58 We have seen examples of inmates being escorted for admission to a mental health care institution, such as a local acute psychiatric ward, only to be returned to the prison immediately or after only a few days. A review of administrative decisions, logs and reports shows that many of the inmates are transferred back and forth between the prison and specialist health care institutions. After a short stay in a mental health care institution, the inmate often returns to solitary confinement in prison without treatment. Figures from the Directorate of the Norwegian Correctional Service show that the majority of transfers from prisons to mental health care institutions are of less than three days’ duration.188 These problems were also observed by the CPT when it visited Norway in 2018. The delegation was particularly concerned that it once again observed major problems in transferring ­inmates with severe mental health problems to ­psychiatric hospitals (especially for longer-term treatment). The CPT stressed that it was not uncommon for the inmates concerned to be returned after only a few days from an acute psychiatric ward to the prison, where they did not receive the care and treatment they required. In particular at Oslo Prison, several severely mentally ill inmates had been sent back and forth between the prison and a psychiatric health care institution.189 There are a number of circumstances under which inmates with psychiatric disorders are either not ­transferred to the specialist health services or are returned to the prison very soon. One barrier seems to be the capacity of the mental health care services. In some cases, we have been told that the inmate must wait to be transferred to a psychiatric inpatient ward because of a shortage of places. Meanwhile, the inmate is left to serve under a regime that entails a high degree of isolation and thus a risk that his or her condition deteriorates and becomes irreversible. During some of the NPM’s visits, we have found examples of inmates who have been returned directly to a prison security cell on account of serious concerns that they are dangerous or suicidal. Because of the duty of confidentiality and the risk of ­identification, we have not described these cases in the individual reports from our visits. Special Report to the Storting Document 4:3 (2018–2019) We pointed out in one report that: ‘The NPM was particularly concerned that an inmate was discharged from hospital and returned to the prison despite the specialist health care service having stated at the same time that the inmate’s severe mental health ­problems could be exacerbated by the prison ­environment. The prison administration stated that the inmate in question needed treatment and follow-up that neither the prison nor the prison health service could provide’. 190 In connection with visits to mental health care ­institutions, we have been told by several therapists that one of the reasons why inmates have been returned has been that the hospital has disagreed with the diagnostic assessments of the referring specialist. Patients are discharged because the criteria for admission to ­compulsory mental health care are deemed not to have been met. According to several sources, behaviour or symptoms assessed as psychotic or ‘suspected ­psychosis’ by the referring specialist and the prison staff abated shortly after the inmate was admitted to hospital.191 This meant that the patient was therefore not assessed as being psychotic or suffering from other acute mental illness. Our reason for concern is that inmates are admitted to hospital for symptoms that may be caused by solitary confinement, and which are abated when the isolation ceases, only to be returned to what caused these symptoms in the first place. In connection with some of our visits to high security prisons, we have found inmates serving under an administrative decision on forced medication in prison. It is a condition for such a decision that the individual in question is subject to compulsory mental health care. This is, in turn, conditional on the patient suffering from a severe mental health disorder. Furthermore, it is a condition for compulsory mental health care and forced medication that the patient is ‘clearly incompetent to give consent’ (the Mental Health Care Act as amended with effect from 1 September 2017). The above ­conditions, if they are met, indicate that the inmate suffers from severe functional impairment for the period the administrative decision is meant to be in force. This raises concerns about whether the inmate should be transferred to the health services and not serve time in prison.192 188 Directorate of the Norwegian Correctional Service, Reply to query from the Parliamentary Ombudsman concerning the need for information for the special report to the Storting, letter of 20 February 2019 to the Parliamentary Ombudsman. 189 Council of Europe: Committee for the Prevention of Torture (CPT), Report to the Norwegian Government on the visit to Norway 2018, CPT/Inf (2019) 1, paragraph 97. 190 The Parliamentary Ombudsman’s report after its visit to Tromsø Prison, 10–12 September 2014. 191 During its visit to Norway in 2018, the CPT also pointed out that an inmate was discharged and sent back to prison for the same reason; see Council of Europe: Committee for the Prevention of Torture (CPT), Report to the Norwegian Government on the visit to Norway 2018, CPT/Inf (2019) 1, paragraph 80. 192 See also the Norwegian Directorate of Health’s interpretative statement to the Attorney General of Civil Affairs of 3 February 2010 on compulsory mental health care without admission for prison inmates. 59 8.4 Solitary confinement of minors and young inmates Solitary confinement of young inmates is a highly intrusive measure that is potentially very harmful. Minors and young inmates have a high prevalence of mental health problems and learning difficulties, and many come from backgrounds of neglect and trauma in the form of maltreatment and abuse. Normally, the brain of young adults continues to develop until they are well into their twenties, and the risk of harmful effects is greater, including in those aged over 18 years. See also the more detailed description of the increased risk of harmful effects of solitary confinement on minors and young adults in section 4.1 Harmful effects in particularly vulnerable individuals. Our findings and figures provided by the Directorate of the Norwegian Correctional Service show that both minors and young adult inmates in Norwegian prisons are held in isolation, however, sometimes for long periods. According to the Directorate, there were 14 incidents of ­exclusion for three days or more of inmates under 18 years during the period 2014–2018. In eight of these instances, the exclusion lasted for five days, and the longest duration was 15 days. Figures from the Directorate show that several inmates between 18 and 23 years are excluded from the company of other inmates for prolonged periods. During the period 2015–2018, 11 inmates between 18 and 23 years of age were subject to 14 administrative decisions on exclusion for 42 days or more. Four of these decisions were for more than 100 days, and one covered a period of more than two years (760 days). Seven of the exclusions were on the inmate’s request, six of them in Åna Prison. The other exclusions were based on administrative decisions in the prison. Prolonged solitary confinement of young inmates puts their normal development and rehabilitation at risk. The risk is present even if the individual is over 18 years of age (see section 4.3 Harmful effects in ­particularly vulnerable individuals). There is no breakdown by age available for inmates who have served in isolation for up to 42 days. In one prison we visited, we found that many of those who chose to isolate themselves were under 23 years of age. Inmates and staff told us that one of the reasons was that some individuals wanted to be shielded from other inmates, often because of anxiety disorders. Among others, we met a young inmate who clearly suffered from mental health problems, who had been in de facto solitary confinement for a long time. Main findings Some inmates are particularly prone to end up in solitary confinement and more vulnerable to the detrimental effects of isolation than others. Vulnerability to isolation can be a result of severe mental health problems, young age, war or other traumas in the past and language problems, among other things. In many prisons, there is too little awareness of such risk. We have observed inmates whose functional abilities have gradually deteriorated in most areas while in solitary confinement. Some of them clearly had an unmet need for health care. We have also met inmates who have chosen solitary confinement because they felt the communal sections to be unsafe. Minors and young people are isolated, sometimes for long periods. This gives grounds for concern considering the risk isolation entails for the cognitive development of young individuals and their possibility of being reintegrated into society and turning their back on crime. Some who are held in isolation clearly suffer from severe mental disorders. Several of them have been in solitary confinement for very long periods, in some cases for months and even years. It is often difficult to get them admitted to specialist health care institutions. In some cases, they are discharged from psychiatric inpatient wards after a brief stay without receiving treatment, and returned to prison where some of them continue to be held in solitary confinement. The gradual escalation of prison security measures in response to undesirable behaviour appears to have very poor effect on some inmates. It often results in a very strict level of security; whereby meaningful human contact becomes difficult and the individual concerned becomes even more isolated.