The Quality and Supervisory Agency of Welfare (GEV) concludes an investigation into a serious unexpected incident.
19th April 2024
GEV has now completed an investigation into a serious unexpected incident that occurred at a treatment home run on the basis of the Child Protection Act no. 80/2002. According to the Quality and Supervisory Agency of Welfare Act no. 88/2021 (the GEV Act), the administration is required to publish inspection reports, or extracts from them, in an accessible and organized manner. Taking into consideration the 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 on the GEV website.
In august 2022, GEV received a notification from the National Agency of Children and Families (BOFS) that a serious unforeseen incident had occurred at a youth home. The notification and the accompanying incident description stated, among other things, that a service user of the youth home (hereinafter: service user X), who had a multifaceted problem, had attempted suicide at the home. The notification also stated that immediately after the incident measures were taken at the home in order to make living conditions in the home safer. On September 6, 2022, GEV began the investigation into the serious unforeseen incident in accordance with the Act on GEV. The aim of GEV´s investigation, under the abovementioned legal provision, is to seek explanations for the serious unforeseen incident that can be used to prevent similar incidents from occurring and thus improve the safety of services provided at the home. In the course of the investigation a thorough data collection was carried out.
GEV´s investigation revealed that there was not one simple explanation for the incident. GEV looked into a few factors that collectively contributed to X being able to make a suicide attempt in the home:
An item belonging to X was not removed from their possession despite being on a checklist of items that employees should remove if they are worried about possible self harm or even suicide.
X´s room in the youth home had pipes that X could use in the attempt.
The serious unforeseen incident can also be explained to a large extent by the systemic problem that exists in Iceland when it comes to implementing services for children with multifaceted problems that need services from both health and welfare systems. In this regard, the recommendations of a steering committee on the arrangements of services for children with multifaceted problems, published by the Ministry of Education and Children’s Affairs in 2023, were taken into consideration. These include recommendations for specialized and integrated services for substance abuse and emergency reception for children with severe mental and/or behavioral problems. In addition, GEV´s investigation also considered that a formal screening interview is generally not conducted when a service user is admitted to the youth home.
On behalf of the Quality and Supervisory Agency of Welfare,
Herdís Gunnarsdóttir Director.