Jenny Herbert was placed in the Sis home Margretelund in Falköping according to the law with special provisions on the care of young people (LVU), she was also judged to be suicidal.

Despite the fact that there should be staff on hand for young people who are suicidal, Jenny did not receive any extra supervision on the day of the suicide.

Margareta Jonsson admits that the resident's assessment of Jenny was not correct and that she should have had better supervision.

- Since the outcome was the way it was, it is probably the case that we have not made a correct assessment.

Ivo notes shortcomings

The Inspectorate for Care and Care (Ivo) notes several shortcomings in the accommodation.

They believe that the accommodation should have taken into account Jenny's previous suicide attempts:

"There was a known history of suicide attempts - according to Ivo, this knowledge should have been weighed into the ongoing assessment of the girl

," the authority writes in a decision from November 2022.

No one fired

Margareta Jonsson believes, however, that it is not any staff who made a mistake, but rather the routines that broke down.

All regular staff are still working.

Since Jenny's suicide, the facility has worked intensively on changing the routines.

- We saw that the documentation was not quite as good as we would like, so we are working hard on that now, says Margareta Jonsson.

Start the clip to see Margareta Jonsson, ultimately responsible for the business, being questioned about how Jenny was able to get hold of loose objects.