Places visited by the National Preventive Mechanism in 2011 During the visit in Elbląg, it was noted that although the staff did control the condition of immobilised persons every 15 minutes, this was done only through a peephole. As a rule, the fact of conducting such controls was not recorded and entries in the book of reports were made only when the state of the immobilised person raised concerns. Moreover, a fragment of a recording from the monitoring system, showing how a direct coercive measure is used against a patient, revealed that this patient was immobilised with straps from 10.20 p.m. until 6.00 a.m., yet a staff member recorded in the book of records that the application of this measure ended at 2.10 p.m. Pursuant to § 11(1c) of the Ordinance, a staff member designated by the director of the sobering-up station shall check the physical status of the immobilised person at least every 15 minutes, also when that person is asleep. § 11(1d) stipulates that during the check referred to in paragraph 1c, the staff shall: – assess if immobilisation is correct, and in particular if straps, holds, sheets or straitjacket are not too loose or too tight; – ensure a short release from immobilisation to allow the immobilised person to change position or to alleviate his/her physiological or hygienic needs, at least every 4 hours. When the patient was immobilised, which lasted for almost 8 hours, a staff member personally checked his state only once by entering into the room. In the morning, the patient unbuckled his lower straps, which also was not noticed on time by the staff member. In the situation described above, the requirement that a physician performs medical examination of the patient was not complied with, which is necessary before extending the application of direct coercive measure for over 4 hours, as stipulated in § 11(1b) of the Ordinance. In his response, the director of Elbląg facility informed the Mechanism that its recommendations were implemented by drafting regulations specifying the procedures for applying direct coercive measures, and notifying personnel of the facility, including physicians on duty, about the need to observe the rules for reliable recording of the applied direct coercive measure and physical examination when a patients is go be immobilised for over 4 hours. The information gathered during the visit in Grudziądz establishment has shown that direct coercive measure was applied against one of the patients, namely he was put in a straightjacket and strapped to bed in an unprofessional and sloppy manner. Pursuant to § 19 of the Ordinance, every sobering-up station should have a separate room for persons whose behaviour poses a serious threat to their health or life, or to health or life of other persons staying in the room. The Mechanism considered the fact of strapping a patient to bed in a room not suited for the purpose as ill-treatment, not grounded in the applicable law provisions. This situation should be viewed as unacceptable and leading to cruel, inhumane or degrading treatment. The director of the facility did not have any reservations regarding this position. 119