them to sign the document.289 It is important to obtain informed written consent from the patient at all stages of starting, continuing and changing treatment. Inter-patient violence The European Committee for the Prevention of Torture says in its report that the duty of care which is owed by staff in a psychiatric establishment to those in their charge includes the responsibility to protect them from other patients/residents who might cause them harm. This requires not only adequate staff presence and supervision at all times, but also that staff be properly trained in handling challenging situations/behaviour by patients. The European Committee calls on the Georgian authorities to remedy the above problem.290 As in previous years, inter-patient violence and conflicts still occur at the National Mental Health Centre and Batumi Medical Centre, which is caused by the insufficient supervision by staff. In some cases, patients sustain serious physical injuries. The Group found that conflicts mainly arise after one patient grabs or steals the personal belongings of another patient (e.g., cigarettes or coffee). In addition, the Special Preventive Group believes that one of the most important risk factors of inter-patient violence at the National Mental Health Centre is the fact that acute291 and long-term292 inpatients, as well as persons with mental retardation and other patients are placed together in the 2nd and 7th wards. Safeguards against ill-treatment The system of assessing and reducing the risks posed by patients, the existing practice of documenting and responding to the incidents of violence, the system of controlling the performance of staff and reviewing complaints, as well as provision of information to patients about legal protection mechanisms and their accessability, represent challenges in the psychiatric institutions. It should be noted that the National Mental Health Centre and Batumi Medical Centre have not developed a conflict prevention strategy or detailed instructions for staff. The medical staff of the institutions have not been trained in handling an agitated patient, protection of human rights, use of non-violent de-escalation methods or physical restraint. 289 For example, one of the patients at the National Mental Health Centre confirmed in an interview that he had signed the informed consent form, but according to him, he signed it after doctors told him they would apply to court in case of his refusal and would leave him at the facility for six months. 290 Report (CPT/Inf (2019) 16) of the European Committee for the Prevention of Torture on its visit paid to Georgia on September 10-21, 2018, para. 108, available in English at: <https://rm.coe.int/1680945eca> [last accessed: 17.02.2020]. 291 “Inpatient care for acute cases involves relieving acute psychotic symptoms or treating behavioral or affective symptoms that endanger the life and health of the patient or others." 292 Long-term inpatient care includes inpatient treatment of persons with chronic mental disorders who suffer from severe psychosocial dysfunction and/or prolonged psychotic symptoms (including continuation of treatment of acute cases after inpatient care). 102