway and then ends up in the lungs, causing a pneumonia,” she testified.
However, Panicker made it clear that she did not have access to those March records when she later examined Kekana.
“When I saw the patient, I did not have this previous record,” she told the court.
“I only had the two from page 71 onwards, and I was not given this information.”
Panicker was therefore unable to tell the court whether the earlier pneumonia had cleared up by the time she examined Kekana in April.
When Panicker examined Kekana on 17 April 2024, her contemporaneous notes recorded a very different account of his condition.
“On the 17th of April 2024, at 18:02, I saw a 35-year-old male who came in complaining of a two-week history of cough, which was productive of a yellow sputum, and then he also complained of chest pain while coughing,” she testified.
“The history he gave on the day was that he was suffocated at the police station, and since then had been coughing red blood with sputum,” she said.
Kekana also complained of night sweats and weight loss.
Panicker stressed that this part of her hospital notes recorded information supplied by the patient.
“The first page is all subjective information. It’s what the patient tells me. None of this is my own information,” she said.
She also confirmed that she had no independent recollection of the consultation and was relying on her contemporaneous medical records.
Panicker testified that she found bilateral crackles and expiratory wheezing when she examined Kekana.
“I then moved on to the respiratory examination, where I had found that he had bilateral crackles on his chest and also had expiratory wheezing,” she told the court.
She sent him for a chest X-ray, which showed bilateral opacifications.
Panicker said the finding was non-specific.
“That discoloration could mean multiple things in our field,” she testified.
She assessed Kekana as having a lower respiratory tract infection and recorded a query of pulmonary tuberculosis with haemoptysis.
Haemoptysis, she explained, meant “coughing up of blood or blood mixed with sputum,” she said.
Panicker said she did not have a definitive diagnosis at the time.
“I did not have a definitive diagnosis at the time of assessing him, but I was worried about a possible infective cause,” she said.
She referred Kekana to an internal medicine doctor for further investigation and management.
The court heard that Panicker’s examination records included a section for visible external injuries.
Asked whether she had recorded signs she would generally look for in a person who had been suffocated, Panicker replied:
“Not that I have noted.”
But she told the court that the absence of visible injuries did not necessarily rule out suffocation.
“Depending on the severity, it can leave marks, but not having marks does not exclude that a suffocation had occurred,” she said.
She was also asked about allegations that Kekana had been restrained with a belt, pressed down on his stomach and suffocated several times.
“From what you’ve described, that sounds like a severe assault,” Panicker testified.
Her evidence-in-chief concluded before Kekana’s counsel, Advocate Riaan Gissing, began his questioning.
