Activities overview 2018/19

This past operating year is the first since 2012 that the Opcat Unit has been fully staffed. This has meant that it has been possible to expand the inspection activities. During the year, the number of inspections has doubled compared to the previous year. Furthermore, there has been scope to develop methodological processes within the operations, on, for example, how observations are followed up, when and how dialogue with government agencies shall be pursued, and what issues are best dealt with in project form. This year also saw the introduction of a new case category in the Parliamentary Ombudsmen’s case series; request for a follow-up report, and the Opcat operations were assigned their own case series. These changes mean firstly that it is possible to report the different types of cases being handled by the Opcat Unit, and secondly, improved opportunities to communicate the results achieved.

The focus of the unit’s operations is regular inspections. From the start in 2011, the Parliamentary Ombudsmen has conducted over 200 Opcat inspections. The observations presented in the inspection reports are, and will continue to be, an important basis in the follow-up carried out at each authority, and in the selection of thematic orientations and inspection objects.

The methods for the unit’s work have been developed over the years. For example, the ombudsmen more frequently request follow-up reports from the inspected authority in one or several matters. A request for a follow-up report generally relates to how the inspected authority intends to remedy a shortcoming identified during the inspection. This may, for example, involve deficiencies in the physical environment or structural deficiencies. A request for a follow-up report means that the Parliamentary Ombudsmen can follow up on the inspected activities and that the authorities implement measures to prevent inhumane treatment. On frequent basis authorities also report other measures taken following an inspection by the Parliamentary Ombudsmen. For example, this may relate to the clarification of internal decision-making processes and governing documents etc. During the past year, the Parliamentary Ombudsmen has made several principled decisions after receiving follow-up reports that concern the Prison and Probation Service and the National Board of Institutional Care.

In order to be able to communicate the results of the inspections, the work with producing different reports has been prioritised during this operating year. The reports fulfil an important function in highlighting and communicating what the situation is like for persons deprived of liberty. During the year, a year-end report was published for the operation for the period 2015–2017, as was a thematic interim report on the transport of detainees.

This year, the Opcat Unit has participated in two Nordic NPM meetings, one of which was hosted by the Parliamentary Ombudsmen and held in Lund in August 2018. In addition, during the year, the unit participated in several European meetings and at a national level had contact with a number of volunteer organisations.

Opcat inspections during the operating year

In the past operating year, 34 inspections were conducted, 33 of which related to facilities that house those deprived of liberty (20 were in the supervisory area of Chief Parliamentary Ombudsman Elisabeth Rynning, 4 in the supervisory area of Parliamentary Ombudsman Thomas Norling and 10 in the supervisory area of Parliamentary Ombudsman Cecilia Renfors). The theme for the Opcat activities in 2018 and 2019 was domestic transport of persons deprived of liberty. Within the framework of the theme, Chief Parliamentary Ombudsman Elisabeth Rynning decided on three enquiries and Parliamentary Ombudsman Thomas Norling decided on one enquiry. In total, the Parliamentary Ombudsmen has made decisions on nine enquiries following Opcat inspections. In addition to the inspections conducted during the past operating year, this report also covers several inspections carried out during previous years, which are reported in this operating year.

The number of inspections and inspection days has increased since the previous year and the inspections have been carried out across the country. During the year, both dialogue meetings and inspections of institutions have been conducted. As in previous years, the composition of the inspection team has varied and has been adapted to the type of inspection being carried out. Furthermore, the size of the inspection object, target group and possible security classification are important factors in determining the composition of the team. Over the course of the year, 15 unannounced inspections were performed; among others, all inspections at detention centres within the scope of the project concerning occupancy rate in the Prison and Probation Service were unannounced. The unit has conducted several follow-up inspections during the year, including at the National Board of Institutional Care substance abuse home Fortunagården, the police lock-ups in Helsingborg and Värnamo, and Haparanda prison.

