When the patient was outgoing and had a joint ban, supervision would take place through a glass pane through the door. The room the patient sat in would be suicidal - which means that the room would be overhauled to minimize the risk of suicide.

However, the remediation work had not been completed in full, and at the event in question the staff could not see all parts of the room through the glass pane. In addition, it has been found that the staff lacked knowledge of how the supervision would go.

Routines that were not followed

The suicide attempt could be interrupted, but the clinic's routines were not followed.

The case is now reported according to Lex Maria, writes Kronoberg Region in a press release. The routines and premises must now be reviewed.