Several reports of concern were directed at a person with substance abuse problems in the interior of Västerbotten.
The home service reported the person as a concern at the end of August last year at the latest.
It wasn't until the person himself sought help for alcohol abuse that the municipality's social services began an investigation.
Before the investigation came into effect, the person was found dead in the home.
- The person in question has not previously been interested in receiving help but finally changed his mind, and by then it was too late, says the social manager in the municipality.
According to a Lex Sarah notification to the municipality, coercive measures should have been introduced earlier.
The report also mentions shortcomings in the form of organizational relocations, ignorance on the part of the staff and wrong priorities.
The municipality will now introduce guidelines for the handling of abuse cases.