Within four months of the child's birth in late 2009, health workers at a local paediatric clinic in Linköping in central Sweden noticed that the baby's growth wasn't progressing normally.
A specialist was called in and determined that the child was suffering from malnutrition, causing it to lose weight.
The local clinic informed the family that it needed to adjust the child's diet, promising to follow up with special counseling sessions and additional weight controls.
But the additional measures never took place in part because the clinic was unstaffed during the summer holiday period and no one was assigned to follow up on the baby's condition.
A home visit was finally carried out by a nurse from the clinic in September 2010, by which time the infant was ten months old.
After further tests were carried out six days later, the decision was taken to rush the child to the paediatric ward of a nearby hospital, where it received care for the next two weeks.
The same day the child was hospitalised, the incident was reported to Sweden's National Board of Health and Welfare (Socialstyrelsen).
In its review of the incident, the agency found it "remarkable that no further report was made to others at the paediatric clinic to follow the growth curve during the holiday period".
Nevertheless, the health board refrained from any formal reprimand, finding that the clinic had already taken appropriate measures to ensure a similar incident wouldn't happen again.