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1 Summary in English


1 Summary in English

1. Summary in English

About the assignment

The Norwegian Board of Health Supervision was commissioned by the Norwegian Ministry of Children and Family Affairs to review all cases in which children associated with child welfare institutions lost their lives between 2018 and the end of January 2023. The purpose of the review was to summarise all of the cases together, in order to identify any shortcomings and contribute to learning, development and quality in the services. In order to contribute to the above, we found it appropriate both to describe the need for improvements and to reference any relevant changes and improvements that have already been implemented or that are planned.

This review is primarily based on documents obtained from the Norwegian Directorate for Children, Youth and Family Affairs (Bufdir), municipal child welfare services and county governors (including documents relating to health services). The Norwegian Board of Health Supervision has also conducted meetings with the professional communities involved in child welfare and child and adolescent psychiatric services, as well as various public bodies with knowledge and experience of working with young people experiencing complex and extensive issues.

Last but not least, the relatives of several of the children have also contributed by sharing their experiences.

This report is primarily based on information relating to eight girls between the ages of 13 and 18 years who lost their lives over the last five years while associated with child welfare institutions. We have also briefly addressed four cases in which children affiliated with centres for parents and children lost their lives.

About the eight girls

The first reports of concern to the municipal child welfare services were raised at an early stage of the girls’ lives. The reports were investigated and the majority were dismissed. The girls’ subsequent contact with the child welfare services did not occur until they became adolescents and the contents of these reports of concern triggered emergency intervention. During the emergency intervention phase, the girls were moved either to an emergency shelter or to emergency care institutions before being moved to foster homes or institutions.

The girls all struggled with different forms of mental illness or disorders. All of the girls were examined by the clinic for child and adolescent psychiatry (BUP) and all of the girls were admitted for emergency care under the auspices of the mental health services on multiple occasions.

Based on the stories of these eight girls, the Norwegian Board of Health Supervision would like to highlight five issues that we consider to be key learning points that can help us prevent similar tragedies in the future.

1. Ineffective collaboration

Based on minutes and records, we can see that there was frequent dialogue and meetings between the services the girls had access to. For the girls , it was not enough for each service to do their job. In reality, providing adequate support to children with significant and complex issues is about collaborating with other professionals and services. It is crucial to ensure that the focus remains on the child and that the services establish a mutual understanding of the needs and best interests of the child. Only then will it be possible for the intervention system to adapt to the needs of the child so that the child does not have to adapt to the services that are available.

2. Inadequate mental health care

The way in which health services are organised has not been designed with this patient group, young people with complex issues and frequent relocation, in mind. The services available to the children were characterised by a lack of continuity and were not adapted to their situation and needs.

3. Mismatch between the needs of the girls and the interventions that were chosen

The quality of the child welfare services’ identification and assessment of the needs of the children varied. In several cases, this resulted in the children being moved to services that were unable to safeguard the children and they therefore had to move several times within a short period.

4. Difficulties ensuring consistent care for children at child welfare institutions

Institutional life was characterised by serious incidents such as escapes, self-harm, institutional use of force or other interventions, as well as restrictions on the privacy and personal integrity of the girls. The institutions described that they did not have the necessary framework in place to safeguard the girls and that they experienced great difficulty managing the girls’ health issues. Employees received limited guidance on how to deal with the children.

5. Lack of coordinated efforts from the supervisory authorities

The supervisory authorities have a unique opportunity to consider the totality of the services children receive across the health services and child welfare services, thereby contributing to ensuring that the services collaborate to ensure a holistic approach. This opportunity is underutilised.

Children at centres for parents and children

Four babies associated with centres for parents and children lost their lives during the period from 2018 to 2023. We have reviewed the documents available in relation to these cases and we cannot see that there was any overall or systematic failure with a potential for learning in these cases. Supervision has been or will be carried out by the county governors in connection with all of the cases so that each service can receive feedback relating to any need for improvements. No dissatisfactory health or child welfare services have been identified in connection with the cases that have been closed.


Our recommendations follow from the features of the services that we believe led to the children not being able to access consistent services of the quality they required. Mental health services for children and adolescents, as well as child welfare services, must be adapted to the needs of these children to a greater extent than currently and, not least, the collaboration between the various services involved needs to become more flexible, resilient and binding.