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Healthcare for Individuals with Severe Mental Illness and Risk of Violence 

On October 13, 2021, an entire local community was impacted when a man committed five homicides and eleven attempted murders. In 2022, the court sentenced him to mandatory mental health care. For several years prior to the homocides, the perpetrator struggled with severe mental illness and had been involved with the police multiple times for threats and violence. 

Our investigation focuses on the healthcare services the perpetrator received in the years prior to the tragedy. This report is based on this individual case and does not address all questions in such a complex field. We chose this event due to its severity in order to highlight learning points. Several issues we uncovered in this case will also apply to other patients with severe illness who has an increased risk of violent behavior. 

The Norwegian Healthcare Investigation Board does not use the names of those involved. Therefore, we have referred to the perpetrator as "Ole". We have examined and identified contributing factors to why Ole did not receive adequate help in the years prior to committing  murder 

The report is divided into four main areas: 

  • Healthcare services fell short. 
  • Ole went under the radar and lived in isolation. 
  • The care of relatives. 
  • Coordination and safeguarding of public safety. 

Healthcare Services Fell Short, Ole Went Under the Radar and Lived in Isolation 

It is difficult to assist people who do not seek health care themselves. After 2017, Ole declined much of the healthcare offered to him and had previously opted out of municipal services. 

Ole was considered too ill for legal punishment and too well for compulsory mental health care, resulting in him being left to fend for himself. Our investigation emphasizes the importance of healthcare being tailored to the patient's circumstances, needs, and motivation. 

Both relatives and the police had important information about Ole’s condition that the health service was unaware of. Healthcare providers also lacked information concerning his functional level and history of violence. This resulted in a lack of necessary information for decisions on diagnosis, assessment of violence risk, conditions for compulsory mental health care, and the need for follow-up. The involved services did not collaborate sufficiently and therefore did not share necessary information with each other or the relatives. 

The inadequate coordination and collaboration may be due to how healthcare personnel interpret confidentiality rules, often interpreting their leeway more narrowly than the rules allow. 

The investigation highlights the importance of assessing the risk of violence based on updated information, for example, from relatives and the police. To prevent future violence, measures must be based on identified risk factors. When a patient is discharged from mental health care, a follow-up plan must accompany the patient. The report also discusses the importance of considering the danger condition. 

The Care of Relatives 

Close relatives have the right to be heard before decisions on compulsory mental health care are made. In Ole's case, relatives were not involved in the treatment or asked about their own need for help. They were not contacted in connection with the establishment and termination of compulsory mental health care, partly because Ole did not want his relatives to be involved. 

The relatives faced a challenging situation over several years. No one discussed their need for advice, guidance, and support. When Ole declined the help offered, much responsibility and worry fell on the relatives In order to protect themselves from violence and threats from Ole, they contacted the police, who imposed a restraining order on Ole. This worried the parents because it led to Ole becoming even more isolated. The investigation shows the need to recognize the role of relatives. Close relatives can provide important information to the health service. They are often the patient's most important support in daily life and need to be cared for. 

Coordination and Safeguarding of Public Safety 

The County Governor concluded in their inspection reports that both the specialist health service and the municipal health and care service had provided Ole with adequate healthcare. The inspection reports do not address who is responsible for the overall health service. 

The responsibility for patients with severe mental illness and increased risk of violence needs further clarification. 

The state is responsible for preventing individuals from harming each other, known as the duty of care. This duty is divided between the municipal, health, and justice sectors, each responsible for their area. They also have a responsibility to assist each other. There is a risk that some patients fall between the cracks , only to be caught by the courts after committing a crime. The current cooperation between the specialist health service, the municipality, and the police is insufficient to prevent violent incidents and ensure healthcare for this patient group. 

Ukom's Recommendations 

Ukom offers several recommendations to the health and care service, some of which also concern the justice sector. We hope the recommendations will: 

  • Further clarify who is responsible for upholding the state's duty of care and who should have the overall responsibility for this patient group. 
  • Ensure this patient group receives integrated and equitable services regardless of where they live, and that individually tailored work is an integral part of the healthcare provided. 
  • Ensure a solid basis for the assessments and decisions made regarding healthcare. Healthcare providers must consider all available information from relatives and others when making their decisions. There is a need to clarify and emphasize the provisions of confidentiality and the duty to obtain and share necessary information. 
  • Better care for and involve relatives when necessary to provide good healthcare. 

The translation from Norwegian to English is based in AI. Ukom has reviewed, edited and quality assured the translation.