26 behaviour. At one of the hospitals, the doorknobs on the inside of the doors to patient rooms were difficult to open, particularly for patients with shaky hands as a result of the side effects of medication or somatic conditions. In a number of the units visited, the conditions in the segregation unit made it difficult to attend to all the patients’ needs, particularly when it was fully occupied. Some of the premises were cramped and inflexible, which made it difficult to be near the patients without appearing invasive. Noise and commotion could lead to increasing unrest and, in some cases, the patients being aggressive towards the staff. Restraint beds in the segregation units increased the risk of patients perceiving segregation as unsafe. Many of the segregation premises visited did not have direct access to outdoor areas. The patients therefore had to be accompanied out of the segregation units by staff, but this was contingent on staff being available. In practice, many patients were not able to spend time outdoors every day.6 Many patients also had limited freedom of movement. A number of the segregation units did not have common rooms. Some of the hospitals had segregation units with access to a communal living room. A high occupancy rate in the segregation units meant that the patients often had to share the time spent in the living room, and were assigned ‘living room time’. As a result, the patients had to spend a lot of time in their rooms. At one hospital, beds had been placed in the common rooms in the segregation unit to increase capacity. NORWEGIAN PARLIAMENTARY OMBUDSMAN National Preventive Mechanism ANNUAL REPORT 2017 Implementation of segregation creates sense of isolation One key finding was that segregation measures were implemented in ways that meant that the intervention clearly resembled isolation or had to be considered isolation. At some hospitals, written procedures or informal practices were identified that indicated that blocking a patient’s door for a few minutes was regarded as ‘part of an administrative segregation decision’. Such coercive measures constitute isolation pursuant to Section 4-8 of the Mental Health Care Act, and can only be implemented in situations where they are absolutely necessary. Patients in segregation units spent a lot of their time alone in their room with little contact with the staff. Segregation was often practised by patients being told to stay in their rooms, but without the door being closed. A number of the patients found such verbal messages humiliating, and said that they felt lonely and needed someone to talk to. Where the staff were during segregation varied. A member of staff often sat outside the door of the patient’s room, generally with the door slightly ajar or closed. In some places, segregation was practised by the patient being left alone in the unit with the door to the common area left open. The patients were then asked to stay in their own rooms as much as possible, while the staff sat in a spot in the common area, from where they could see into the segregation unit. It appeared to be uncommon for the staff to be together with the patient, although the legislation on segregation requires close follow-up and contact with health personnel. 6 By comparison, according to the Mandela Rules, Rule 23 No 1, prisoners shall have at least one hour of exercise in the open air daily. In a number of its reports, the Parliamentary Ombudsman has pointed out that patients in mental health care should also have the opportunity to spend time outdoors every day.