Opcat inspections of the Prison and Probation Service

In the previous year’s annual report, it was highlighted that one of the most important issues for the Opcat activities in the coming years is the Prison and Probation Service’s work with measures to prevent isolation. Furthermore, it was noted that the high occupancy rate in detention centres and the increased need for places in prisons were cause for concern, as this may lead to a lack of space in the correctional system and thereby difficulties in satisfying the need for common areas and other facilities in detention centres.

During the past year, the unit has continued to focus on these issues. Chief Parliamentary Ombudsman Elisabeth Rynning, after receiving the Prison and Probation Service’s follow-up report concerning measures to prevent isolation in June 2018, decided to continue the examination of inmates’ isolation in detention centres (ref. no. O 7-2018). Within the framework of an enquiry, representatives from the Prison and Probation Service were called to a dialogue meeting with recorded minutes in March 2019 that was led by the Chief Parliamentary Ombudsman. A decision in the matter can be expected during the operating year 2019/20.

The concerns regarding occupancy rate that were raised in last year’s annual report were realised during the year. Prompted by media reports, among other things, Chief Parliamentary Ombudsman Elisabeth Rynning decided in March 2019 to initiate an enquiry into the occupancy situation within the Prison and Probation Service (ref. no. O 19-2019). The Opcat Unit worked with the case in project form. A document compiling the issues was produced, and a total of nine inspections were carried out during the period from 26 March to 15 May. The series of inspections encompasses seven detention centres, one prison and one police lock-up. All inspections within the Prison and Probation Service indicated a space problem within an occupancy rate of above 100 per cent at times. The lack of space has meant that the Prison and Probation Service has needed to move inmates between different detention centres. During the site inspections, it was evident that the Prison and Probation Service’s prisons, with a higher security classification, were and are a major reason for inmates being kept in detention centres. When the Parliamentary Ombudsmen inspected the National Reception Centre in Kumla prison, the capacity had recently been increased by a significant extent. In a short time, the number of cell spots had close to doubled through the implementation of measures such as doubling the occupancy of cells based on the principle that the last person in has to share a cell. The Prison and Probation Service has been asked to make a statement regarding what had emerged during the inspections, and one question directed at the authority is to specify what other measures besides double occupancy are being implemented to improve the space problem in the country’s correctional facilities. A decision in the case is to be completed in autumn 2019.

Decisions after receiving follow-up reports

During the year, Chief Parliamentary Ombudsman Elisabeth Rynning completed a significant decision concerning the matter of what time spent with others; in common facilities is, in detention centres. An inspection of the Ystad detention centre took place in February 2017 (ref. no. 583-2017). In the report following the inspection, a follow-up report from the Prison and Probation Service was requested. In the decision, after reviewing the follow-up report, Chief Parliamentary Ombudsman Elisabeth Rynning stated that spending time with other inmates in common facilities may be considered to refer to time spent together with several other inmates. This means, for example, that sharing a space with another inmate cannot be equated with spending time in common facilities with other inmates. If an inmate is not in the common facility during daytime, he or she is in isolation. Furthermore, the Chief Parliamentary Ombudsman stated that a section must consist of at least three cells in order to meet the basic requirements of the legislation regarding inmates’ right to spend time in common facilities.

Chief Parliamentary Ombudsman Elisabeth Rynning also stated that it is worrying that the Prison and Probation Service sets up housing for inmates that in the authority’s own words are somewhere in the middle ground between isolation and a common facility. There may be a need to set up sections that can accommodate the needs of inmates to be in a smaller group. However, such section must, according to the Chief Parliamentary Ombudsman, be designed in a way that does not limit the inmate’s right to spend time in the common facilities during daytime. This is necessary in order to prevent the activity being conducted in a grey zone between isolation and the common facilities. When it came to the conditions in one section in Ystad detention centre, it could be noted that it only comprises two bunks. The detention centre was encouraged to, in consultation with the head office of the Prison and Probation Service, consider whether these bunks should be used for holding inmates.

