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In this report, the Norwegian Board of Health Supervision considers four supervisory cases involving serious incidents. The cases concern children who are facing vulnerable life situations. They express themselves via particularly challenging actions and need support from both the child care services and the mental health services. This imposes considerable demands on the health and child care services’ professionalism, cooperation and work related to safety.

When we began the review, we particularly focused on the interaction between the services and the risk management practised by the various services. We found a pattern of challenges which proved to be more complex. The whole was greater than the sum of the parts.

The Norwegian Board of Health Supervision believes that a multidisciplinary initiative with joint responsibility which explicitly has this group of children as its target group is lacking. There is no initiative which has sufficient availability, expertise and the necessary legal framework for it to carry out its work.