JOHANNESBURG -- During a regular visit, Sophie Mangena was shocked to find that her mother withhad been transferred from the psychiatric facility without so much as a phone call to the family, and the nurse on duty didn't know exactly where she was. Desperate for information, the daughter heard from a security guard that her mother might have been taken to Takalani, a little-known facility in Johannesburg's Soweto township.
When the family finally found their mother, the 56-year-old matriarch had lost so much weight she was barely recognizable. Shivering and hungry, she was in dirty clothes and barefoot. Days later, she died.
Mangena was one of at least 144 after South Africa's Gauteng provincial government hastily transferred 1,711 state-funded psychiatric patients in 2015 and 2016 from Life Esidimeni, a private health care provider, to other facilities, dozens of which were not properly licensed.
The death toll is expected to be higher: Two years later, the whereabouts of 44 patients are still unknown.
The experience is "a terrible tale of death and torture of mental health care users," ruled former Deputy Chief Justice Dikgang Moseneke, who last week issued a report awarding Mangena's family and 134 other relatives of victims $101,000 each.
The award sets an important precedent for human rights abuses in South Africa, observers say.
"It was emotionally overwhelming," said Boitumelo Mangena, Sophie's sister. "We've come to the end, but we still don't have the answers we're looking for. We still don't know why this happened."
The revelations of gross mistreatment have shocked South Africans and raised troubling questions about the government's commitment to its most vulnerable citizens more than 20 years after the end of apartheid.
"This is the biggest mass death since democracy," said Sasha Stevenson, an attorney with Section 27, a public interest law center that represented Mangena and more than 60 other patients' family members. "This is a huge system failure."
For reasons that remain unclear, the government made the transfers between October 2015 and June 2016 in a rushed process that family members and Life Esidimeni staff have repeatedly described as "chaotic."
Some patients were tied up with bed sheets and loaded into trucks or were relocated without their identification or medical records. Others were moved multiple times between facilities. A health ombudsman's report released in February 2017 called the process "negligent and reckless and showed a total lack of respect for human dignity."
Conditions at some facilities were abysmal. Many patients were not given sufficient water and food, regular baths or appropriate medication. Many of the centers were overcrowded; in some cases severely ill patients were left to sleep on benches or the floor.
The incompetence was fatal. Most of the deaths occurred in five facilities, including Takalani.
The arbitration hearings into the tragedy were nationally televised and the hearings were a harrowing account of what the patients endured.
Health Minister Aaron Motsoaledi wept during his testimony in which he apologized to the victims' families and the country.
"I couldn't imagine in our new democracy . human rights breached in this manner, in a way that is reminiscent of our apartheid era," Motsoaledi said. "I feel personally betrayed that colleagues who I am working with could do something like that."
The vast majority of patients have been moved back to Life Esidimeni centers or another facility.
Three officials central to the "project" have resigned and there are calls for them and others to face criminal charges.
But the arbitration process did not succeed in determining why the officials ended the Life Esidimeni contract in the first place. The reasons given by officials - budget constraints, pressure to diversify private contractors and a policy to place patients into community-based care - did not stand up, the judge concluded.
"All of those reasons fell apart," said Stevenson of Section 27. "We still don't know what the reason for the termination was." South Africa's police are investigating whether there was fraud, she said.
The fact that no key official yet faces criminal charges has left some victims' family members feeling like they don't have closure.
Nomvula Nonjabe, whose younger sister survived, said she remains wary.
"There are still a lot of people in the mental health system who are ignored and neglected," she said. "We're a stressed country. We will forever need to keep a watch on the government."