Young people were found lifeless in treatment homes in Västmanland

The youth had for some time before the incident withdrawn from the treatment home's joint activities and meals.

Investigation shows that the company tried to contact the social services to point out the young people's changed mood, but that routines and action plans for how to work to reduce young people's isolation and loneliness were lacking.

When the youth did not come out of their room one morning, the staff lingered until 12.42 before entering the room. The youth, who had then been alone in the room for twelve hours, were found lifeless. Medical personnel and police were called, but the lives of the youth could not be saved. The Lex Sarah incident was reported.

The investigator in the case points out lack of routines and action plans and points out that the operation had a strained staff at the time of the incident.

Due to the extensive and numerous shortcomings in the case, it is not possible to determine exactly when the suicide occurred, and whether the suicide could have been prevented.

The investigator's assessment is that the deviation is a serious misconduct, but that the measures taken by the business after the incident are sufficient to ensure that similar deviations do not occur again.