Monitoring visits to institutions etc. for adults in 2025

The table immediately below first shows the number of monitoring visits which we carried out to institutions etc. for adults in 2025. This is followed by the numbers of talks we had with inmates, residents, patients etc. and with relatives, social guardians etc. (relatives, guardians, social guardians of persons under a treatment or placement order and patient advisers) in connection with the visits. Under the OPCAT[1], the Ombudsman cooperates with DIGNITY – Danish Institute Against Torture and the Danish Institute for Human Rights (IMR), which participate in monitoring visits, among other things. Therefore, the table also shows the numbers of visits in which DIGNITY and IMR participated. In addition, it shows the numbers of announced and unannounced visits and how many visits were concluded with and without recommendations, respectively.

Below the table is a list of the monitoring visits which we carried out in 2025. Click the individual visit for information about the type of institution etc. visited and any special focus of the visit, whether the visit was announced or unannounced, how many talks we had with inmates, residents, patients etc. and with relatives, social guardians  etc., and whether DIGNITY and/or IMR participated in the visit. This information is followed by a list of any recommendations given to the institution. If the visit caused the Ombudsman to open one or more cases on his own initiative at the same time, this is also stated.

[1] OHCHR | Optional Protocol to the Convention against Torture (OPCAT)

 
NUMBER OF VISITS 28
TALKS WITH INMATES, RESIDENTS, PATIENTS ETC. 213
TALKS WITH RELATIVES, SOCIAL GUARDIANS ETC. 100
WITH PARTICIPATION OF DIGNITY 28
WITH PARTICIPATION OF IMR 13
ANNOUNCED/UNANNOUNCED VISITS 24/4
CONCLUDED WITH RECOMMENDATIONS 28
CONCLUDED WITHOUT RECOMMENDATIONS 0

State prison (two open and two closed units)

Announced visit

Talks with 14 inmates

DIGNITY participated

Recommendations:

  • That the institution’s management, together with the area office, follow the development in the use of forced exclusions from association and analyse the reasons for the development
  • That management follow the development in the number of decisions on imposition of disciplinary cells and the number of disciplinary cell days and, to the extent possible, analyse the reasons for the development, including through comparisons with similar institutions
  • That management ensure that internal instructions on placement in an observation cell are in accordance with the Executive Order on Exclusion of Inmates from Association, Including Placement in an Observation Cell etc., in State and Local Prisons and with the Department of Prisons and Probation’s Information Note of 14 July 2014 on handling of clients under the influence
  • That management draw up guidelines for following up with inmates who are deemed to have been subjected to violence or threats
  • That management, in cooperation with the health unit, seek to uncover the extent of unreported figures in relation to violence and threats among inmates

Forensic psychiatric bed units

Announced visit

Talks with 24 patients and 34 relatives, social guardians etc.

DIGNITY and IMR participateder

Recommendations:

  • That management ensure that treatment plans contain the information required under the applicable rules
  • That management ensure that discharge agreements and coordination plans contain the information required under item 8 of the Guidance Notes on Force
  • That management seek to enter into cooperation agreements with relevant municipalities on discharge of forensic psychiatric patients
  • That management ensure increased focus on comprehensive documentation in the patient record for maintaining forced immobilisation for the duration of the immobilisation period
  • That management ensure increased focus on the permanent guard keeping records at least every 15 minutes on the current condition of the person being forcibly immobilised
  • That management ensure that a belt inspection that has been postponed as an exception because the patient is asleep is carried out as soon as possible after the patient wakes up
  • That management ensure that use of force protocols are completed correctly, including that there is accordance between the use of force protocol and the other records and that the use of force protocol does not give the impression that a belt inspection has been carried out while the patient was asleep
  • That management ensure that the notification requirements under Section 31 of the Mental Health Act are met
  • That management ensure increased focus on follow-up interviews being held and that it appears from the patient record if the patient does not want a follow-up interview as well as the reason for this
  • That management ensure that consent for seclusion in own room is obtained and documented in accordance with the relevant applicable rules and practices
  • That management draw up a policy for handling violence and threatened violence etc. among patients, including for when a police report is to be made and how to follow up with everyone involved
  • That management ensure that the patient screens in the staff rooms are placed in a way that avoids the risk of patient details being read by unauthorised persons

Department of forensic psychiatry

Announced visit

Talks with 18 patients and 24 relatives, social guardians etc.

