the national board of institutional care 55 During the inspection of the special residential home for young people Långanäs, the Parliamentary Ombudsmen’s employees noted that the segregation room in one of the departments was located on a different floor to the department. For this reason, staff had to take individuals down a flight of stairs when segregating them. On some occasions, the staff had even carried individuals. Following the inspection, the Parliamentary Ombudsman found that such a method of transfer obviously entails considerable physical risks for everyone involved, not least the young persons being segregated. For this reason, the Parliamentary Ombudsman called on the National Board of Institutional Care to take measures to ensure that segregation can take place in a way that is safe and dignified for both the individuals and staff members.9 Also, during the inspection of the special residential home for substance abusers Gudhemsgården, the Parliamentary Ombudsmen’s employees noted that some of the segregation rooms were inadequately set up.10 During the inspection of the special residential home for young people Långanäs, it was noted that the decisions stated that a nurse or doctor “consented” to the segregations, and that, via two consecutive decisions, a young person had been segregated for seven and a half hours. Following the inspection, the Parliamentary Ombudsman stated that the role of the health and medical care staff is not to take a position on the measure taken. Furthermore, the Parliamentary Ombudsman stated that the legislation provides no room for a segregation to continue for longer than four hours. A segregation that in practice is extended by staff directly making a new segregation decision when the deadline has expired is, therefore, unacceptable. When the four hours have passed, the National Board of Institutional Care must, therefore, break the segregation and let the young person return to their department. Only if it turns out that the individual continues to be disruptive, should a new segregation decision be considered.11 Use of ”pinning down” During several inspections, the Parliamentary Ombudsmen’s employees noted the fact that the National Board of Institutional Care’s staff use physical restraint through “pinning down” individuals when enforcing segregation decisions. Following an OPCAT inspection in 2017 of the special residential home for young people Tysslinge, the Parliamentary Ombudsman decided to investigate a situation where the staff had pinned down a young person. According to Chapter 2, Section 6 of the Instrument of Government, each and every individual is protected against forced physical intervention. This protection may be limited by law. In the view of the Parliamentary Ombudsman, 9 See the Parliamentary Ombudsmen’s report p. 15 and 16, ref. no. O 57-2019. 10 See the Parliamentary Ombudsmen’s report p. 5, ref. no. O 58-2019. 11 See the Parliamentary Ombudsmen’s report p. 16, ref. no. O 57-2019. It is unacceptable to extend a four-hour period of segregation with a new decision