It was during a planned morning visit to the person that the home care staff discovered that the key that was to be hung on a numbered board at the care operation could not be found. The employee tried to ring the doorbell several times – but got no answer – and then asked the care planner for help finding the key.
At lunchtime, the key was found, which had a different number than what was written on the keyboard. When another employee later made a dinner visit, the patient was found dead on the floor.