The man had cerebral palsy, and was cared for in the respirator via tracheostomy. He lived in a municipal residence with 24-hour supervision.

When he was moved to bed, while the hose was moved from the permobil's respirator to the one next to the bed, the staff forgot to put the respirator on the bed.

When, according to the report, it was delayed before the mistake was noticed, the man suffered from oxygen deficiency, which caused his heart to stop.

After the ambulance was called and resuscitation started, the man showed signs of life, and he was taken to hospital. The next day he passed away in an intensive care unit.

The Lex Maria notification came in to Ivo on May 26.