The young woman walked around barefoot last fall, even though it was freezing outside. The ambulance was called and took her to an urgent care center where she got to see a doctor, something P4 West was the first to report on.
The doctor was informed that the woman had previously been treated for a psychotic illness and had been discharged just weeks earlier. The ambulance staff also said that they felt that the woman had psychotic symptoms. Despite this, no care certificate was written and the woman was not committed to psychiatric care, writes Bohuslänningen.
The woman left the health center without shoes and went out into the cold again. The ambulance then drove her to the psychiatric emergency room. She was not admitted there either, as it was believed that she did not meet the criteria for compulsory care.
The paramedics persuaded the woman to take her to the emergency room so her feet could be taken care of. She was offered a place in a shelter but refused and disappeared from the emergency room. The next day she was found dead in a snowdrift with no clothes on.
– This tragic event illustrates when several links have broken in a chain, says Jesper Swärd, chief physician for Uddevalla and Trollhättan hospitals to P4 West.
Met all criteria for compulsory care
The incident was reported to the inspectorate for care and care, Ivo, and an investigation was launched. It was established that the woman froze to death when she was not admitted.
“The findings and the circumstances suggest that the death was caused by an accident, where the patient’s psychiatric illness put him in a life-threatening situation,” writes the investigator in the report.
Despite the fact that the woman visited three different care facilities and four different doctors were involved in one day, she was not forcibly cared for. In the investigation, it is pointed out that she suffered from a serious mental illness and met all the criteria for compulsory care.
The measures: New routines and more training
The investigation believes that the woman’s history and behavior should have been sufficient to fulfill the first condition for compulsory care. After the incident, several measures have also been drawn up that must be implemented.
The staffing company that provided the call center with doctors must ensure that they have knowledge of the Act on Compulsory Psychiatric Care before they are allowed to work in the region. The procedures for handing over patients must also be reviewed.
The ambulance staff must be trained in psychiatry and adult psychiatry staff in compulsory care legislation.