It was in 2018 that the patient sought care for urinary tract problems and blood in the urine.

Just blood in the urine can be a sign of a more serious illness and should always be followed up according to the care guidelines.

However, the patient was never investigated but treated for urinary tract infection.

During the following years, the patient contacted the same health center twice more, among other things for problems with urination.

No investigation was initiated on these occasions either.  

The patient's problem with recurrent blood in the urine eventually led to another doctor in another operation referring the patient on.

An investigation was started and bladder cancer was discovered.   

- It is of course extremely tragic.

We have a clear goal that no one should have to be injured in care, says chief physician Johan Nordmark to SVT Nyheter Västmanland.

What will you do to prevent this from happening again?

- It is partly about strengthening the introduction of new employees, but also about the work environment, says Johan Nordmark and refers to the lack of time which unfortunately causes staff to miss things.

- But you must be able to handle the lack of time: make sure that you take care of test results and have time to review previous notes even though it is stressful.

He also mentions that the health center will work more to ensure that hired staff are informed about routines and quality work.

The supervisory authority will assess whether the measures are sufficient.

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