Annual Report 2015 - Spain’s National Preventive Mechanism it was communicated that staff of the Directorate-General of Justice and Cooperation had travelled to the centre to check, among other things, the response protocol for the use of restraint measures. Following visual inspections, and the statements made by members of the Civil Guard over the course of the legal proceedings initiated as a result of the images, four detentions were ordered (three security guards and one former inmate of the facility), with temporary release later granted, on account of the recording and dissemination of the video, according to the report by the Public Prosecutor. Death in the Es Pinaret facility (Balearic Islands) §283, 284 AR 2014 192.  Following the death of a minor in the Es Pinaret facility (Balearic Islands) due to a fire in his bedroom, proceedings were initiated with the Department of Social Services and Cooperation of the Autonomous Community of the Balearic Islands. The conclusions of the NPM following its visit in February 2015 had been directed to this Department months before. Information was requested from said Department on the results of the investigation into the causes of the fire, as well as from the internal investigation which had been carried out in the facility into whether or not the actions of the staff aligned with the response protocols for emergency situations. 193.  Various proceedings were also begun in relation to residential facilities which provide health, social or rehabilitation services. Deaths of 8 residents in the Santa Fe facility (Zaragoza) 194.  A complaint was processed resulting from the deaths of eight residents in the Santa Fe facility in Zaragoza in a fire allegedly caused by a resident who would be incapable of doing so. Information was requested from the competent Department of the Government of Aragon and from the Local Council of Zaragoza about the inspections carried out in the residence, the fate of the other residents and the evacuation procedure followed. It was established that the residence did not meet the conditions around suitability and legality, but remained open because the public administrations involved had not taken the appropriate measures. This case is currently before the courts. Two Recommendations were made to the stated administrations in order that they intensify and improve the surveillance in these residences and that they apply appropriate sanctions where there are inconsistencies, which have been accepted by both administrations. Death in Ciempozuelos (Madrid) §397 AR 2014 195.  Follow-up was also continued regarding the case of the death of an inmate at the hands of another in the Ciempozuelos Psychiatric Facility (Madrid), where the NPM carried out a follow-up visit in 2015. Use of restraints §340, 341, 342 AR 2014 196.  In May 2015 the proceedings initiated in 2014 with the Department of Health and Social Affairs of Castilla-La Mancha were concluded, with the Recommendation being accepted to regulate or, at least, create a protocol around the use of restraints and physical or pharmacological containment under the principles of last resort, periodic reviews, informed consent and medical prescriptions. This Administration also accepted the Recommendations about the need to create a protocol for the supervision and investigation system in relation to injuries with uncertain Investigation into injuries 132

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