NORWEGIAN PARLIAMENTARY OMBUDSMAN National Preventive Mechanism ANNUAL REPORT 2019 50 We found that the hospitals had very different practices for using ECT based on the principle of necessity. We also found some examples of use that were clearly not in line with the principle of necessity. A balcony for patients in a psychiatric hospital ward. Following the amendments to the law, DIPS – the largest supplier of electronic patient records in the specialist health service – introduced new templates for administrative decisions for e.g. treatment without the consent of the patient and segregation. The specifications in the regulations and changes in the templates are in line with the observations made by the Ombudsman ­concerning the conditions at several hospitals and are ­important for the patients’ legal safeguards. More rigorous oversight of electroconvulsive therapy (ECT) used on grounds of necessity During all visits to hospitals in 2017 and 2018, we ­examined the use of electroconvulsive therapy (ECT) on the basis of necessity. As ECT therapy is considered to be a serious intervention, it is illegal to administer it without the patient’s informed consent.5 In some hospitals, ECT is nonetheless sometimes administered without the patient's ­consent, with ­reference to the provision on the ­principle of ­necessity of the Penal Code. This entails that there must be a danger to the life and health of the patient that cannot be averted in 'any other reasonable manner’.6 The Norwegian Directorate of Health subsequently implemented several measures to strengthen legal safeguards and supervision of the use of ECT based on the principle of necessity. There is a high threshold for situations that could warrant the use of ECT based on the principle of necessity, which was specified in the new guidelines published in 2017.7 In addition, in 2018 the oversight commissions (called Control Commissions) were tasked with supervising the institutions’ decisions on initiating ECT on grounds of necessity.8 Although the principle of necessity would still be very problematic as a basis for such an intrusive treatment against the patient’s will, these measures have contributed to improving the possibilities of oversight. The difference between means of restraint and segregation It has been necessary to point out in several of the visit reports that segregation9 is not a restraint measure, and that the threshold and conditions for using restraint measures and segregation are different. During our visits, we have seen manual restraints being used on several occasions – without a separate administrative decision being made – as a means of initiating and maintaining the segregation of a patient. For instance, several hospitals have employed a practice where patients are taken by force or carried to the segregation unit or their room, as part of a segregation decision. 5 The Patient and User Rights Act Section 4-1 and the Mental Health Care Act Section 4-4 second paragraph. 6 The General Civil Penal Code Section 7. See also the ministry's preparatory works to the Mental Health Act regarding use of ECT warranted by the principle of necessity, Proposition No 11 (1998–1999) to the Odelsting page 108–109. 7 The Directorate of Health (June 2017): National guidelines for the use of electroconvulsive therapy (ECT), page 26–28. 8 The Directorate of Health’s letter to the supervisory commissions in mental healthcare, ‘Behov for styrket kontroll med bruk av elektrokonvulsiv behandling (ECT) uten samtykke’ (The need to improve control measures regarding the use of electro-convulsive treatment (ECT) without consent), 17 April 2018. See also the Directorate of Health’s comments to the Mental Health Care Act S. 4-4 second paragraph, where our findings and assessments are highlighted. 9 Segregration in this context describes a particular form of open area seclusion used in Norway, where patients are segregated from other patients but have healthcare personnel present in the area. The measure is referred to as 'shielding' in Norwegian legislation and may be imposed for up to 14 days at a time.