The Swedish Agency for Public Management
Meny

Grief: what words cannot express. Commission of inquiry into certain cases of death (2014:19)

6 children on average lose their lives each year as a result of crime. 17 women and 4 men die as a direct consequence of violence from someone they have or have previously had a close relationship with. In many cases, those involved had already been in touch with authorities prior to the death due to being subjected to violence. Since 2008, the National Board of Health and Welfare has been tasked with investigating these cases. The aim of the inquiry operation is to provide a basis for proposals for procedures to prevent children from suffering harm, in addition to preventing women and men being subject to violence or other attacks from someone close to them, or someone who was previously close to them.

In three reports, the National Board of Health and Welfare has presented the conclusions from the inquiry operation. The reports cover 31 child cases and 12 cases in which adults have died.

Statskontoret's mission

The Swedish Agency for Public Management (Statskontoret) was commissioned by the Government to follow and evaluate the inquiry operation by the National Board of Health and Welfare; regarding certain cases of death. The commission involves:

  • inquiring into whether the aim of the inquiries into the deaths has been achieved,
  • analysing and following up the National Board of Health and Welfare's inquiry system and
  • analysing the extent to which the inquiries have functioned as a basis for proposals for measures to prevent avoidable harm.

Statskontoret submitted an interim report on 01 October 2012. This report constitutes the final report of the commission.

Statskontoret's overall conclusions

The aim of the inquiry operation has not been achieved

The aim of the inquiry operation is to provide a basis for proposals for procedures to prevent children from suffering harm, in addition to preventing women and men being subject to violence or other attacks from someone close to them, or someone who was previously close to them Statskontoret establishes in this final report that the activities are not known and that the investigations of the deaths have not led to any useful, concrete results. Our assessment is that today, six years after the inquiry operation began, its aims have still not been achieved.

The activities have been developed but several fundamental problems remain

Compared with two years ago, when Statskontoret produced its interim report, the National Board of Health and Welfare has developed its inquiry operation. The National Board of Health and Welfare is now presenting a structured approach and is striving for a more uniform assessment of the cases.

Statskontoret establishes that the legislation that governs the inquiry operation contains a number of limiting factors. Some of these are that it is impossible for the National Board of Health and Welfare to obtain information on the perpetrator when an adult has been killed by someone close to them or someone who was previously close to them. The law also includes a number of criteria for which cases can be investigated, which means a limitation of the number of cases of deadly violence that are inquired into. Nor can the National Board of Health and Welfare's inquiries commence before the perpetrator's judgment has become legally binding, which means partly that the investigation is drawn out, and partly that affected authorities fail to inform the National Board of Health and Welfare of all relevant cases.

Alongside the existing limitations in relevant legislation, however, the National Board of Health and Welfare's approach entails certain other difficulties achieving the goal of the inquiry operation. Statskontoret's assessment is that the biggest deficiency in this respect is that the National Board of Health and Welfare has not analysed what is required to achieve the aim. The management of the work has been handed over from management to the supervisors without sufficient quality assurance. The National Board of Health and Welfare has also in various ways hampered implementation of a complete analysis of the underlying causes of the deaths. It has for example chosen not to interview anyone from operations involved in the cases before the deaths occurred. There are also areas in which the current expert groups that are to conduct the analyses have insufficient competence. This is both because certain relevant professional groups are not represented and because the inquiry operation has too great a focus on the National Board of Health and Welfare's ways of working. Statskontoret's assessment is that research competence and experience from practical activities are not sufficiently represented.

The inquiry operation is still of marginal significance

Two years ago, Statskontoret pointed out that neither the Government nor other involved actors had benefited from the reports that the National Board of Health and Welfare had published. Since this, the National Board of Health and Welfare has issued one more report and developed special information material for activities in social services, healthcare, preschool and school. However, the results remain the same. The few authorities and other activities that know of the National Board of Health and Welfare's work assess that this is of marginal significance to their own work. The material contains no new knowledge, but could possibly serve as a reminder of the problems with being subject to crimes.

Statskontoret's proposal

Knowledge of the most serious cases required

Even if the National Board of Health and Welfare has not achieved the overall goal of the inquiry operation, Statskontoret's assessment is that the activities should continue in some form or other. Statskontoret believes the Government's expectations in connection with the activities being initiated are still relevant. The Government's assessment was then that the knowledge from the investigations of the deaths can be expected to function as a basis and support in the work to protect, support and help the vulnerable person and thus reduce the risk of something similar happening again.

Considering different ways of organising the activities

Statskontoret has analysed which conditions should be in place for an effective inquiry operation. Based on this analysis, we have considered the following solutions:

  • retain the current solution with the National Board of Health and Welfare as the responsible authority,
  • transfer the activities to another responsible authority,
  • broaden the National Board of Health and Welfare's task to include cases other than those with a deadly outcome,
  • cease with the National Board of Health and Welfare's current activities and instead conduct supervision in the cases in question and
  • combine supervision in each individual case with a summarising, overall analysis.

A changed inquiry system should be introduced

Statskontoret's overall assessment is that the only alternative that completely fulfils the requirements for an effective inquiry operation is the solution involving supervision in each and every one of the cases in combination, with the result of the supervision being aggregated in a summary analysis. In such a system, it is possible to gain a complete picture of how the municipalities and care work when children and adults are at risk of suffering harm. The supervision affords opportunities to draw conclusions about how individual activities and authorities can improve their procedures. At the same time, the supervision provides deep insight in each case, which makes it possible to identify structures and connections not picked up on today. Statskontoret therefore proposes that the inquiry system be changed in this way. We also submit proposals for how the new system should be introduced.

In order to improve the conditions for gaining access to all relevant cases, Statskontoret believes that the notification obligation, i.e., the police's obligation to notify of a death, should be moved from the time that the judgment comes into force to the time at which a preliminary investigation is launched.

Statskontoret's assessment is that greater efficiency can be achieved if the overall analyses take place within the same authority that is responsible for supervision of the cases involving deaths. Our proposal involves the Health and Social Care Inspectorate carrying out the supervision, and accordingly, responsibility for the analyses should also be placed there.

If the Government still assesses that the investigation operation should continue to be run within the scope of the National Board of Health and Welfare, Statskontoret shall report on a number of defined measures that are thus necessary to implement.