GEV has now completed an investigation into two serious unexpected incidents that occurred in and around a residential center for people with disabilities in Hólmasundur 2 in Reykjavík, operated on the basis of Act No. 38/2018, on services for people with long-term support needs. According to Article 4(1) of Act No. 88/2021, on the Quality and Supervisory Authority of Welfare (the GEV Act), the institution is required to publish the inspection reports, or extracts from them, in an accessible and organized manner. With reference to this and taking into account the privacy concerns of all parties involved, the report has now been published on the GEV website.

In August 2024, GEV received two notifications from the director of Hólmasund 2 that a serious unexpected incident had occurred in the service. In the first notification and the accompanying incident description, it was stated that the incident occurred inside the apartment of the service user when a user fell/slip from a magnet lift onto the floor. In the second notification and the accompanying incident description, it was stated that the incident occurred in such a way that a user fell from his wheelchair while going down the side steps for a walk with an employee of the service provider, with the result that he suffered a fracture of the bones among other causes. As the abovementioned notifications were concerning the same service provider and the same service user, they were consolidated in the GEV case file.

On 11 September 2024, GEV initiated investigation of the serious unexpected incidents 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 for the serious unexpected incidents that can be used to prevent similar incidents from occurring and thus improve the quality and safety of services provided in Hólmasundir 2. During the investigation of the case, a thorough data collection was carried out and also had consultation with the parties concerned, while the lawyer of the user of the service, his family members and a personal spokesperson was given the opportunity to comment.

In parallel with the investigation of the serious unexpected incidents, the GEV instituted an initiative review of the service in Hólmasundur 2 on the basis of Article 14 of the GEV Act. That review was concluded in December 2024 with a report published on the GEV website, which set out recommendations for improvements to the service provider regarding the issues that needed to be improved in the service in Hólmasundur 2, which the GEV will follow up.

The study of the GEV revealed that there were explanations behind the incidents that were attributed to issues that the service provider was responsible for and were detailed in the GEV report, see brief summary below. Following the study of the serious unexpected incidents and the GEV’s own initiative study of the service in Hólmasundur 2, the service provider has worked to correct deficiencies in the service to prevent incidents like this from happening again and to ensure quality and safety in the service provided to disabled residents in Hólmasundur 2 in Reykjavík.

Key findings of the GEV report:

• As there was no radio/security button located inside the apartment of the service user, the service provider had to leave the user alone in a magnet elevator while he went out and called for the help of an employee. The service provider has now called for an offer for a radio and in the meantime, radios will be used.

• Because the service user was not mounted in a wheelchair in accordance with his individual service plan, he fell from the wheelchair when an employee went down outdoor steps with the chair and suffered a broken bone among other injuries. The service provider is currently working on collecting important basic information about users in Hólmasundur 2, e.g. how to mount the user in the wheelchair when he goes out, in work folders so that staff can access them in a simple and visible way.

The report of the GEV for the study can be accessed (only in Icelandic)