One incident occurred at Kronan's nursing home in Luleå.
The patient was left at 19:00 in the evening without the opportunity to sound the alarm.
The person also did not receive his planned medication an hour later.
Nor did the incoming staff know about the user during the shift change at 9 pm the same evening.
- It is serious that the user has been exposed to the suffering caused by the incident.
We can state that there has been a breakdown in the handling of the routines on several points, says Monika Forsberg, operations manager, in a press release.
It took five hours before the patient was found in a toilet.
The investigation has led to a new routine being developed for shift changes and for staff to ensure that nursing, medicine, alarms and more are ensured.
Found on the roof
The second incident occurred at Ingridshem in Gammelstad.
A patient had reached out onto a roof through an unlocked balcony door.
The person was found unharmed by staff who had to help the patient down from the roof.
“The investigation has led to the development of a new routine and rules of procedure. Among other things, that all balcony doors must be locked and that the user in this case must always have staff with them when staying on the balcony ", writes Luleå municipality on its website.