Annual Report 2012: Spain’s National Preventive Mechanism tance of external security personnel is requested. When preventive separation from the group is applied an educator is always with the minor. In the 2011 An­ nual Report it states that no means of restraint were used that year (personal physical fixation, rubber baton, physical fixation or temporary separation from the group) and in 2012 preventive separation was used as a means of restraint on two occasions, namely on the 7th of June and the 25th of November. This informa­ tion in respect to 2011 and 2012 was confirmed by the female minors interviewed. During the inspection visit of the facilities at the «Teresa de Calcuta» center, the file of an adolescent who died at the center was examined A suggestion was made to the Community of Madrid to have protocols drafted regarding the simultaneous use of means of restraint and provisional solitary confinement 120 152. As mentioned, according to the 2011 Annual Report of the «Teresa de Cal­ cuta» center, separation from the group was used 317 times, of which 105 was as a preventive solitary confinement measure. During the inspection visit to that center, the file of a minor who died there of sudden cardiac arrest at dawn on Saturday, July 9th 2011, while serving a weekend custodial measure, was exam­ ined. At the time he was admitted to the center he suffered several episodes of «anxiety attacks» and a situation of conflict with the security personnel, as a re­ sult of which he had to be overpowered twice by applying means of physical and mechanical restraint and provisional solitary confinement in a room, where he apparently remained alone and shackled for an indeterminate period of time, without surveillance or the presence of educational or security personnel, pass­ ing away in said room. In the file there is no evidence that a physician, psycholo­ gist or psychiatrist examined the minor at the time of admission or when it was resolved to apply the restraint and provisional solitary confinement. There are no clinical notes by a professional who may have examined the adolescent at that moment or that certify that the symptoms he had corresponded to anxiety. No request was made for a medical assessment of the symptoms, in accordance with appropriate medical practice. As a result of the death preliminary proceedings were initiated by a Court of First Instance and Magistrates’ Court of Arganda del Rey, in which it was resolved to provisionally stay and shelve the proceedings, due to lack of evidence that the actions taken by staff of the center could be the cause of the death. At present, the center has a daily observation Record in each module where it was confirmed that a psychologist or educator passes by to speak to a minor in separation at least once every three hours and the doctor visits the mi­ nor every day. In the interviews with educators, it was noted that they do not have formal training in crisis intervention and that the psychologists do not intervene unless the educator wishes a posteriori to consult them regarding an incident and receive feedback, or if it is discussed at a coordination session. In order to prevent that an incident similar to the one described occur again in the future, the Ombudsman Institution has suggested to the Ministry for the Presidency, Justice and Spokesperson of the Community of Madrid (Consejería de Presidencia, Justicia y Portavocía del Gobierno) that protocols be drafted re­ garding the simultaneous use of means of restraint, such as physical restraint, mechanical fixation and provisional solitary confinement on minors in custody in centers for juvenile offenders. These protocols must carefully determine the manner in which staff members should act in these cases, and if necessary, reTHE OMBUDSMAN OF SPAIN