It is a central issue for the Parliamentary Ombudsmen to monitor how the Prison and Probation Service resolves the issue of allowing inmates in detention centres, who are not subject to restrictions, to be housed in a way that allows for time in the common facilities during daytime. This matter will be addressed in the ongoing enquiry concerning measures to prevent isolation.

Opcat inspections of in-patient psychiatric care and forensic psychiatric care

During this operating year, Chief Parliamentary Ombudsman Elisabeth Rynning conducted an Opcat inspection of the Regional Forensic Psychiatric Clinic in Växjö. On behalf of the Chief Parliamentary Ombudsman, three psychiatric clinics were inspected; Länsakuten at S:t Göran Hospital, Region Stockholm’s Helix Forensic Psychiatric Clinic, and Sahlgrenska Hospital’s emergency ward Östra. The inspections have mainly been confined to the care environment, coercive measures and the transport of persons deprived of liberty.

The Opcat annual report 2015–2017 addresses the issue of “low-stimulus” environments, and states that some management teams at clinics find minimalistic environments to be a necessary element in motivating patients. This is not unopposed, and the experiences gathered from one inspection in June 2018 at Visby Hospital suggest that a low-stimulus environment does not necessarily need to take aim at the physical care environment. Instead, it could involve other types of measures to reduce stimuli. In addition, the inspection in Visby shows that it is possible to achieve a positive care environment if a holistic approach is employed when designing the premises of an organisation. The two inspections carried out in June and September 2018 in the Stockholm area indicate that there is room for improvement within the area of care environment. With regard to the psychiatric clinic Länsakuten at S:t Göran Hospital, the issue is that the clinic appears to be significantly undersized, it emerged that it was originally intended to accommodate 7,000 patients per year, but 23,000 patients sought care there in 2017 and due to problems with local transportation has been forced to provide care to patients to an extent that far exceeds its design. According to Chief Parliamentary Ombudsman Elisabeth Rynning, it can be strongly questioned whether the situation described in the report is in line with the basic requirement that all care is to be provided with respect for the equal value of all people and for the dignity of the individual (ref. no. 5990-2018). The operations at Danderyd Hospital were inspected in June, and it was revealed that the hospital has no access to outdoor exercise areas and that the care environment was perceived during the inspection to be dark, cramped and minimalistic. Furthermore, it emerged that patients felt insecure because they were unable to lock their own rooms. They additionally felt it was uncomfortable to share a room with other patients. The Chief Parliamentary Ombudsman issued a reminder that the Parliamentary Ombudsmen has in previous cases stated that the departure point should be that a patient is given the opportunity to have at least one hour outdoors every day, and she recommended that Healthcare Provision Stockholm County (SLSO), in consultation with the clinic management, review how the care environment can be improved and how to enable daily outdoor access for the patients (ref. no. 3887-2018).

Chief Parliamentary Ombudsman Elisabeth Rynning emphasised after her inspection of Länsakuten that the regions have a responsibility to set up a framework for how the transport of patients to and from their units is achieved. For this reason, Stockholm County Hospital, Healthcare Provision, was encouraged to take measures to address the problems that the staff perceived as prevalent with the Prison and Probation Service’s method of conducting judicial assistance transports. The Chief Parliamentary Ombudsman suggested that it would be logical to exchange experiences with the Prison and Probation Service in this work, thus attempting to design working methods where the patients are treated better in conjunction with transport so as to reduce the stigmatisation they feel, among other reasons. A follow-up report was requested from Stockholm County Hospital, Healthcare Provision with an outline of measures that have been taken to reduce the stigmatisation in conjunction with the transport of patients (ref. no. 16-2019).

During the inspection of Danderyd Hospital, it emerged that there were diverging opinions among the doctors in the matter of whether a detention decision made at Länsakuten psychiatric clinic also applies to the hospital, or if a new decision needs to be made when the patient has arrived. After the inspection of Länsakuten, Chief Parliamentary Ombudsman Elisabeth Rynning concluded that these circumstances raise questions regarding, for example, Region Stockholm’s organisation of its psychiatric in-patient care, the meaning of the term “care facility”, and the scope of a decision concerning detention.

