Norwegian Healthcare Investigation Board

Latest from Norwegian Healthcare Investigation Board

1. News article1 Oct 2026

   Ukom hosted NHS England and addressed systems thinking, preoperative failure, and reporting culture at multiple events in September 2026

   • Three representatives from NHS England — the body that runs England's health service — visited Ukom in Stavanger to learn from Norway's approach to patient safety. The visit was prompted by Norway being ranked the best country in the OECD for patient safety in a 2025 report by Imperial College London.
   • The University of Stavanger presented European research projects on teamwork and resilience in health care during the visit.
   HospitalMental healthPrison
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2. News article22 Sept 2026

   Norway's patient safety commission launches inquiry into double homicide in Ski to identify systemic failures

   • Ukom – a state body that investigates failures in Norwegian health care – will look into a double homicide in Ski, where one family member killed two relatives.
   • The commission will not decide who is to blame, but will try to understand what went wrong in the system that made it impossible to help over several years.
   Mental healthMunicipalitiesPublic administration
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3. News article28 Aug 2026

   Ukom offers condolences following the death of King Harald V on 28 August 2026

   • King Harald passed away at Rikshospitalet on Friday 28 August 2026 at 06:35, after 35 years as Norway's king.
   • Ukom Director Andres Neset expressed condolences on behalf of all staff to Queen Sonja and the royal family.
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4. News article1 Jul 2026

   Ukom expresses condolences following King Harald's death on 28 August

   • Ukom director Andres Neset, on behalf of all staff, expresses condolences after King Harald passed away at Rikshospitalet on 28 August at 06:35, following 35 years as Norway's king.
   • Condolences are extended to Queen Sonja and the royal family.
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5. Evaluation1 Jul 2026

   PwC delivers evaluation of Norway's healthcare investigation commission (Ukom) to the Ministry of Health

   • PwC evaluated Ukom on behalf of the Ministry of Health and Care Services, covering goal achievement, cost-effectiveness, societal mandate, utility value, and future direction.
   • The report has been delivered to the ministry; Ukom director Andres Neset states the organisation will use it in its ongoing development work.
   Public administrationPublic health
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6. Report23 Jun 2026

   Norwegian Patient Safety Authority: Fragmented care for severely addicted patients poses safety risks

   • Ukom concludes that services are too fragmented and difficult to navigate for people with severe substance use disorders and co-occurring mental and somatic health problems, constituting a genuine patient safety risk.
   • The report draws on three patient histories (Aud, Kristian, Lars) and a review of more than 250 serious incident reports related to substance use.
   HospitalMental healthSubstance abuse treatment
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7. Report23 Jun 2026

   Norwegian Patient Safety Authority finds people with drug addiction and co-occurring mental illness receive dangerously fragmented care

   • The report is based on three patient histories: Aud (died in her 60s from a respiratory infection after late entry into LAR and untreated complex illness), Kristian (died young after being trapped in a circular system where drug use blocked psychiatric assessment and lack of assessment blocked LAR access), and Lars (functional decline after moving between health trusts with inconsistent practices and repeated conflicts with services).
   • Findings align with earlier reports from the Norwegian Board of Health Supervision, the Office of the Auditor General and the Norwegian National Human Rights Institution — all of which have previously documented fragmentation, poor coordination and wide practice variation, with national reforms failing to resolve these issues.
   MedicinesMental healthSubstance abuse treatment
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8. Report17 Jun 2026

   Norwegian Patient Safety Authority: Substance-dependent patients receive fragmented, poorly coordinated care – three patients died

   • Ukom's report (published 23 June 2026) concludes that services for patients with severe substance use disorders are fragmented, inconsistent and poorly coordinated, with unclear lines of responsibility that undermine patient safety.
   • Kristian was denied opioid agonist therapy (LAR) because services required a psychiatric assessment first – yet his substance use disorder prevented that assessment; he died young.
   HospitalMental healthSubstance abuse treatment
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9. Report16 Jun 2026

   Norwegian patient safety body: systemic failures in pre-operative pathways caused a death and serious injury – five recommendations issued

   • Two patients undergoing cancer treatment – Bjørn and Ingrid – were approved for planned surgery despite the hospital lacking sufficient insight into their overall health; one died, one was seriously injured.
   • The report 'When the whole picture slips away' is published by Ukom, Norway's independent patient safety investigation body, led by director Andres Neset.
   Elder careHospitalPublic health
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10. Report16 Jun 2026

    Norwegian Patient Safety Investigation Board: failures in preoperative safety barriers led to death and serious injury in cancer patients

    • Two cancer patients – Bjørn and Ingrid – were cleared for surgery without the hospital having sufficient overview of their general health, either at the time of the decision or at the time of the cancer operation; one died, the other was seriously injured.
    • Planned stop-points in the preoperative phase did not detect the risk – the routines did not function as intended safety barriers.
    HospitalPublic health
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