When home care staff made one of their supervisory visits, they found that the person they would visit was not home. A new attempt was made a quarter later but even then the person was away from his home.

The staff reported it happened to the nearest manager and to the night patrol, but left the residence without trying to find out where the person was.

- We have routines that say that the unit manager and relatives should be notified if a person we visit is not home. There it has failed, says Lena Hurtigh, who is the head of department for ordinary housing.

Several similar cases

The next day a new visit was made to the same residence. This time, measures were taken to try to locate the person who was still missing. Later that night, the person was found dead outside his home.

In a similar case, a deceased woman was found after the home patrol's night patrol tried to get into the wrong house. Another case where information and communication has been broken is for a person who has fallen and injured himself.

- We have three cases with obvious shortcomings. That is why we are now dusting off our already clear procedures and also introducing new staff, says Lena Hurtigh.