These questions will be investigated by the Parliamentary Ombudsmen within the scope of a specific enquiry (ref. no. 1732-2019).


The annual report 2018/19 raised the question of whether the Health and Social Care Inspectorate is fulfilling its assignment of keeping an automated register of healthcare facilities and units where it is permitted to provide care under the Compulsory Psychiatric Care Act (1991:1128) or the Forensic Mental Care Act (1991:1129), and of units for forensic psychiatric examination (Chapter 2, Section 4, second paragraph and Chapter 7, Section 7 of the Patient Safety Act [2010:659]). It has emerged during the past years that it is still difficult to get an overview of the number of places available for compulsory psychiatric care, which is troubling for a number of reasons.

To follow up on this issue, among others, Chief Parliamentary Ombudsman Elisabeth Rynning decided, within the framework of a case to initiate a dialogue with the Health and Social Care Inspectorate (ref. no. O 5-2018). On her instruction, the Opcat Unit has engaged in dialogue meetings with all six of the supervisory divisions at the Health and Social Care Inspectorate during the first half of 2019. In addition to the safety register, questions have also arisen about how the Health and Social Care Inspectorate, besides supervision, exercises the use of coercive measures within compulsory psychiatric care and forensic psychiatric care. One particular issue was the way in which the Health and Social Care Inspectorate supervises care institutions where there are patients that have been in isolation for a long period, so-called long-term isolated patients. All meetings were recorded through the keeping of minutes. The dialogue with each division and what came up at these meetings will be followed up in the autumn of 2019 through dialogue with the Health and Social Care Inspectorate’s management. The Chief Parliamentary Ombudsman will thereafter make a decision in the case.

Opcat inspections of the National Board of Institutional Care’s youth homes and substance abuse homes

During the operating year, Parliamentary Ombudsman Thomas Norling headed an inspection of the youth home Johannisberg, and the Opcat Unit was instructed by him to inspect two youth homes, Sundbo and Vemyra, and conduct a follow-up inspection of the substance abuse home Fortunagården.

There are several points of contact between the activities of the National Board of Institutional Care and the Prison and Probation Service. As with inmates in the correctional system, residents at one of the National Board of Institutional Care’s institutions are entitled during the daytime to spend time with other residents in the common facilities. In some cases, the National Board of Institutional Care has the right to restrict this right by deciding to separate the resident or provide care in isolation. Care in isolation is to be tailored to the patient’s individual care needs. A case of care in isolation shall be continuously examined and always reviewed within seven days of the latest assessment.

During the inspection of the youth home Johannisberg, it emerged that units can be sectioned off, and in this way it is possible to separate young people who are not considered able to socialise with each other. At the inspection, one of the units had been sectioned off. Only two residents were housed in one section. When talking with one of the young people, it transpired that the sectioning had happened because he was not allowed to interact with one of the residents who was placed in the other section. Following the inspection, Parliamentary Ombudsman Thomas Norling stated that the starting point for care provided at a special youth home is that a resident shall be given the possibility of spending time with other residents in the common facilities. Time in common facilities entails that a resident spends time together with at least two other residents. This right may be restricted through a decision to administer care in isolation, or separation. If the preconditions for such measures are not met, the resident is to have the right to spend time in the common facilitates during the daytime (ref. no. 6204-2018).

