Monitoring visits to institutions for adults in 2021

The table immediately below shows the number of visits which we carried out to institutions for adults in 2021. In addition, it shows the total numbers of talks we had with users (inmates, residents, patients etc.) and relatives etc. (relatives, guardians, social guardians of persons under a residential care order and patient advisers). Under the OPCAT[1], the Ombudsman cooperates with DIGNITY – Danish Institute Against Torture and the Danish Institute for Human Rights (IMR), which participate in monitoring visits, among other things. For this reason, the table also shows the total numbers of visits in which DIGNITY and IMR participated (as the Ombudsman’s OPCAT mandate did not include Greenland at the time of the monitoring visits in Greenland, IMR and DIGNITY did not participate in those visits). In addition, the table shows the numbers of announced and unannounced visits, the numbers of physical, virtual, phone and partial phone visits and how many visits were concluded with recommendations and without any comments, respectively.

The visits which we carried out in 2021 are listed below the table. For each visit, information is provided about the type of institution visited and any special focus of the visit, how many talks we had with users and with relatives etc., whether DIGNITY and/or IMR participated and any recommendations given to the institution. If the visit caused the Ombudsman to open one or more cases on his own initiative, this is also stated.

[1] OHCHR | Optional Protocol to the Convention against Torture (OPCAT)

NUMBER OF VISITS	33
TALKS WITH USERS	126
TALKS WITH RELATIVES ETC.	68
WITH PARTICIPATION OF DIGNITY	13
WITH PARTICIPATION OF IMR	9
ANNOUNCED/UNANNOUNCED VISITS	33/0
PHYSICAL/VIRTUAL/PHONE/PARTIAL PHONE VISITS	22/9/1/1
CONCLUDED WITH RECOMMENDATIONS	33
CONCLUDED WITHOUT ANY COMMENTS	0

