2.2 Hospitals and psychiatric institutions and facilities 2.2.1 Introduction During the reporting year, the commissions visited 23 psychiatric hospitals and other medical facilities, whereby the commissions monitored and controlled mainly psychiatric wards (19). After a visit by Commission 1 in a special medical facility for internal medicine and neurology, the mandate for commission visits was explicitly disputed. The NPM refuted this restriction of its monitoring authority. An informational letter sent in October 2014 to all Governors by the Federal Ministry of Health made it clear that within the meaning of Section 4 (1) of the OPCAT monitoring by the NPM indeed includes all medical facilities and hospitals and their departments and wards, as it cannot be excluded a priori that patients in these facilities could not be subject to restrictions of freedom (restraints, coercive measures). Comprehensive mandate clarified The commissions found that both doctors and other hospital staff are committed and endeavour to ensure treatment and care that is beneficial for the patients’ welfare. Compliance with human rights guarantees and with the conditions for coercive treatment defined in legislation and case law as a last resort should furthermore create trust between patients and their professional caregivers in psychiatry and establish a basis for fruitful therapeutic relationships. This challenging work in psychiatric institutions and facilities or wards is often significantly complicated by inadequate resources, time pressures, often out-dated and practically unalterable structural conditions, as well as deficits in the atmosphere of the facility. Patients are overwhelmed by these conditions, as well as by forced inactivity due to restraints, which endanger a positive therapeutic environment or make it impossible. Furthermore, if patients’ dignity is not respected causing shame, if they are overpowered by well-meant care measures without being able to articulate their needs, a climate is created that is susceptible to verbal and physical attacks and that can sometimes be reflected in violence against professional caregivers. Structural deficits impede work The frequency of admissions, restraints and isolation that occur against the patient’s will or involuntary administration of medication is – from a human rights perspective – an indicator of quality for stationary psychiatric treatment. Persons who have had experience with psychiatric institutions have been reporting for years that different facilities and different wards dealt with their rights differently. One hears the same from medical and care staff that have worked in different facilities and faced different treatment cultures and attitudes. Despite a uniform legal framework, the point where a failure of treatment is assumed and coercive measures are taken apparently seems to depend on the respective situation and the decisions of the persons involved. Restrictions of movement, however, must always be “subsidiary", i.e. used only as a last resort. In the tug-of-war between De-escalation management indispensable 38