Upon inspection of the substance abuse home Fortunagården, representatives from the home said that they lacked the possibility of offering residents care in isolation. The home’s locked unit is divided into two parts, and the residents in each part are kept separate from each other. Parliamentary Ombudsman Thomas Norling stated that it would be logical to view both parts as two units. Residents are generally placed in the smaller intake section when they first arrive at the substance abuse home, and the inspection revealed that such a placement can continue for a relatively long duration. When talking with the staff from the Parliamentary Ombudsmen, one resident indicated that she had been staying alone in the intake section. According to Parliamentary Ombudsman Thomas Norling, such a placement shares similarities with the conditions experienced by a resident receiving care in isolation. If an inmate is placed alone in the arrivals section because she is not deemed to be able to socialise with other residents due to being under the influence of narcotics, this is according to Thomas Norling a case of care in isolation that must be documented in a decision. It is not acceptable for compulsory care to be carried out in a grey zone where it is difficult to assess whether the substance abuse home, in a more or less formless manner, has used the special powers conferred by the Care of Substance Abusers (Special Provisions) Act (1988:870) (ref. no. 5569-2018).

During the inspection of the special youth home Sundbo, the young people at the home said, among other things, that the staff subjected them to unjustified violence. This was in particular the situation described by the young people at one of the youth home’s units (Aspen). Similar claims were heard during an inspection that the Health and Social Care Inspecorate had conducted one year earlier. Over the course of a two-year period, the National Board of Institutional Care had also made five so-called Lex Sarah reports (an obligation on care providers to report mistreatment) concerning serious abuses at the youth home. The youth home management had implemented some measures in an attempt to remedy the situation. Following the inspection, Parliamentary Ombudsman Thomas Norling concluded that the youth home management in November 2018 had not taken sufficient measures to change the situation. For this reason, the National Board of Institutional Care was asked to provide information on what measures had been taken or were planned to ensure that the young people receive safe and secure care.

In its follow-up report, the National Board of Institutional Care concluded that neither the measures taken by the youth home management nor the support initiatives implemented by the responsible operations office had had the desired effect. According to the National Board of Institutional Care, after the Parliamentary Ombudsmen’s Opcat inspection, it was indisputable that there were significant deficiencies in the operation and the Aspen unit has been closed temporarily. Parliamentary Ombudsman Thomas Norling made a decision in the follow-up report case on 30 April 2019 and the decision is presented on page 537.

The National Board of Institutional Care’s work with evaluation and changes to the youth home Sundbo is shining a light on issues that, according to the authority, are also relevant in relation to other substance abuse homes and youth homes. It is therefore necessary for the Opcat Unit to follow up on the ongoing work to prevent those deprived of liberty within the National Board of Institutional Care facilities from being subjected to inhuman or degrading treatment etc.

Opcat inspections of police lock-ups

During the operating year, Parliamentary Ombudsman Cecilia Renfors inspected the lock-up Borlänge and instructed the Opcat Unit to inspect an additional nine police lock-ups, of which four were follow-up inspections. During an inspection of lock-ups, the focus is primarily on finding out how the rights of those deprived of liberty are being safeguarded. This includes their right to food, the ability to take care of their personal hygiene, and time spent outdoors on a daily basis. Another important issue for the inspections is the safety of the detainees. It is not unusual for those people placed in a police lock-up to be in a poor physical or mental state. It is therefore essential that safety assessments are performed on those placed in lock-up. Furthermore, it is important that the detainees are checked on regularly and that this supervision is documented. During the Parliamentary Ombudsmen’s inspections, the physical environments in the lock-ups are also examined.

Upon inspecting the Luleå lock-up, it was noted that during a ten-year period, a high number of suicide attempts had taken place through inmates suspending nooses from fixtures in the holding cells. After the inspection, Parliamentary Ombudsman Cecilia Renfors noted that as far back as 2007, an inmate had attempted to hang himself with a noose that he had attached to the toilet door of a holding cell. Despite this, no changes had been made, and in 2009, at least another four incidents had taken place where inmates had tied nooses to toilet doors. The toilet doors were thereafter used in at least an additional nine suicide attempts during 2010–2014 and 2017. It was only in 2018 that the Police Authority decided that the lock-up cells would be rebuilt. Before the rebuild could commence, two more suicide attempts took place, one of which resulted in a death. According to Parliamentary Ombudsman Cecilia Renfors, it is grave that it took more than ten years for necessary changes to be made, and this delay received severe criticism. Furthermore, it is noteworthy that the stool that is fixed to the wall in the holding cells was not changed in conjunction with the rebuild. This stool has been used during at least three suicide attempts in the Luleå lock-up. Parliamentary Ombudsman Cecilia Renfors has stated that it is essential that the Police Authority benefits from the experience gained from the Luleå lock-up and uses it in its continued work with preventing suicide and other acts of self-harm. This experience should in the first instance be valuable in designing the Police Authority’s lock-up cells (ref. no. O 2-2019).