MONITORING VISITS	RECOMMENDATIONS
23 February Mental Health Services in the Region of Southern Denmark, Esbjerg Psychiatric Hospital Two integrated bed units for general and forensic psychiatric patients Talks with 3 users and 10 relatives etc. DIGNITY and IMR participated	that management ensure that offered and held follow-up interviews are documented in accordance with applicable rules that management ensure continued focus on preventing and reducing use of force that management ensure that the internal guidelines on when forced immobilisation is to be terminated are in accordance with the relevant applicable rules and practice that management ensure that the name(s) of the involved staff appear(s) from the protocols on use of force that management ensure that information on all types of interventions used appear from the protocol on use of force that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for initiating and maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act stating separate grounds for initiating and maintaining restraint with straps that management ensure that it is assessed as soon as possible whether a patient’s restraints can be loosened when an external doctor has assessed that there are no longer grounds for restraining the patient that management ensure new medical assessment of the need for continued forced immobilisation at least three times a day at regular intervals that management ensure that records about forced immobilisation state that external medical examinations under Section 21(5)-(7) of the Mental Health Act have been carried out by a doctor who is not employed in the psychiatric unit where the intervention takes place that management ensure that house rules and practice are reviewed and adjusted in accordance with the Ministry of Health’s statements most recently forwarded from Danish Regions to the regions on 26 March 2021, so that no extensive measures are carried out without the patients’ consent or clear legal authority with respect to restriction of the patients’ access to a mobile phone that management ensure that consent to extensive measures is obtained and documented in accordance with the relevant applicable rules and practice
25 February Mental Health Services in the Region of Southern Denmark, Middelfart Forensic Psychiatric Hospital Two closed bed units for forensic psychiatric patients Talks with 10 users and 5 relatives etc. DIGNITY and IMR participated	that management ensure continued focus on offering follow-up interviews in accordance with the applicable rules and on documenting offered follow-up interviews, including the reason that offered follow-up interviews are not carried out that management ensure continued focus on preventing and reducing use of force that management ensure that the staff have been instructed in the care staff’s access to terminate forced immobilisation when it is no longer necessary to maintain it, cf. Section 16(10) of Executive Order No. 1075 of 27 October 2019 that management ensure that the internal guidelines on when forced immobilisation is to be terminated are in accordance with the relevant applicable rules and practice that management ensure that protocols on use of force are in accordance with the applicable rules and that they contain information on any disagreement between the external doctor and the attending doctor the name of the prescribing doctor name(s) of the involved staff the name of the doctor who carried out the new medical assessment that management ensure new medical assessment of the need for continued forced immobilisation at least three times a day at regular intervals that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for initiating and maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act stating separate grounds for initiating and maintaining restraint with straps that management ensure that house rules and practice are reviewed and adjusted in accordance with the Ministry of Health’s statements most recently forwarded from Danish Regions to the regions on 26 March 2021, so that no extensive measures are carried out without the patients’ consent or clear legal authority with respect to restriction of the patients’ use of a mobile phone and PC restriction of the patients’ access to visits that management ensure that practice concerning the opening and checking of the patients’ mail reflect the applicable rules, including the condition of suspicion, cf. Section 19 a of the Mental Health Act that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room that management ensure that consent to shielding in own room and other extensive measures is obtained and documented in accordance with the relevant applicable rules and practice
10 and 11 March Mental Health Services in the Capital Region of Denmark, Psychiatric Center Glostrup Two closed emergency 24-hour units, one closed forensic psychiatric unit and one integrated intensive 24-hour unit Talks with 9 users and 8 relatives etc. DIGNITY and IMR participated	that management ensure continued focus on documenting held follow-up interviews in accordance with the applicable rules and on documenting offered follow-up interviews, including the reason that offered follow-up interviews are not carried out that management ensure continued focus on preventing and reducing use of force that management ensure that the staff have been instructed in the care staff’s access to terminate forced immobilisation when it is no longer necessary to maintain it, cf. Section 16(10) of Executive Order No. 1075 of 27 October 2019 that management ensure new medical assessment of the need for continued forced immobilisation at least three times a day at regular intervals that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act that management ensure that house rules and practice are reviewed and adjusted in accordance with the Ministry of Health’s statements most recently forwarded from Danish Regions to the regions on 26 March 2021, so that no extensive measures are carried out without the patients’ consent or clear legal authority with respect to restriction of the patients’ access to a mobile phone and PC restriction of the patients’ access to sexual intercourse with each other that management ensure that practice concerning search of belongings and body searching reflects the applicable rules, including the condition of suspicion, cf. Section 19 a of the Mental Health Act that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room, other area restrictions or washing of clothes upon suspicion of drugs that management ensure that consent to shielding in own room and other extensive measures is obtained and documented in accordance with the relevant applicable rules and practice
17 and 20 May The State Prison of Kragskovhede Two open wards Talks with 10 users DIGNITY and IMR participated	that management ensure that the instructions on handling inmates refusing to work and expelled inmates, which were being drafted at the time of the monitoring visit, will include a maximum number of inmates that can be placed in the work refusal room at the same time that management ensure that it is checked whether there is legal authority for video surveillance in the work refusal room and what conditions must be met, including what information about the surveillance that inmates placed in the work refusal room must be given that management ensure that the prison’s practice of placing inmates subject to increased monitoring in a solitary confinement cell is in accordance with the rules on exclusion from association, including the rules on placement in an observation cell that management ensure that a policy is drafted about handling violence and threats among the inmates, which should include registration and follow-up of episodes, including follow-up of non-specified information about threats and violence among inmates Own-initiative case opened against the Department of Prisons and Probation concerning dental treatment
2 June The Prison and Probation Service in Kolding, ’Pension Lyng’ Half-way house under the Prison and Probation Service, especially for convicted persons who are serving the last part of their sentence or are under supervision Talks with 4 users DIGNITY participated	that the residents, for instance in the consent form, are made aware that consent to search of car only applies when the car is parked in Pension Lyng’s premises and that the consent can be withdrawn at any time that management ensure that expulsion cases are processed in accordance with the circular on the use of the Prison and Probation Service’s half-way houses, including that the expulsion is recorded and that the resident is informed about his or her rights
