Region Sörmland has made an investigation of the incident and concluded that there were two things that went wrong during the birth and that may have contributed to the baby's injuries.
On the one hand, the staff misinterpreted the tool that measures the child's heart rate, and on the other hand, they did not follow the routines that existed for pain-stimulating drip.
All maternity staff will now receive in-depth training in how to interpret the tool correctly.
They should also receive training in why it is important to follow the routines that exist regarding pain-stimulating drip.