25 Selected topics from 2017 where a person’s autonomy is already limited, the European Court of Human Rights (ECtHR) takes a strict view of measures that further limit people’s autonomy.4 The implementation of segregation measures that provide so little opportunity for human contact that they, in practice, constitute isolation pose a high risk of inhuman and degrading treatment. Human rights standards in mental health care stipulate that isolation cannot be regarded as a therapeutic measure, but only a coercive measure.5 Coercive measures must only be used as a last resort and if they are the only way of preventing patients from inflicting harm to themselves or others. The UN Convention on the Rights of Persons with Disabilities has recommended that member states discontinue the use of isolation in legislation and in practice. The scope of segregation The use of segregation was extensive in a number of the hospital departments visited by the NPM. Segregation appeared to be an integral part of the treatment regime at some of them, in that a large proportion of the available beds were in segregation units. At one hospital, the number of beds in the segregation units accounted for almost 30 per cent of all beds. Such a high proportion of segregation beds in itself entails a risk that the threshold may be low for using segregation. It was consistently found that the grounds for administrative decisions on segregation were inadequately documented. The grounds given for segregation being considered necessary were often not sufficiently detailed, and the inadequate grounds also made it difficult for patients to have the administrative decisions reviewed in connection with complaints. The review showed that the administrative decisions often made reference to agitated behaviour, treatment purposes etc., without this being linked to concrete incidents or circumstances. A number of patients were subject to segregation to prevent them from embarrassing themselves in relation to the other patients, often referred to as ‘bringing shame on themselves'. Given that the patients were committed, there often appeared to be a low threshold for acceptable behaviour. Unlawful measures were also identified, such as the routine segregation of substance abuse patients without individual assessments. Other measures, such as the segregation of voluntarily admitted patients in cases where it was not documented that the patient had been informed about their right to discharge themselves, is also problematic. In a number of decisions, no reference was made to whether segregation was implemented as a treatment measure in the interest of the patient or out of consideration for other patients. The findings make it clear that segregation is a difficult mix of use of force and treatment. The fact that there were restraint beds in several of the segregation units visited reinforced the impression of segregation being a coercive measure. Physical conditions in the segregation units Segregation measures were often implemented in dedicated segregation units. They consistently had a sterile feel, and the staff and patients at several of the units visited referred to them as being prison-like. The patient rooms were generally painted white with no decoration or pictures on the walls. The rooms had no furnishing apart from a bed and sometimes a table and a chair. It is not clear why all the rooms are furnished with a minimum of furniture and sensory impressions. Recent research does not support the assumption that segregation rooms with a minimum of furnishing reduces mental symptoms or violent 4 Munjaz v United Kingdom, Application no. 2913/06, 17 July 2012, section 80: ‘...when a person’s personal autonomy is already restricted, greater scrutiny [will] be given to measures which remove the little personal autonomy that is left.’ 5 CPT, ‘Means of restraint in psychiatric establishments for adults (Revised CPT Standards)’ 21 March 2017, page 2. Also see the recommendation of the Council of Europe’s Committee of Ministers, Rec (2004) 10, Article 27 no 1: ‘Seclusion and restraints should only be used (...) to prevent imminent harm to the person concerned or others, and in proportion to the risk entailed.’ In an international context, ‘seclusion’ mainly appears to mean that the patient is locked in a room alone.