3 and 8 June Sdr. Omme Prison One semi-open ward, one education ward and one treatment ward Talks with 10 users DIGNITY and IMR participated	that management ensure increased attention on the handling of mentally vulnerable inmates, including that management ensure supplementary training of the staff or in another way instructs the staff in what to keep an eye on and how the staff should handle this type of inmates that management, in cooperation with the nurses, endeavour to uncover whether there are unreported figures in relation to violence and threats among inmates Own-initiative case opened against the Department of Prisons and Probation concerning dental treatment
25 August Mental Health Services in the Capital Region of Denmark, Psychiatric Center Copenhagen (Bispebjerg) Emergency admission Talks with 2 users and 2 relatives etc. DIGNITY and IMR participated	that management ensure continued focus on short-term restraint only taking place after a specific assessment, where the patient’s advance statement is considered, including that the action card about the emergency patient is in accordance with guideline No. 9552 of 10 August 2020 that management ensure that long-term restraint lasting more than 30 minutes is avoided that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act that management ensure new medical assessment of the need for continued forced immobilisation at least three times a day at regular intervals that management ensure that, in connection with long-term restraint, external medical examinations are made in accordance with Section 21(5)-(7) of the Mental Health Act that management ensure that the written house rules are handed out to the patients on admission, cf. Section 2a(2) of the Mental Health Act that management ensure that practice is reviewed and adjusted in accordance with the Ministry of Health’s statements most recently forwarded from Danish Regions to the regions on 26 March 2021, so that no extensive measures are carried out without the patients’ consent or clear legal authority with respect to a ban or restriction of the patients’ access to a mobile phone etc. that management ensure that practice concerning search of belongings and body searching reflects the applicable rules, including the condition of suspicion, cf. Section 19 a of the Mental Health Act that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room that management ensure that consent to shielding in own room and other extensive measures is obtained and documented in accordance with the relevant applicable rules and practice
8 September Mental Health Services in the North Denmark Region, Frederikshavn Psychiatric Hospital One open bed unit for general and forensic psychiatric patients Talks with 4 users and 1 relative DIGNITY participated	that management ensure that house rules and practice are in accordance with applicable law that management ensure that consent to shielding in own room is documented in accordance with the relevant applicable rules and practice
13-14 September Mental Health Services in Region Zealand, ‘Sikringen’ Secure ward with three identical units Talks with 11 users and 18 relatives etc. DIGNITY and IMR participated	that management ensure that valid and current figures for use of force are available at all times that management ensure that long-term restraint lasting more than 30 minutes is avoided, and that management systematically follow up on the development in the number of long-term restraints that management – to the extent deemed relevant – bring up questions in relevant professional forums about access to forced medication of patients, and consider informing relevant authorities about it that management consider if there are grounds for setting specific objectives for reducing use of force that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act, as well as separate grounds for initiating and maintaining restraint with straps that management ensure that follow-up interviews are offered and documented in accordance with applicable rules that management ensure that house rules and practice are in accordance with applicable law, including that the wording in the house rules and practice on opening patients’ mail reflects the applicable rules, including the condition of suspicion, cf. Section 19 a of the Mental Health Act that the wording in the house rules on monitoring of locked-in patients at night reflects the rules of Section 30(2) of the executive order on use of other kinds of force than deprivation of liberty in psychiatric wards that management ensure that a concrete assessment is made in each individual case whether a newly arrived patient meets the conditions for door locking, cf. Section 18 a of the Mental Health Act that management consider if the restraint measures fixed to the bed in the 0-room (zero room or zero stimulus room) can be removed when a patient is in the room under Section 18 a of the Mental Health Act
15 September Mental Health Services in the Central Denmark Region, Horsens Psychiatric Hospital One closed bed unit and Psychiatric Admission Talks with 3 users and 5 relatives etc. DIGNITY and IMR participated	that management ensure new medical assessment of the need for continued forced immobilisation at least three times a day at regular intervals that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room that management ensure that consent to shielding in own room is obtained and documented in accordance with the relevant applicable rules and practice
22-23 September Mental Health Services in the Central Denmark Region, Viborg Psychiatric Hospital One intensive bed unit, one bed unit, one forensic psychiatric unit and one unit for special care beds Talks with 23 users and 10 relatives etc. DIGNITY participated	that management ensure that the staff’s understanding of the reasons for and purpose of forced immobilisation is reflected in minutes of follow-up interviews, and that follow-up interviews are documented in the correct place in the records that management ensure that long-term restraint lasting more than 30 minutes is avoided that management ensure continued focus on preventing and reducing use of force that management ensure systematic follow-up of overrulings by the Psychiatric Patients' Board of Appeal, and that the staff is made aware of the practice that management ensure that the name(s) of the involved staff appear(s) from the protocols on use of force that management ensure new medical assessment of the need for continued forced immobilisation in accordance with the applicable rules that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act that management ensure that house rules and practice are in accordance with applicable law, including that the wording of the house rules and practice on search of patients’ belongings and body searching reflects the condition of suspicion in Section 19 a of the Mental Health Act that management ensure that no shielding in own room is carried out without the patient’s consent, and that the house rules on shielding in own room are changed so that it is clear that such interventions cannot be carried out without the patient’s consent that management ensure that consent to shielding in own room is documented in accordance with the relevant applicable rules and practice
6-7 October Mental Health Services in the North Denmark Region, Aalborg Psychiatric Hospital Two general psychiatric bed units and two forensic psychiatric bed units Talks with 8 users and 4 relatives etc. DIGNITY participated	that management ensure continued focus on preventing and reducing use of force that management ensure that the name(s) of the involved staff appear(s) from the protocols on use of force that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act that management ensure new medical assessment of the need for continued forced immobilisation in accordance with the applicable rules that management ensure that house rules and practice are in accordance with applicable law that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room that management ensure that consent to shielding in own room is documented in accordance with the relevant applicable rules and practice
