A South African mental health policy implementation project resulted in the deaths of at least 144 vulnerable human beings. This tragedy occurred irrespective of the vision of the relevant policy of an improved mental health care project for all in South Africa. This project, known as the Gauteng Mental Health Marathon Project, was implemented in Gauteng, one of South Africa’s nine provinces. 

Efforts by various individuals, institutions and organisations to make sense of these implausible occurrences followed this tragedy. Two of these formal sensemaking endeavours are the widely reported investigation by the Health Ombud and the alternative dispute resolution process under the guidance of retired Deputy Chief Justice Dikgang Moseneke. In addition to these formal and structured processes, a variety of scholarly articles have been published in an effort to make sense of the series of events.