GEV has now completed an investigation into a serious unexpected incident that occurred in short-term care for children. According to Article 4(1) of the Act on Quality and Supervision Authority of Welfare No. 88/2021 (the GEV Act), the Administration is required to publish the inspection reports, or extracts from them, in an accessible and organized manner. With reference to the strong privacy concerns of the person concerned, GEV does not believe it is possible to publish the report in its entirety but an extract will be published here on the GEV website.

On 11 October 2023, GEV received a notification from the director of a short-term care facility for children that a serious unexpected incident had occurred in the facility. In the notification and the accompanying incident description, it was stated that the incident occurred in the evening after the users of the service had gone to sleep. If user A has been assaulted by user B, when it was believed that A and B were asleep in the bedroom that the users shared that night. In the wake of the serious unexpected incident, user A was taken to the emergency department as well as the police and child protection services were contacted for B.

On 14 November 2023, GEV initiated investigation of the serious unexpected incident in accordance with Article 12(3) of the Act on GEV. The purpose of the investigation of GEV according to the abovementioned legal provision is to seek explanations of the serious unexpected incident that can be used to prevent similar incidents from occurring and thus improve the safety and quality of service provided in the short-term care in question. In the investigation of the case, a thorough data collection took place.

The study of GEV revealed that the service provider’s activities did not provide a definitive explanation for the serious unexpected incident. However, certain aspects of the service provider’s activities that may have contributed to the fact that user B knew that user A was using violence were specifically examined:

Housing and sleeping accommodation during the short term stay:

• The study revealed that two users of the service usually share a bedroom, as the accommodation does not offer a different arrangement. In the opinion of GEV, this can create situations that may increase the likelihood of conflict between service users, who are often children with autism spectrum disorder. In such situations, the staff is very hard to find out which users can stay together based on their individual needs. With reference to, among other things, the behavior of user B earlier in the evening before the serious incident took place, in the opinion of GEV, it would have required increased supervision of user B, for example, by having an employee inside the bedroom until user B had a proven sleep.

• User A was sleeping in a bed with a rim when the serious incident occurred. The bed has rims on all sides that all reach up into the air. While the use of the bed does not explain the serious unexpected incident itself, the GEV estimates that its use may have led to A having even more difficulty getting away from the B, as the bed was closed on all sides.

Monitoring of service users during the short term stay:

• The study by GEV revealed that there is no written procedure for supervising users of the service at night. In GEV’s opinion, B had to be supervised more closely during the discussion, but B had acted violently earlier in the evening and had also just completed integration and therefore B’s knowledge of the staff was limited. In GEV’s opinion, however, it cannot be confirmed that more supervision would have prevented the serious unexpected incident but it could possibly have reduced its severity, for example, if an employee had been in the room until A and B had effectively put asleep or if a so-called ‘baby phone’ had been located in the bedroom. It could possibly have been an abnormal sound and/or thunder that could have led to an employee’s entering the bedroom of A and B rather than A having to go to get assistance. In GEV’s opinion, regular entering of employees on night shift into the room of service users could prevent similar incidents from occurring.

Procedures, manual and registration in the short-term residency:

• The study revealed that the procedures for the operations are mostly verbal and there is no general manual for the operations. It also seems that the registration is somewhat arbitrary, for example regarding the employee’s entrance into the user’s room at night. In the opinion of GEV it is important that there are clear written procedures for the main tasks of the employees who are on duty at any given time, which is to increase the quality and safety of the service in the short-term accommodation.

Given that the synergistic factors that were considered in the GEV investigation are such in nature that none of them would have prevented the incident, it was not considered that an initiative control was necessary alongside the GEV investigation of the serious unexpected incident. It is also known that the service provider intends to review procedures regarding the control of new users, will examine the possibility of increasing the number of “babysitters” in the bedroom and has additionally removed the rim bed that A slept in during his discussion. It is the opinion of the GEV that the above improvements are suitable for improving the quality and safety of the service and can help to prevent serious unexpected incidents of this kind.