patients. This concept also aims to thus minimise the number of fixations. The Commission found the concept of internal differentiation to be altogether convincing. It is also worth mentioning the comprehensible prison rules that were displayed in the acute psychiatry corridor, as well as the daily and weekly schedule. This helps to make a stay in the clinic transparent and structured. Recommendations of the Joint Commission and the reaction of the Hamburg Authority for Health and Consumer Protection The indications of possibilities to complain were inadequate in all three wings that were visited. Corresponding information sheets should be made available in all the wings. The patients only had the internal possibility to use opinion cards to submit their concerns to the responsible complaint manager. The respective wings receive regular feedback on the content of the complaints concerning them. The Commission does not consider this to be sufficient by itself. Reaction: A circular letter to all wings of the specialist departments for psychiatry and psychotherapy of the hospital would ensure that any such indications are displayed visibly in each wing. Distributing them had been less successful in practice in the view of the specialists since these often got lost during accommodation. During the inspection of the gerontological psychiatric wing, the Commission became aware of a patient who was suffering from frontal lobe dementia, who according to the assistant medical officer had been permanently fixed for ten days (with a two-day interruption) because of causing a risk to himself and to others. This took place at the beginning with the consent of his daughter, and later with a court order. There was no constant and direct supervision by an officer. Instead, the patient was checked by the staff on an hourly basis. The Commission spoke to the daughter, who happened to be present. She appeared to be very concerned, and complained of the permanent fixation of her father. She went on to state that no physical physiotherapy activities were being carried and that she therefore feared that her father would suffer irreversible muscle loss. The assistant medical officer, as well as the head nurse, largely justified the permanent fixation by stating that, because of his symptoms, the patient had shown extremely aggressive conduct towards the staff and that there was no other way to ensure that he was taken care of. The Commission urgently recommended to examine the question of the need for fixation very frequently. It particularly considers constant supervision of the patient (direct supervision by an officer) to be indispensable. Until the fixation is ceased, the Commission furthermore considered physiotherapeutic exercise to be necessary in order to compensate for the loss of mobility. 70