External reviewers support previous conclusions about the freezer failure
The external review of the previous internal investigation into the freezer failure in Neo during the Christmas holidays 2023, supports the conclusions and recommendations of the internal report. This was clear when the external investigation was presented to KI's management and affected staff on 20 August.
“The external investigation group's report is very valuable for the whole of KI, not only regarding freezing infrastructure. It emphasises the need for clarity about responsibilities and roles, the importance of a clear structure and good quality work – this is an improvement work that KI has begun within the framework of the work with our nine focus areas,” says KI President Annika Östman Wernerson.
It was due to a closed valve during the Christmas holidays in 2023 that the freezing infrastructure in Neo on the Flemingsberg campus suffered a breakdown when 16 out of 19 cryotanks thawed.
Chain of shortcomings
The cryo tanks stored large amounts of biological research material, collected over decades. When the freezer breakdown was discovered, a significant part of the contents of the freezers had been destroyed.
An internal investigation was appointed to investigate the causes of the breakdown and propose measures with the aim of minimising the risk of similar incidents at KI.
Independent review by external experts
The internal investigation was presented on April 12, 2024, and concludes that a chain of shortcomings, technical as well as organizational, led to the breakdown.
To obtain an independent assessment and review, an external investigation team was also appointed, led by Anna Beskow, head of Uppsala Biobank.
The external report confirms the conclusions of the internal investigation: it is a number of shortcomings that caused the breakdown and not a single incident.
“The conclusions of the external investigation team are well in line with the conclusions of our internal investigation team. Now we will go through the external report in detail as it will be an important support in our improvement work,” says Annika Östman Wernerson.
In summary, the external investigation concludes that the extent of the shortcomings indicates a system failure that spans an extensive chain of responsibility, accountability, infrastructure, legal questions and quality systems, including monitoring.
Optimised research infrastructure
The work on measures is underway in several parts. Among other things, one of the nine focus areas is about optimised use of KI's infrastructure, which involves an inventory and review of existing research infrastructures. The goal is to create a competent organisation that supports KI's research in the best possible way.
KI must also submit documents and requested information to IVO (the Health and Social Care Inspectorate). An action plan must be completed and submitted to the supervisory authority by 1 September 2024.