Dutch care home deaths rarely reach court
Fatal incidents in Dutch care institutions rarely result in criminal prosecution, even in serious cases in Eindhoven involving Lunet Zorg and GGzE, according to an investigation by Pointer and De Gelderlander examining 58 deaths over 17 years.
The investigation found that 58 fatal incidents occurred across youth care, disability care, and elderly care facilities. Of those, the Public Prosecution Service (OM) investigated 30 cases and brought 13 to court. Since 2009, no more than four cases involving care institutions have gone to trial.
In practice, a death in a care facility is not automatically reviewed by a court. The OM first investigates and then decides whether to prosecute.
One of the earliest court cases involved Lunet Zorg in Eindhoven in 2009. A 40-year-old man was placed in a seclusion room at the Eckartdal location when he set a fire and suffered severe burns. He later died in the hospital. Prosecutors argued the death resulted from what they described as “a combination of shortcomings and omissions.” The court rejected that argument and acquitted the institution.
A second Eindhoven case involved GGzE in 2013. A 29-year-old woman, Janneke, was admitted to the emergency psychiatric department of the Geestelijke Gezondheidszorg Eindhoven facility due to severe mental health symptoms. She was treated with the drug clozapine, reportedly administered by a trainee physician.
She died one month later. Medical findings showed she was hypersensitive to the medication, which caused inflammation of her heart muscle. The legal process took 10 years before a final ruling in appeals court.
The court found that the institution failed in its duty “to provide timely medical care.” It said there were multiple warning signs that should have led staff to act differently, including specific instances of neglect and failure to respond to patient needs that were documented in the case. The court concluded the death was attributable to GGzE. The institution received a conditional fine of 19,500 euros, meaning it would only have to pay if it committed another offense. Janneke’s parents criticized the outcome, with her mother saying, “It’s outrageous.”
The broader investigation identified repeated types of fatal incidents in care settings, including fires, medication errors, drowning, suffocation, overdoses, suicides, and falls. In five cases, clients died after being physically restrained by caregivers.
Experts say prosecution is uncommon despite repeated and systemic problems. Olga Floris, a lecturer in health law and chair of Klokkenluiders Gehandicaptenzorg, said, “The Public Prosecution Service should prosecute care institutions far more often for gross negligence.” She added, “Despite structural shortcomings in care, prosecution is rarely initiated.”
The investigation also found that the Health and Youth Care Inspectorate does not keep statistics on non-natural deaths. Care institutions are required to report deaths themselves and then conduct internal investigations. Floris said the system is effectively stalled, warning, “As a result, people are dying unnecessarily and often not receiving proper care.”
