Annual Report 2019 psychiatric centres. At the same time, there was an increase in the number of vulnerable target individuals. These include detainees with a minor mental impairment or those suffering from psychological disorders or drug addiction. There was also a relatively older target group who suffered from somatic problems and there were more detainees with a combination of psychiatric and somatic problems. Quality of performance of duties In the NPM’s annual report for 2017–2018, the Inspectorate of Justice and Security, which is part of the NPM, reported on an investigation into the quality of the performance of duties within the prison system. The investigation found that the majority of prison staff had insufficient time to perform their regular duties within penitentiary institutions properly. A lack of staff and consequently lack of detainee supervision undermines internal safety. Staff also stated to the investigators that they faced more aggression from detainees and that the number of aggressionrelated incidents had risen. The issues of inadequate internal safety and the lack of staff do not yet seem to have been resolved in 2019. The Commissions of Oversight, which are part of the NPM, found that conflicts among detainees and the use of violence against staff resulted in placement into solitary confinement and transferral more often. In addition, there was an increase in the number of emergencies recorded. The Commissions also noted that the recruitment of new staff is not an easy task. In addition to experience and vigilance, service-mindedness and understanding are prerequisites for the quality of work in penitentiary institutions. In view of staff ageing, rejuvenation of the workforce is urgently required. In addition to thematic and incident investigations, the Inspectorate of Justice and Security also conducted nine site visits to penitentiary institutions and detention centres in 2019. The purpose of a site visit includes maintaining contact with the location and obtaining location-specific information directly from the source. The Inspectorate of Justice and Security aims to visit all penitentiary institutions and detention centres every three years. Incident investigation The Inspectorate of Justice and Security, which is part of the NPM, investigated an incident in which a man randomly stabbed a passenger in the Amsterdam metro. The purpose of the investigation was to obtain an insight into how the various bodies involved in this case treated this man and what lessons can be learned. In its investigation, the Inspectorate concluded, among other things, that the organisations concerned failed to get a proper grip on the man and the opportunities for doing so were underused. Additionally, the Inspectorate concluded that the man had not been properly prepared for his return to society during his detention at Vught Penitentiary Institution. Even though the problems and the associated risks had been identified during his detention, they had been insufficiently taken into consideration when determining the procedure following his detention. This concerned a civil procedure, even though a parallel criminal procedure was ongoing. The Inspectorate established that it was not clear who was responsible for the perpetrator and that there was limited contact between the parties concerned. 4 Table of conte