12 October Mental Health Services in Region Zealand, Slagelse Psychiatric Hospital One integrated psychiatric ward for adults and psychiatric emergency admission Talks with 6 users and 5 relatives etc. DIGNITY and IMR participated	that management ensure continued focus on preventing and reducing use of force, including focus on preventing that belt restraint is maintained for longer than a few hours that management ensure continued focus on follow-up interviews being offered and documented in accordance with the applicable rules, including documenting offered follow-up interviews and the reason that offered follow-up interviews are not carried out that management ensure that the 2017 guideline on forced immobilisation is kept up-to-date that management ensure documentation that the patients have been informed about the access to complain about force used that management ensure that the name(s) of the involved staff appear(s) from the protocols on use of force that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act that management ensure that house rules and practice are reviewed and adjusted in accordance with the Ministry of Health’s statements most recently forwarded from Danish Regions to the regions on 26 March 2021, so that no extensive measures are carried out without the patients’ consent or clear legal authority with respect to restriction of sexual intercourse that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room that management ensure that consent to shielding in own room and other extensive measures is obtained and documented in accordance with the relevant applicable rules and practice
7-20 October Prison and Probation Service institutions in Greenland ‘Anstalten for Domfældte’, Tasiilaq ‘Anstalten for Domfældte’, Sisimiut ‘Anstalten for Domfældte’, Aasiaat ‘Anstalten for Domfældte’, Qaqortoq ‘Anstalten for Domfældte’, Ilulissat ‘Anstalten for Domfældte’, Nuuk Talks with 22 users	Recommendations to the Prison and Probation Service in Greenland ensuring increased attention in the institutions on whether the rules on placement in solitary confinement are applied correctly, including distinguishing between solitary confinement under Section 223 and under Section 227 of the Greenland Criminal Code following up on whether ‘Anstalten for Domfældte’ in Aasiaat has ensured that inmates cannot let themselves into each other’s rooms ensuring that the staff in the institutions are systematically instructed in how to prevent and become aware of harmful effects of isolation ensuring that the institutions have increased attention on documentation of the basis for placement in observation and solitary confinement cells and the need for maintenance of the placements reviewing the house rules in order to ensure that they are in accordance with the applicable rules, and ensuring that the house rules state that criminal offences can lead to a report to the police, and that it is possible for detainees to complain to the district court ensuring that the house rules are made easily available to the inmates drafting guidelines for handling violence and threats among inmates implementing a fixed procedure for screening whether inmates are at risk of suicide ensuring that trained staff are always present in the institutions ensuring that the institutions follow the Prison and Probation Service’s guidelines on instructions in the event of fire Recommendations to individual institutions ‘Anstalten for Domfældte’ in Tasiilaq: ensuring that meetings with the inmates are held regularly ‘Anstalten for Domfældte’ in Sisimiut: making it clear what terms apply to convicted persons staying in the institution ‘Anstalten for Domfældte’ in Aasiaat: ensuring as soon as possible that inmates cannot let themselves into each other’s rooms ensuring that voluntary placement in solitary confinement in the institution is monitored, including in relation to focus on possible harmful effects of isolation ensuring that there is an overview of complaints about and suspicion of harassment, bullying, violence and threats etc. among the inmates ‘Anstalten for Domfældte’ in Qaqortoq: ensuring that complaints from inmates are answered ‘Anstalten for Domfældte’ in Ilulissat: ensuring that minutes are taken of meetings with the inmates and meetings with the inmate spokespersons ‘Anstalten for Domfældte’ in Nuuk: ensuring increased attention on the hierarchies among the inmates and considering initiatives to prevent and reduce harassment and bullying among the inmates ensuring that the minutes of the meetings with the inmates are worded neutrally
7-19 October Police authorities in Greenland Police station, Kangerlussuaq (with detention facility) Municipal bailiff, Sarfannguit (without detention facility) Municipal bailiff, Kulusuk (with detention facility) Police station, Tasiilaq (with detention facility) Police station, Aasiaat (with detention facility) Municipal bailiff, Narsarsuaq (with detention facility) Municipal bailiff, Saarloq (without detention facility) Municipal bailiff, Alluitsup Paa (with detention facility) Municipal bailiff, Kangaatsiaq (with detention facility) Police station, Qaqortoq (with detention facility) Municipal bailiff, Oqaatsut (without detention facility) Police station, Ilulissat (with detention facility) Police station, Nuuk (with detention facility) Municipal bailiff, Kapisillit (without detention facility) Talk with 1 user	Recommendations to the Chief Constable of Greenland ensuring that guidelines on fire safety are followed, including in relation to alarm call to the fire service when fire detectors are triggered the possibility of evacuation of inmates increasing focus on the police’s self-inspection of the physical conditions in the detention facilities, including in relation to ensuring that calling systems and video surveillance are working, and especially that the calling systems in the detention facilities in Kangerlussuaq and Aasiaat are fixed as soon as possible ensuring that all municipal bailiffs and police stations have the equipment to relieve the effects of pepper spray considering if there is a need to draft instructions for medicines management and the documentation thereof considering if there is a need for rules about more intensive monitoring of detainees needing medical attention who are placed in the detention facility before they are seen by a doctor ensuring that police stations and municipal bailiffs have the necessary information leaflets about the detainees’ rights, including in relation to use of force with, for instance, pepper spray ensuring that the information about rules – or references thereto – in the detention facilities are kept up-to-date updating the orders of the day about detention facilities and municipal bailiffs, so that it is clear how often detainees must be monitored in detention facilities without permanent police staffing how placement in detention facilities must be documented when the custodial parent or guardian must be informed about placement of a minor in a detention facility ensuring that detainees’ stay in the detention facilities takes place in accordance with the special rules applicable to this group, including in relation to access to open air and the furnishing of the cells increasing the focus on teaching staff who have not been trained in Greenland about the Greenlandic rules on detention facility placement ensuring that the municipal bailiffs receive peer-to-peer training and participate in a training course for municipal bailiffs increasing the focus on ensuring correct and comprehensive documentation, for instance in relation to monitoring of the detainees searching, including which officers participated in the search notifying custodial parents or guardians and the social authorities in cases about minors account to a doctor, including the background for a detainee having been placed in the detention facility before receiving medical attention detained and convicted persons’ access to open air and the furnishing of their cells Recommendation to individual police authorities The municipal bailiff in Kapisillit: to seek to enter an agreement with, for instance, the municipality about using a suitable room for deprivations of liberty, if any

