26 As example, we found a description in a decision that an inmate had repeatedly banged his head so hard against the floor in a police custody cell and subsequently in a security cell that he sustained visible head injuries. The inmate said that he wanted to die and asked to speak to a psychiatrist or a psychologist. Despite several telephone conversations with the accident and emergency unit, the doctor on call decided not to come and attend to the patient in question, but recommended over the phone to the corrections officer that the inmate be placed in a restraint bed. The accident and emergency unit did not follow up and attend to the patient while he was in restraints, despite being informed of the fact that he was vomiting due to his head injuries. In another case, an inmate with known and extensive trauma due to sexual abuse over many years, was placed in a restraint bed following an attempt to harm himself after being placed in a security cell. According to the administrative decision, the prison’s health service believed there was a major risk to life and health, and efforts were made to transfer the inmate to the specialist health service. After the health service closed, the inmate was supervised by a doctor from the accident and emergency unit, who ­concluded that the inmate did not wish to be in prison. The doctor confirmed to the inmate that he would remain in restraints until further notice. Our visits and review of documents have uncovered many weaknesses in the supervision provided by medical personnel. These are in contrast to the rules applicable to the mental healthcare service requiring continuous supervision by nursing staff when patients are placed in restraints.27 NORWEGIAN PARLIAMENTARY OMBUDSMAN National Preventive Mechanism ANNUAL REPORT 2019 Most inmates are transferred to the restraint bed from a security cell, like this one. A decision regarding the use of restraints in compulsory mental health care can only be made by a doctor who is an approved specialist, or a clinical psychologist with the relevant practice and further education set out in the regulations. The decision can be appealed to an oversight commission (called Control Commission) independent of the hospitals.28 The oversight commission must at its own initiative revise all decisions regarding restraints.29 There is increasing recognition in the mental healthcare service that self-harm and suicidal tendencies should not be met with coercive measures such as restraint beds, as this increases the risk of coercion being used rather than reducing the behaviour one wishes to prevent. The role of doctors in connection with decisions to use restraints must be limited to advising against using such measures if there are health reasons for doing so. Our review shows that there were several instances where medical personnel ­recommended using a restraint bed. In some ­cases, the medical personnel also stated that supervision by medical personnel was ­unnecessary as the prison staff carried out continuous ­supervision. 27 The Mental Health Care Act Section 4-8 fourth paragraph. 28 The Mental Health Care Act Section 4-8 fifth paragraph. 29 The Control commission’s case processing, Circular, the Directorate of Health, 22 November 2016.