40 Some staff had misunderstood the rules on coercive measures and incorrectly believed that an administrative decision was not necessary when patients were physically restrained (i.e. held by manual control) for a short period as a form of ‘self-defence’ when they behaved in an uncontrolled manner. Another misunderstanding was that it was not necessary to make an administrative decision on physically restraining a patient in connection with segregation, even if the patient physically resisted. The clinic used a medicine as a coercive measure that had a duration of action lasting several days. Coercive measure can only be used in emergency situations, and the use of prolonged duration of action medicine is problematic. Sandviken had also made an abnormal number of administrative decisions on isolation compared to other hospitals. It was also pointed out that all of the segregation units included isolation cells. Bergen Hospital, Sandviken psychiatric clinic NORWEGIAN PARLIAMENTARY OMBUDSMAN National Preventive Mechanism ANNUAL REPORT 2018 This meant that isolation as a coercive measure were readily available and increased the risk of them being used. Many decisions on segregation were also implemented in isolation cells, thereby lessening the distinction between coercive measures and segregation for the patients and staff. Although the clinic made good efforts to ensure reliable figures on the use of coercive measures, there was limited reflection on possible causes of the high and increasing figures. The findings indicated low willingness at the institution to critically reflect on its own practices, particularly to what degree attitudes, conduct, and practices affect the use of coercive measures. A number of patients who had been medicated against their will had experienced unpleasant side effects or had been forced to take high doses of medication over long periods. The NPM underlined that forced medication must be limited to what is strictly necessary, and that the beneficial effect must clearly outweigh the disadvantages of the measure. Many patients felt that they had not received enough information about the side effects of the medications they were being administered. An NPM review of the decisions on forced medication revealed several shortcomings in terms of how the decisions were reasoned. The clinic stated that Electroconvulsive treatment (ECT) had been performed on nine patients on grounds of necessity in the period 2016–2018. (i.e. without informed consent in a life-threatening situation). Cases were found in which it appeared doubtful that ECT was the only satisfactory treatment option available to avert acute risk of harm to the patient. In a number of cases, ECT had been performed repeatedly without an assessment of necessity being conducted each time. Few patients felt that they had received sufficient information about their rights during their stay. Nor had the patients been given a routine offer of an evaluation interview after being subject to invasive coercive measures, as stipulated in legislation.