MONITORING VISITS

RECOMMENDATIONS

23 February

Mental Health Services in the Region of Southern Denmark, Esbjerg Psychiatric Hospital

Two integrated bed units for general and forensic psychiatric patients

Talks with 3 users and 10 relatives etc.

DIGNITY and IMR participated

that management ensure that offered and held follow-up interviews are documented in accordance with applicable rules
that management ensure continued focus on preventing and reducing use of force
that management ensure that the internal guidelines on when forced immobilisation is to be terminated are in accordance with the relevant applicable rules and practice
that management ensure that the name(s) of the involved staff appear(s) from the protocols on use of force
that management ensure that information on all types of interventions used appear from the protocol on use of force
that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including
- stating precise and comprehensive grounds for initiating and maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act
- stating separate grounds for initiating and maintaining restraint with straps
that management ensure that it is assessed as soon as possible whether a patient’s restraints can be loosened when an external doctor has assessed that there are no longer grounds for restraining the patient
that management ensure new medical assessment of the need for continued forced immobilisation at least three times a day at regular intervals
that management ensure that records about forced immobilisation state that external medical examinations under Section 21(5)-(7) of the Mental Health Act have been carried out by a doctor who is not employed in the psychiatric unit where the intervention takes place
that management ensure that house rules and practice are reviewed and adjusted in accordance with the Ministry of Health’s statements most recently forwarded from Danish Regions to the regions on 26 March 2021, so that no extensive measures are carried out without the patients’ consent or clear legal authority with respect to restriction of the patients’ access to a mobile phone
that management ensure that consent to extensive measures is obtained and documented in accordance with the relevant applicable rules and practice

25 February

Mental Health Services in the Region of Southern Denmark, Middelfart Forensic Psychiatric Hospital

Two closed bed units for forensic psychiatric patients

Talks with 10 users and 5 relatives etc.

DIGNITY and IMR participated

that management ensure continued focus on offering follow-up interviews in accordance with the applicable rules and on documenting offered follow-up interviews, including the reason that offered follow-up interviews are not carried out
that management ensure continued focus on preventing and reducing use of force
that management ensure that the staff have been instructed in the care staff’s access to terminate forced immobilisation when it is no longer necessary to maintain it, cf. Section 16(10) of Executive Order No. 1075 of 27 October 2019
that management ensure that the internal guidelines on when forced immobilisation is to be terminated are in accordance with the relevant applicable rules and practice
that management ensure that protocols on use of force are in accordance with the applicable rules and that they contain information on
- any disagreement between the external doctor and the attending doctor
- the name of the prescribing doctor
- name(s) of the involved staff
- the name of the doctor who carried out the new medical assessment
that management ensure new medical assessment of the need for continued forced immobilisation at least three times a day at regular intervals
that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including
- stating precise and comprehensive grounds for initiating and maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act
- stating separate grounds for initiating and maintaining restraint with straps
that management ensure that house rules and practice are reviewed and adjusted in accordance with the Ministry of Health’s statements most recently forwarded from Danish Regions to the regions on 26 March 2021, so that no extensive measures are carried out without the patients’ consent or clear legal authority with respect to
- restriction of the patients’ use of a mobile phone and PC
- restriction of the patients’ access to visits

that management ensure that practice concerning the opening and checking of the patients’ mail reflect the applicable rules, including the condition of suspicion, cf. Section 19 a of the Mental Health Act

that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room

that management ensure that consent to shielding in own room and other extensive measures is obtained and documented in accordance with the relevant applicable rules and practice

10 and 11 March

Mental Health Services in the Capital Region of Denmark, Psychiatric Center Glostrup

Two closed emergency 24-hour units, one closed forensic psychiatric unit and one integrated intensive 24-hour unit

Talks with 9 users and 8 relatives etc.

DIGNITY and IMR participated

that management ensure continued focus on documenting held follow-up interviews in accordance with the applicable rules and on documenting offered follow-up interviews, including the reason that offered follow-up interviews are not carried out

that management ensure continued focus on preventing and reducing use of force

that management ensure that the staff have been instructed in the care staff’s access to terminate forced immobilisation when it is no longer necessary to maintain it, cf. Section 16(10) of Executive Order No. 1075 of 27 October 2019

that management ensure new medical assessment of the need for continued forced immobilisation at least three times a day at regular intervals

that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act

that management ensure that house rules and practice are reviewed and adjusted in accordance with the Ministry of Health’s statements most recently forwarded from Danish Regions to the regions on 26 March 2021, so that no extensive measures are carried out without the patients’ consent or clear legal authority with respect to
- restriction of the patients’ access to a mobile phone and PC
- restriction of the patients’ access to sexual intercourse with each other

that management ensure that practice concerning search of belongings and body searching reflects the applicable rules, including the condition of suspicion, cf. Section 19 a of the Mental Health Act

that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room, other area restrictions or washing of clothes upon suspicion of drugs
that management ensure that consent to shielding in own room and other extensive measures is obtained and documented in accordance with the relevant applicable rules and practice

