The incident occurred earlier this year.
A care recipient resident in Skellefteå municipality alerted the home care service via their security alarm, but a misunderstanding that arose among the home care staff meant that they never went on the alarm.
- We need to review these alarms and see how it can work in a safe and good way in the future, says head of health and care Ejja Häman-Aktell.
The care recipient received a visit from the home care service a short while later.
The person's condition had then deteriorated and the home health service contacted 112 and an ambulance was called.
The patient died in the morning.
Lex Sarah registration established
Talks have been held with the employee substitute about the incident.
The working group has also straightened out who is responsible for the emergency telephone, who should wear it during the sessions and how planned and unplanned matters should be prioritized between each other.
A lex Sarah report has been prepared by the Swedish Health and Care Inspectorate (IVO).