72 Special Report to the Storting Document 4:3 (2018–2019) Medical ­personnel must see to inmates in isolation at the time of placement in isolation, and on a daily basis thereafter, and must provide prompt medical assistance and treatment.220 Inmates in isolation should be assessed by medical personnel with special training in how to perform mental health assessments.221 Any adverse effect on the inmate’s physical or mental health must be reported to the administration immediately. The medical personnel must advise the prison administration if they consider it necessary to terminate the measure for medical reasons.222 They must also have the authority to review the involuntary exclusion from social ­interaction of an inmate to ensure that such exclusion does not exacerbate the inmate’s medical condition or mental or physical disability.223 Medical personnel should also examine the physical surroundings of inmates in solitary confinement, including the hygiene and cleanliness of the cell, temperature, lighting conditions and ventilation, and the inmate’s possibility of physical activity.224 10.1 Organisation of prison health services 10.2 Notification of medical personnel The municipal authority in the district where the prison is located is responsible for providing inmates with primary health services, while the regional health trusts are responsible for offering specialist health services.225 Notification of the health service shall ensure that it can provide proper health care, that any injuries suffered in connection with detainment or transfer to a restrictive unit or security cell are identified, and that the inmate’s health does not deteriorate as a result of solitary ­confinement. It is especially important to ensure immediate medical assessment and care of individuals in an acute mental crisis, for example entailing a risk of suicide. One possible measure can be to transfer the inmate to a mental health institution, but other medical assistance without transfer to a hospital can also be relevant. The assessment and care should be given without delay. Our experience from visits to prisons shows that the fact that the organisation of the health service varies from prison to prison has consequences for the follow-up and care of inmates in solitary confinement. While several nurses and doctors are often available in large prisons, small prisons often depend on emergency units in local hospitals or doctors on rotation duty who seldom visit the prison. It can be an advantage if ­doctors who work with the prison health service also get some of their practice outside the prison with a view to professional development and keeping updated. At the same time, it is important that the inmate is followed up by a member of staff who is updated about the special health issues experienced by ­inmates.226 Doctors who only sporadically work in prison ­environments will be less equipped to identify and treat detrimental health effects caused by isolation. 220 221 222 223 224 225 226 227 The Execution of Sentences Act states that a doctor must be notified of exclusion without undue delay.227 As regards the use of a security cell or restraint bed, the Act states that ‘insofar as this is possible’, a medical opinion shall be obtained and taken into account when use of such coercive measures is being considered. Unlike in the case of exclusion, the Act does not require a doctor to be notified when an inmate is placed in a security cell. This does, however, follow from the current guidelines to the Act, as amended.228 Despite the requirement for notification of a doctor, it is usually a health service nurse that is notified. If an inmate is placed in a security cell outside the prison health service’s office hours, the health service is usually not notified until the following day. The Parliamentary Ombudsman has criticised this practice in several reports.229 The Nelson Mandela Rules, Rule 46(1); The European Prison Rules, Rules 43.3 The UN Special Rapporteur on Torture’s report to the UN General Assembly, 2011, A/66/ 268, paragraph 100. The Nelson Mandela Rules, Rule 46(2). The Nelson Mandela Rules, Rule 46(3). The UN Special Rapporteur on Torture’s report to the UN General Assembly, 2011, A/66/ 268, paragraph 101. The Health and Care Services Act Section 3-9 and the Specialist Health Services Act Section 2-1 For an overview of available healthcare services, see the Norwegian Directorate of Health (2017). Annual Report 2017. The Execution of Sentences Act Section 37 seventh paragraph. Human rights standards are based on medical personnel being informed of all use of solitary confinement; see the Nelson Mandela Rules, Rule 46, and the European prison Rules, Rule 43.2. 228 Directorate of the Norwegian Correctional Service (2002). Guidelines to the Execution of Sentences Act and its Regulations, section 38.7. Revised version of 15 March 2019. 229 See, inter alia, the Parliamentary Ombudsman’s report after its visit to Åna Prison, 13–15 November 2017, p. 37 ff. 73 The professional ethics of medical personnel Medical personnel supervising inmates who are held in solitary confinement must recall that they are tasked with following up the inmate as a patient and that they shall not partake in any ­decision on the use of solitary confinement. ­Medical personnel are only tasked with safe­ guarding the patient’s health and welfare in accordance with the ‘primum non nocere’ principle of avoiding harm to the patient. In one prison, we found that a doctor from the accident and emergency unit had recommended that an inmate should continue to be strapped to a restraint bed, in conflict with his role as medical personnel. Similar findings were made during visits to two other prisons. Medical personnel should therefore always introduce themselves as medical personnel and clearly inform the inmate as a patient of their role and responsibility. According to Section 38 second paragraph of the Execution of Sentences Act ,’insofar as this is possible, a medical opinion shall be obtained and taken into account in considering whether a decision shall be made to use a security cell or a restraining bed’. This wording can give the impression that a doctor should be present and involved in the decision on whether to use ­coercive measures. Note: The Parliamentary Ombudsman’s report from a visit to the Skien branch of Telemark Prison, 2–4 June 2015, p. 30. The Parliamentary Ombudsman’s report from a visit to Stavanger Prison 16–18 August 2016, pp. 33–34. 10.3 Medical follow-up of inmates in solitary confinement Inmates in solitary confinement are in a ­particularly ­vulnerable situation that requires careful and ­independent follow-up by the health service. This is both due to the potentially harmful effects of being isolated and because the inmate has no possibility of contacting the health service directly. Some inmates are in a state of health that prevents them from requesting help. The health service therefore plays a decisive role in relation to these inmates. In addition to caring for the health of the inmate, the health service’s outreach activities also have a preventive effect.230 The health service’s supervision and presence can help to prevent possible integrity violations. According to human rights standards, the health service shall look in on inmates in solitary confinement at least once every day. There is no such requirement in Norwegian ­legislation.231 Pursuant to the Execution of Sentences Act, the Correctional Service shall notify medical ­personnel of some forms of isolation (see above), but the responsibility of medical personnel to follow up inmates in isolation is neither regulated by law nor regulation. In a guide to health and care services for prison inmates, the Directorate of Health has issued guidelines to medical personnel on follow-up of inmates in solitary confinement.232 The Directorate of Health recommends that medical personnel ‘look in on inmates held in isolation when there are medical reasons for supervision. This can be when requested by the inmate, or when information from the Correctional Service or others suggests that there is a need for supervision’. 230 Council of Europe: Committee for the Prevention of Torture (CPT), Extract from the 3rd General Report, Health care services in prisons, 1993, CPT/Inf (1993) 12, paragraph 30. 231 Directorate of the Norwegian Correctional Service (2002). Guidelines to the Execution of Sentences Act and its Regulations, section 38.7. Revised version of 15 March 2019. According to these guidelines, inmates in security cells or restraint beds shall, insofar as it is possible, be attended to by medical personnel at least once a day. In the case of inmates who are excluded from the company of other inmates, the guidelines state that the prison doctor ’is encouraged to look in on the inmate at the soonest opportunity’, if there is information to indicate that the inmate is ill or otherwise needs medical assistance. 232 The Norwegian Directorate of Health (2013). Veileder for helse- og omsorgstjenester til innsatte i fengsel (‘Guide to health and care services for prison inmates’), p. 44.