The investigation shows that shortcomings in the operations probably have contributed to the tragic course of events. The shortcomings relate to supervision, physical environment, communication and information, organisation and the systematic quality work. A decision has therefore been taken to close down the operations. In addition thereto, Humana intends to further develop and sharpen the follow-up of the Group’s systematic quality work.
Humana's Lex Sarah investigation reveals that lack of supervision from staff during a few minutes, along with deficiencies in the physical environment, are likely explanations to why the boy could disappear from the care home. The investigation also reveals other underlying deficiencies in the operation that may have contributed to the tragic course of events. Several of these shortcomings have previously been pointed out both by IVO and by Humana’s internal quality organisation, as a result from internal controls. Despite implemented measures, it has become clear that certain issues should have been handled in a more consistent manner, for example shortcomings in the matching of children's needs with staff competence, deficiencies in systematic quality work, such as the form of reporting deviations and conducting risk analyses, and shortcomings in compliance with Humana's routines and guidelines.
An extensive analysis has been made of the operations in connection with the Lex Sarah investigation and this has formed the basis for the measures that Humana has taken.
“What must not happen has happened and we take the accident extremely seriously. Our thoughts are with the boy, his parents and relatives, as well as with the other children who were present in the care home, and our staff. The tragic incident could take place due to a combination of reasons, the human factor and shortcomings in the operations, for example in the physical environment. Therefore, we see no other option than to close down the operations. We have also identified areas where we should have followed up more closely”, says Rasmus Nerman, President and CEO of Humana.
Humana has informed relatives, management and employees within Platea, and IVO about the conclusions of the Lex Sarah investigation. Humana is cooperating with the authorities in their further investigations.
“Humana and our operations should always focus on providing children with a safe environment in our care. We must never compromise on quality or safety – it is unacceptable. Within our organisation there is competence, routines and premises adapted to provide children and young people with safe and secure care. It is with great sadness that I conclude that we have failed in the operation in question, and that we are therefore taking a number of measures to ensure that routines are complied with throughout the organisation”, says Rasmus Nerman.
Humana has, among other things, decided to discontinue with Platea's HVB operations. Thus, IVO's decision to temporarily ban the operations will not be appealed.
“We have clear procedures and an extensive quality assurance work that applies to the entire Group. These should be followed; any deviation is unacceptable. We will now strengthen the follow-up of self-monitoring, internal control and risk analyses and, not least, ensure that criticism from IVO is being promptly addressed. Here we need to act earlier and more clearly as a Group in the future,” says Eva Nilsson Bågenholm, Quality Director Humana.
The Lex Sarah investigation that has been conducted and submitted to IVO can be found here: Lex Sarah investigation (in Swedish)
For more information, please contact
Patrik Silverudd, Press Officer Humana