In the supplement, written by the medically responsible nurse at Katrineholm municipality, MAS, two shortcomings in Karin Wigertz's care appear.

Usually, nurses on accommodation can call the patient's doctor directly, but the health center responsible for all accommodation where Karin Wigertz lived had other routines.

The nurses had to provide information to the health center's nurse over the phone and wait for feedback.

Instead of the doctor in charge calling back, as the nurses asked, the feedback was that they had to wait for the next round.

- The nurses have thus sought a responsible doctor repeatedly but have been referred, which is why collaboration and coordination based on the patient's changed health condition has broken down, MAS writes in the supplement to Ivo.

Lack of patient records

Already in early autumn, just when the pandemic broke out, the medically responsible nurse states that she urged the municipal health service to ensure that all patient records were updated.

With an updated health status, it would be clear what kind of care would be provided if the person fell ill with covid.

According to MAS, the update did not take place as certified personnel did not prioritize the task and the managers did not run the work within the business.

Partly because the agreement came in the middle of the pandemic, partly because the caregivers did not understand the assignment.

Investigation without anyone involved

MAS contacted everyone involved in its review of what went wrong in Karin Wigertz's care.

To Ivo, MAS writes that the health center with the doctor responsible for Wigertz's care did not participate.

In a letter to MAS, the health center's operations manager wrote that they were awaiting statements about any errors committed until after Ivo's investigation.

"Given the seriousness of this accusation and that the case will probably be the subject of an investigation via Ivo or prosecutors, we choose today not to comment on any mistakes made in care but await the process that is likely to take place," writes the health center's operations manager. MAS.

Without the health centre's participation, MAS would not have had access to Wigertz's medical records and therefore could not get an overall picture of what had happened.

The case is being reopened

On November 10, Ivo stated that it believes that the municipality of Katrineholm has investigated what happened and that measures to prevent similar incidents have been taken.

The case was then closed.

The case is now being reopened.

Karin Wigertz's relatives made their own report to Ivo where they, among other things, ask the question of how palliative care could be instituted without Karin and her family being informed about this.

On December 15, Ivo announced that they will investigate the case.