63 Visits in 2019 Humana Child Welfare Service East, Jessheim and Hol gård 4–6 September 2019 The NPM visited Humana East, Jessheim section and Hol gård section in September 2019. Visits were made to both places at the same time. Both Jessheim section and Hol gård section are longterm units for adolescents aged 13 to 18, placed there due to serious behavioural problems. There had been a high staff turnover in both units in 2018 and 2019, both at employee and management level. Instability and the high staff turnover rate could pose a risk of insecurity and lack of continuity for the adolescents. It could also mean that some of the staff did not have the training and expertise required. We found that more training was needed to ensure that everyone working in the units has the knowledge and skills needed to safeguard the target group that the institution is approved for. Many changes and a lack of management presence pose a risk of inadequate continuity in, and overview of, the running of the units and the work with the adolescents. During the visit, we noticed, that important routines and procedures had not been sufficiently implemented. We also found that there was lack of records and an inadequate overview of the use of coercion and intrusive measures, such as returning an adolescent to the institution against his or her will after an attempted escape. The administrative decisions and records contained several instances of inadequate descriptions of the sequence of events before the use of coercion, which measures had been attempted or why it was necessary to make a decision on the use of coercion. We also found that incorrect information had been provided in decisions on the use of physical force. Humana Child Welfare Service East In addition, we discovered that illegal use of coercion had been used repeatedly in situations of acute danger. Management did not appear to have a complete overview of these situations and we did not find that adequate measures had been implemented to prevent future situations where adolescents could be subjected to illegal use of coercion. This is not in accordance with the duty to prevent the use of coercion. The report also looks at how weak language skills could affect legal safeguards. An overall assessment of language as a vulnerability and risk for the adolescents, assessments on how to handle this risk, as well as documentation of the need for an interpreter were lacking. The overview and documentation of situations where the institutions had asked for police assistance were also inadequate. Humana has been asked to provide information about how it is following up the recommendations made by the Ombudsman by 30 January 2020.