May 24, 2022

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Decision in a supervisory case in Fosshagen

The accident occurred in November 2020. “Attempts were made to save him until the emergency doctor arrived. The doctor finished the attempt at resuscitation. The emergency doctor concluded that the patient might have been unwell, and that she might have needed something to hold on to,” the state director wrote.

The conclusion in the case of supervision is now clear, and the director of state believes that the Lier municipality has violated the Health Care Services Act on two points:

  • The next of kin did not receive sufficient information about the injuries suffered by the patient after the incident in question.
  • A locker in the rehabilitation department of the Voshagen Resource Center flipped over in June 2019 without any measures being taken to prevent similar things from happening again. The state official came to the conclusion that failure to implement procedures for attaching cabinets to the Fosshagen Resource Center is a violation of the duty to work systematically to improve quality and patient and user safety.

– We regret that the relatives did not receive sufficient information about the injuries sustained by the patient. We have worked with our routine to ensure that in the future we provide adequate information in a good manner in all situations. We also regret that there were cabinets in the living room that were not attached securely, says Hanne Stubberud, Director of Health, Welfare and Welfare in the municipality of Lier.

The state official assumes that the company notes the assessments and organizes its activities accordingly in the future. “We note that the municipality is taking the matter very seriously and procedures have been implemented to connect all tanks on the same day of the new incident,” the letter to the Leer municipality also read. The case is hereby closed.

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Within the Health, Welfare and Welfare Framework in Leer Municipality there has been a lot of focus on non-conformity and non-conformity registration for many years, but we see this as a failure in relation to the treasury rollover incident in June 2019. It is so serious that there is no documentation or action related to this incident . Regular work is done through training and the work of creating attitudes among the employees so that there is a low threshold for reporting deviations.

We have also started to carry out a systematic work called “Green Cross”. Here, all employees will be more actively involved in working with deviations and measures around the reported deviations.

A new non-conformance system has also been introduced in the municipality, which we hope will make it easier for employees to report non-conformities. In Fosshagen, many measures have been taken to ensure a better and more open dialogue with relatives.


Last Updated: April 11, 2022


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