The report shows that psychiatry became aware of the boy's thoughts of suicide when he was nine years old. This was followed by years of regular visits, investigations and medication. The school did not go well and the absence was high.
The mother requested for several years that her son be investigated, but the care awaited certificates from the school, certificates that did not return properly completed. In this regard, the health service believes that the parents and the school had a responsibility, but the report also states that psychiatry should have supported better to get the documentation.
"The review indicates that it is a chain of missing actions that may have contributed to the tragic outcome," the chief medical officer writes in the report.
During a visit to the BUP emergency in February this year, it appears that the boy is feeling poor and has "thoughts of not wanting to live". He is being printed, but there is no contact with the public health services about his depressive image. Important information is provided in a daily note and in a messenger message. Which, due to staff absenteeism, only opens two weeks later.
The patient was then called to a doctor's visit, with a two-week waiting period. Two days before the planned visit, he took his life.
At the end of the report, the chief medical officer writes that "the undersigned's assessment after an internal review is that the care chain between closed and outpatient care has failed."