17 and 20 May

The State Prison of Kragskovhede

Two open wards

Talks with 10 users

DIGNITY and IMR participated

that management ensure that the instructions on handling inmates refusing to work and expelled inmates, which were being drafted at the time of the monitoring visit, will include a maximum number of inmates that can be placed in the work refusal room at the same time

that management ensure that it is checked whether there is legal authority for video surveillance in the work refusal room and what conditions must be met, including what information about the surveillance that inmates placed in the work refusal room must be given

that management ensure that the prison’s practice of placing inmates subject to increased monitoring in a solitary confinement cell is in accordance with the rules on exclusion from association, including the rules on placement in an observation cell

that management ensure that a policy is drafted about handling violence and threats among the inmates, which should include registration and follow-up of episodes, including follow-up of non-specified information about threats and violence among inmates

Own-initiative case opened against the Department of Prisons and Probation concerning dental treatment

2 June

The Prison and Probation Service in Kolding, ’Pension Lyng’

Half-way house under the Prison and Probation Service, especially for convicted persons who are serving the last part of their sentence or are under supervision

Talks with 4 users

DIGNITY participated

that the residents, for instance in the consent form, are made aware that consent to search of car only applies when the car is parked in Pension Lyng’s premises and that the consent can be withdrawn at any time
that management ensure that expulsion cases are processed in accordance with the circular on the use of the Prison and Probation Service’s half-way houses, including that the expulsion is recorded and that the resident is informed about his or her rights

3 and 8 June

Sdr. Omme Prison

One semi-open ward, one education ward and one treatment ward

Talks with 10 users

DIGNITY and IMR participated

that management ensure increased attention on the handling of mentally vulnerable inmates, including that management ensure supplementary training of the staff or in another way instructs the staff in what to keep an eye on and how the staff should handle this type of inmates
that management, in cooperation with the nurses, endeavour to uncover whether there are unreported figures in relation to violence and threats among inmates

Own-initiative case opened against the Department of Prisons and Probation concerning dental treatment

25 August

Mental Health Services in the Capital Region of Denmark, Psychiatric Center Copenhagen (Bispebjerg)

Emergency admission

Talks with 2 users and 2 relatives etc.

DIGNITY and IMR participated

that management ensure continued focus on short-term restraint only taking place after a specific assessment, where the patient’s advance statement is considered, including that the action card about the emergency patient is in accordance with guideline No. 9552 of 10 August 2020
that management ensure that long-term restraint lasting more than 30 minutes is avoided
that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act
that management ensure new medical assessment of the need for continued forced immobilisation at least three times a day at regular intervals
that management ensure that, in connection with long-term restraint, external medical examinations are made in accordance with Section 21(5)-(7) of the Mental Health Act
that management ensure that the written house rules are handed out to the patients on admission, cf. Section 2a(2) of the Mental Health Act
that management ensure that practice is reviewed and adjusted in accordance with the Ministry of Health’s statements most recently forwarded from Danish Regions to the regions on 26 March 2021, so that no extensive measures are carried out without the patients’ consent or clear legal authority with respect to a ban or restriction of the patients’ access to a mobile phone etc.
that management ensure that practice concerning search of belongings and body searching reflects the applicable rules, including the condition of suspicion, cf. Section 19 a of the Mental Health Act
that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room
that management ensure that consent to shielding in own room and other extensive measures is obtained and documented in accordance with the relevant applicable rules and practice

8 September

Mental Health Services in the North Denmark Region, Frederikshavn Psychiatric Hospital

One open bed unit for general and forensic psychiatric patients

Talks with 4 users and 1 relative

DIGNITY participated

that management ensure that house rules and practice are in accordance with applicable law
that management ensure that consent to shielding in own room is documented in accordance with the relevant applicable rules and practice

13-14 September

Mental Health Services in Region Zealand, ‘Sikringen’

Secure ward with three identical units

Talks with 11 users and 18 relatives etc.

DIGNITY and IMR participated

that management ensure that valid and current figures for use of force are available at all times
that management ensure that long-term restraint lasting more than 30 minutes is avoided, and that management systematically follow up on the development in the number of long-term restraints
that management – to the extent deemed relevant – bring up questions in relevant professional forums about access to forced medication of patients, and consider informing relevant authorities about it

that management consider if there are grounds for setting specific objectives for reducing use of force
that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act, as well as separate grounds for initiating and maintaining restraint with straps

that management ensure that follow-up interviews are offered and documented in accordance with applicable rules

that management ensure that house rules and practice are in accordance with applicable law, including
- that the wording in the house rules and practice on opening patients’ mail reflects the applicable rules, including the condition of suspicion, cf. Section 19 a of the Mental Health Act
- that the wording in the house rules on monitoring of locked-in patients at night reflects the rules of Section 30(2) of the executive order on use of other kinds of force than deprivation of liberty in psychiatric wards
that management ensure that a concrete assessment is made in each individual case whether a newly arrived patient meets the conditions for door locking, cf. Section 18 a of the Mental Health Act
that management consider if the restraint measures fixed to the bed in the 0-room (zero room or zero stimulus room) can be removed when a patient is in the room under Section 18 a of the Mental Health Act

15 September

Mental Health Services in the Central Denmark Region, Horsens Psychiatric Hospital

One closed bed unit and Psychiatric Admission

Talks with 3 users and 5 relatives etc.

