A person receiving home care support in a municipality in central Dalarna went without their prescribed tube nutrition for an entire week. The incident has now led to a Lex Sarah notification to the Health and Social Care Inspectorate (Ivo), where the municipality deems this a serious case of misconduct with significant risk to the neglected individual.

The incident took place at the end of November 2024 and involved a person who was dependent on tube feeding for their nutrition. Despite the need, the planned meals were not provided for a total of seven days. The deviation was only discovered after a week, at which point measures could be taken. This was reported by Dala-Demokraten.

At the same time, it took more than a year before the case reached the Health and Social Care Inspectorate (Ivo). The municipality’s Lex Sarah notification was submitted in February 2026. In its documentation, the municipality describes the event as an “obvious risk” and “a serious case of misconduct.”

Image: Samnytt.

Following the incident, home care staff and home nursing claim to have reviewed their routines in order to reduce the risk of a similar situation occurring again.

New Routines for Ordering Tube Nutrition

One of the measures cited is changed routines concerning the ordering of tube nutrition. The new approaches were reportedly developed together with the supplier.

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The municipality also states it has introduced recurring coordination meetings between the home care and home nursing services. These meetings will be held weekly and are intended to improve communication and foster closer cooperation between the services.

Despite the incident, the municipality at the same time commends itself for having home care and home nursing services that are well-staffed and with high continuity among nurses.