compulsory psychiatric care 71 the Compulsory Psychiatric Care Act (1991:1128) must be conducted so that it meets the necessary safety requirements.4 Furthermore, the care provider must conduct systematic patient safety work. This means that the care provider must plan, lead and check the instructions and routines used in its work.5 Stockholm Forensic Psychiatry Care, Section South (Helix) has a special observation unit where patients are initially placed when they are admitted to the facility. The unit has four patient rooms with floor-mounted beds equipped with restraining devices, which patients must sleep on. Patients who find the bed uncomfortable may instead sleep on a mattress on the floor. As there are no tables or chairs, patients must eat their meals in bed or sitting on the floor. The patient rooms have glass walls so that staff can monitor the patients. In conversations with the Parliamentary Ombudsmen’s employees, patients stated that it was a breach of their privacy that the blinds were never pulled down when they were on the toilet or showering. Following the inspection, the Chief Parliamentary Ombudsman stated that it is unacceptable for a patient’s bed to be constantly equipped with a belt and that it is unacceptable for patients to have to eat their meals in bed or sitting on the floor. The premise for the clinic should be to offer care that does not result in unnecessarily abuse of the individual. The Chief Parliamentary Ombudsman recommended the care provider to review how the care environment can be improved in order to ensure that the patients who stay there receive good care and are treated with respect for their human value.6 During the inspection of Sahlgrenska University Hospital’s Emergency Psychiatric Unit at Östra Hospital (Sahlgrenska emergency unit), it emerged that the emergency unit has a significantly larger patient base than was originally intended for, especially during on-call time. Furthermore, it emerged that patients need to stay there overnight despite the fact that the facility officially does not have places for care. The majority of the emergency unit’s patient admissions can be described as troublesome and resource-intensive, and who would have been admitted to an emergency substance abuse clinic if there were one in Göteborg. On occasion, 30 patients, some of them with relatives, have stayed on the premises at the same time. The staff, who have a joint responsibility for the so-called normal monitoring of patients, has then not been able to monitor sufficiently the patients and any monitoring made is not documented. Following the inspection, the Chief Parliamentary Ombudsman stated that on occasions when there is a high influx of patients, it is therefore particularly important that there are clear protective measures in order to reduce the risk of someone suffering harm. The Chief Parliamentary Ombudsman recommended that Västra Götaland Region takes measures to ensure 4 See Section 15 a of the Compulsory Psychiatric Care Act (1991:1128). 5 See Chapter 3, Section 1 of the Patient Safety Act (2010:659). 6 See the Parliamentary Ombudsmen’s report p. 16, ref. no. O 3-2019. Patients having to eat in bed or when sitting on the floor is unacceptable