The Police Authority has decided on supplementary regulations with regard to the equipment in a lock-up cell. A cell shall, as a rule, be equipped with a device that allows the regulation of incoming light along with a blanket, pillow, matrass, mirror, clock and radio. However, there may be cause to limit this equipment, for example, in cases where there is a risk of self-harm. The inspections during the operating year indicate that the holding cells in the vast majority of cases are designed and equipped in accordance with the applicable regulations. In some cases, it has been noted that the lock-up premises are in disrepair, but that they were generally perceived as well-kept. Parliamentary Ombudsman Cecilia Renfors has, however, pointed out that the detainees in some of the lock-ups are not able to regulate the incoming daylight (the Lycksele and Sandviken lock-ups). Furthermore, the inspections show that the safety assessment procedures are followed within the Police Authority. However, some tendencies prove that the supervision is carried out in a perfunctory manner and that the assessments are not properly documented.

With regard to supervision of inmates taken into custody due to intoxication, Parliamentary Ombudsman Cecilia Renfors has made a statement following inspections of the lock-ups in Borlänge, Lycksele, Storuman and Vilhelmina. She pointed out that during the inspection of the Borlänge lock-up, information has emerged to indicate that some of the lock-up staff were under the impression that a person taken into custody due to intoxication is to be held in the lock-up for at least six hours. For this reason, Parliamentary Ombudsman Cecilia Renfors served a reminder that she had previously stressed that the duration of detention is to be as short as possible. A continuous review is to be carried out to check that the conditions for continued detention are met.

The organisation’s thematic focus on transports has led to several statements. With regard to the inspections conducted in 2018, a review of the statements made is presented in the interim report published in June 2019. Among other things, there is a lack of coordination between the Police Authority and the Prison and Probation Service regarding the taking of inmates into custody at police lock-ups during transport stop-offs. A lack of planning in these stop-offs has led to such a strained work situation that the lock-up staff have not been given a reasonable chance to review safety assessments etc. (Värnamo lock-up). Even in other cases, it has been noted that the authority requesting judicial assistance does not hand over information on the detainee to the Prison and Probation Service.

During the inspection of the Borlänge lock-up, it was noted that a number of young people in 2018 and 2019 had been held for several days in the lock-up while awaiting transport. In 2018, seven young people who had been taken into care pursuant to the Care of Young Persons (Special Provisions) Act (1990:52), were placed in the lock-up for two days or more awaiting transport. According to representatives from the lock-up, the reason for the relatively long detention periods was that the Prison and Probation Service was unable to clearly say when a transport could be carried out. According to the representatives from the lock-up, it is not unusual for the Prison and Probation Service to say that a transport will take place on the following day, but then inform them the next day that transport is impossible. Following the inspection, Parliamentary Ombudsman Cecilia Renfors stated that the situation was highly unsatisfactory and she noted that the examination of the documents in February 2019, i.e. almost two years after the possibility of detention was introduced, revealed that a person who had just turned 15 had been placed in lock-up for almost three days. According to Parliamentary Ombudsman Cecilia Renfors, this is unacceptable (ref. no. O 13-2019).

After the inspection of the Lycksele lock-up, Parliamentary Ombudsman Cecilia Renfors stated that the Police Authority has significant work ahead, in terms of improving the conditions for remote supervisory review. Such a review should only be used in exceptional cases. In order to provide the best possible conditions for such a review, it should entail audio and video transmission (ref. no. 7556-2018).

Updated 11/15/2019