DIGNITY and IMR participated

that management ensure new medical assessment of the need for continued forced immobilisation at least three times a day at regular intervals
that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act

that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room
that management ensure that consent to shielding in own room is obtained and documented in accordance with the relevant applicable rules and practice

22-23 September

Mental Health Services in the Central Denmark Region, Viborg Psychiatric Hospital

One intensive bed unit, one bed unit, one forensic psychiatric unit and one unit for special care beds

Talks with 23 users and 10 relatives etc.

DIGNITY participated

that management ensure that the staff’s understanding of the reasons for and purpose of forced immobilisation is reflected in minutes of follow-up interviews, and that follow-up interviews are documented in the correct place in the records

that management ensure that long-term restraint lasting more than 30 minutes is avoided

that management ensure continued focus on preventing and reducing use of force

that management ensure systematic follow-up of overrulings by the Psychiatric Patients' Board of Appeal, and that the staff is made aware of the practice
that management ensure that the name(s) of the involved staff appear(s) from the protocols on use of force
that management ensure new medical assessment of the need for continued forced immobilisation in accordance with the applicable rules
that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act
that management ensure that house rules and practice are in accordance with applicable law, including that the wording of the house rules and practice on search of patients’ belongings and body searching reflects the condition of suspicion in Section 19 a of the Mental Health Act
that management ensure that no shielding in own room is carried out without the patient’s consent, and that the house rules on shielding in own room are changed so that it is clear that such interventions cannot be carried out without the patient’s consent
that management ensure that consent to shielding in own room is documented in accordance with the relevant applicable rules and practice

6-7 October

Mental Health Services in the North Denmark Region, Aalborg Psychiatric Hospital

Two general psychiatric bed units and two forensic psychiatric bed units

Talks with 8 users and 4 relatives etc.

DIGNITY participated

that management ensure continued focus on preventing and reducing use of force
that management ensure that the name(s) of the involved staff appear(s) from the protocols on use of force
that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act
that management ensure new medical assessment of the need for continued forced immobilisation in accordance with the applicable rules
that management ensure that house rules and practice are in accordance with applicable law
that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room
that management ensure that consent to shielding in own room is documented in accordance with the relevant applicable rules and practice

12 October

Mental Health Services in Region Zealand, Slagelse Psychiatric Hospital

One integrated psychiatric ward for adults and psychiatric emergency admission

Talks with 6 users and 5 relatives etc.

DIGNITY and IMR participated

that management ensure continued focus on preventing and reducing use of force, including focus on preventing that belt restraint is maintained for longer than a few hours
that management ensure continued focus on follow-up interviews being offered and documented in accordance with the applicable rules, including documenting offered follow-up interviews and the reason that offered follow-up interviews are not carried out
that management ensure that the 2017 guideline on forced immobilisation is kept up-to-date
that management ensure documentation that the patients have been informed about the access to complain about force used
that management ensure that the name(s) of the involved staff appear(s) from the protocols on use of force
that management ensure focus on precise and comprehensive documentation in records about forced immobilisation, including stating precise and comprehensive grounds for maintaining belt restraint, which – in connection with restraint for longer than a few hours – observe the more rigorous requirements set out in Section 14(3) of the Mental Health Act
that management ensure that house rules and practice are reviewed and adjusted in accordance with the Ministry of Health’s statements most recently forwarded from Danish Regions to the regions on 26 March 2021, so that no extensive measures are carried out without the patients’ consent or clear legal authority with respect to restriction of sexual intercourse
that management ensure that no interventions are carried out without the patients’ consent with respect to shielding in own room
that management ensure that consent to shielding in own room and other extensive measures is obtained and documented in accordance with the relevant applicable rules and practice

