"It is terribly tragic, but we have learnt a lot from this and will take several measures to prevent this from happening again," said Gunilla Hult Backlund, the director general of the The Health and Social Care Inspectorate.
The dentist had substance abuse problems and was first reported to the Inspectorate in 2013, but the case was closed in 2014 without any further actions. A drug test could not prove that he was abusing substances at the time, and his employer, Praktikertjänst, stepped in to show that they were following an action plan to help him out of the drug abuse.
But only two months after the case was closed, the dentist left Praktikertjänst and opened up his own clinic. And after that, no-one followed up what happened to his drug-abuse. In an internal investigation, the Health and Social Care Inspectorate is now criticised for putting too much faith into an employer.
In 2016, new complaints led the Inspectorate to open another investigation into the same dentist. This time they found that the injuries and maltreatment of patients meant that they had to withdraw his dentistry licence.
An internal investigation at the Inspectorate was initiated after Swedish Radio P4 revealed that over 200 patients had been injured or maltreated in the dentist's care. And it is this investigation that now has led the Inspectorate to conclude they need to improve their work in order to prevent similar cases in the future.