7-20 October

Prison and Probation Service institutions in Greenland

‘Anstalten for Domfældte’, Tasiilaq

‘Anstalten for Domfældte’, Sisimiut

‘Anstalten for Domfældte’, Aasiaat

‘Anstalten for Domfældte’, Qaqortoq

‘Anstalten for Domfældte’, Ilulissat

‘Anstalten for Domfældte’, Nuuk

Talks with 22 users

Recommendations to the Prison and Probation Service in Greenland

ensuring increased attention in the institutions on whether the rules on placement in solitary confinement are applied correctly, including distinguishing between solitary confinement under Section 223 and under Section 227 of the Greenland Criminal Code
following up on whether ‘Anstalten for Domfældte’ in Aasiaat has ensured that inmates cannot let themselves into each other’s rooms
ensuring that the staff in the institutions are systematically instructed in how to prevent and become aware of harmful effects of isolation
ensuring that the institutions have increased attention on documentation of the basis for placement in observation and solitary confinement cells and the need for maintenance of the placements
reviewing the house rules in order to ensure that they are in accordance with the applicable rules, and ensuring that the house rules state that criminal offences can lead to a report to the police, and that it is possible for detainees to complain to the district court
ensuring that the house rules are made easily available to the inmates
drafting guidelines for handling violence and threats among inmates
implementing a fixed procedure for screening whether inmates are at risk of suicide

ensuring that trained staff are always present in the institutions
ensuring that the institutions follow the Prison and Probation Service’s guidelines on instructions in the event of fire

Recommendations to individual institutions

‘Anstalten for Domfældte’ in Tasiilaq:

ensuring that meetings with the inmates are held regularly

‘Anstalten for Domfældte’ in Sisimiut:

making it clear what terms apply to convicted persons staying in the institution

‘Anstalten for Domfældte’ in Aasiaat:

ensuring as soon as possible that inmates cannot let themselves into each other’s rooms
ensuring that voluntary placement in solitary confinement in the institution is monitored, including in relation to focus on possible harmful effects of isolation
ensuring that there is an overview of complaints about and suspicion of harassment, bullying, violence and threats etc. among the inmates

‘Anstalten for Domfældte’ in Qaqortoq:

ensuring that complaints from inmates are answered

‘Anstalten for Domfældte’ in Ilulissat:

ensuring that minutes are taken of meetings with the inmates and meetings with the inmate spokespersons

‘Anstalten for Domfældte’ in Nuuk:

ensuring increased attention on the hierarchies among the inmates and considering initiatives to prevent and reduce harassment and bullying among the inmates
ensuring that the minutes of the meetings with the inmates are worded neutrally

7-19 October

Police authorities in Greenland

Police station, Kangerlussuaq (with detention facility)

Municipal bailiff, Sarfannguit (without detention facility)

Municipal bailiff, Kulusuk (with detention facility)

Police station, Tasiilaq (with detention facility)

Police station, Aasiaat (with detention facility)

Municipal bailiff, Narsarsuaq (with detention facility)

Municipal bailiff, Saarloq (without detention facility)

Municipal bailiff, Alluitsup Paa (with detention facility)

Municipal bailiff, Kangaatsiaq (with detention facility)

Police station, Qaqortoq (with detention facility)

Municipal bailiff, Oqaatsut (without detention facility)

Police station, Ilulissat (with detention facility)

Police station, Nuuk (with detention facility)

Municipal bailiff, Kapisillit (without detention facility)

Talk with 1 user

Recommendations to the Chief Constable of Greenland

ensuring that guidelines on fire safety are followed, including in relation to
- alarm call to the fire service when fire detectors are triggered
- the possibility of evacuation of inmates
increasing focus on the police’s self-inspection of the physical conditions in the detention facilities, including in relation to
- ensuring that calling systems and video surveillance are working, and especially
- that the calling systems in the detention facilities in Kangerlussuaq and Aasiaat are fixed as soon as possible
ensuring that all municipal bailiffs and police stations have the equipment to relieve the effects of pepper spray

considering if there is a need to draft instructions for medicines management and the documentation thereof
considering if there is a need for rules about more intensive monitoring of detainees needing medical attention who are placed in the detention facility before they are seen by a doctor

ensuring that police stations and municipal bailiffs have the necessary information leaflets about the detainees’ rights, including in relation to use of force with, for instance, pepper spray

ensuring that the information about rules – or references thereto – in the detention facilities are kept up-to-date

updating the orders of the day about detention facilities and municipal bailiffs, so that it is clear
- how often detainees must be monitored in detention facilities without permanent police staffing
- how placement in detention facilities must be documented
- when the custodial parent or guardian must be informed about placement of a minor in a detention facility
ensuring that detainees’ stay in the detention facilities takes place in accordance with the special rules applicable to this group, including in relation to access to open air and the furnishing of the cells
increasing the focus on teaching staff who have not been trained in Greenland about the Greenlandic rules on detention facility placement

ensuring that the municipal bailiffs receive peer-to-peer training and participate in a training course for municipal bailiffs

increasing the focus on ensuring correct and comprehensive documentation, for instance in relation to
- monitoring of the detainees
- searching, including which officers participated in the search
- notifying custodial parents or guardians and the social authorities in cases about minors
- account to a doctor, including the background for a detainee having been placed in the detention facility before receiving medical attention
- detained and convicted persons’ access to open air and the furnishing of their cells

Recommendation to individual police authorities

The municipal bailiff in Kapisillit:

to seek to enter an agreement with, for instance, the municipality about using a suitable room for deprivations of liberty, if any

Monitoring visits to institutions for adults in 2021

The Danish Parliamentary Ombudsman

Links