IMR and DIGNITY participated

Recommendations:

  • That management ensure that any use of private guards – until such legislation on delegation of use of physical force to private actors should enter into force – takes place within the scope of the delegation of actual exercise of authority; cf. the case FOB 2024-12 (in Danish). For information, I attach the Ministry of the Interior and Health’s letter of 17 December 2024 to the Ombudsman and the Ombudsman’s reply of 10 January 2025 to the Ministry
  • That management ensure that long-term manual restraints lasting more than 30 minutes are avoided and that management systematically follow up on the development in the number of long-term manual restraints
  • That management follow the development in the practice of locking patient rooms and regularly consider if the development gives cause for taking any measures
  • That management ensure increased focus on the forced immobilisation record containing separate grounds for starting and maintaining immobilisation with straps
  • That management ensure increased focus on the permanent guard keeping records at least every 15 minutes on the current condition of the person being forcibly immobilised
  • That management ensure that the notification requirements under Section 31 of the Mental Health Act are met
  • That management ensure that follow-up interviews are held as soon as possible after cessation of any forcible measure, including that several forcible measures are only discussed during the same follow-up interview if they are part of the same episode and that it is documented if patient-related circumstances result in possible postponement of a follow-up interview
  • That management ensure increased focus on use of force protocols about ambulatory forced immobilisation containing the correct time for the beginning of the intervention

Forensic psychiatric bed units

Announced visit

Talks with 4 patients and 2 social guardians

DIGNITY and IMR participated

Recommendations:

  • That management ensure that treatment plans contain the information required under the applicable rules
  • That management ensure that discharge agreements and coordination plans contain the information required under item 8 of the Guidance Notes on Force
  • That management seek to enter into cooperation agreements with relevant municipalities on discharge of forensic psychiatric patients
  • That management ensure increased focus on comprehensive documentation in the patient record for maintaining forced immobilisation for the duration of the immobilisation period
  • That management ensure increased focus on the permanent guard keeping records at least every 15 minutes on the current condition of the person being forcibly immobilised, including that the time of the permanent guard’s observations appears and that the records contain an objective description of the patient’s current condition and behaviour
  • That management ensure that a belt inspection that has been postponed as an exception because the patient is asleep is carried out as soon as possible after the patient wakes up
  • That management ensure that the registrations in the use of force protocol do not give the impression that a belt inspection has been carried out while the patient was asleep
  • That management ensure that follow-up interviews are held and documented in accordance with the applicable rules and that it is documented if patient-related circumstances result in possible postponement of a follow-up interview
  • That management ensure that consent for seclusion in own room is obtained and documented in accordance with the relevant applicable rules and practices
  • That the house rules be adjusted so that it does not appear from them that a patient’s activities can be limited to their own room without the patient’s consent if the staff’s instructions are not observed 

Forensic psychiatric bed units

Announced visit

Talks with 24 patients and 5 social guardians

DIGNITY and IMR participated

Recommendations:

  • That management ensure that treatment plans contain the information required under the applicable rules
  • That management ensure that discharge agreements and coordination plans are drawn up according to the applicable rules, including that they contain the information required under item 8 of the Guidance Notes on Force
  • That management ensure increased focus on comprehensive documentation in the patient record for maintaining forced immobilisation for the duration of the immobilisation period
  • That management ensure increased focus on the permanent guard keeping records at least every 15 minutes on the current condition of the person being forcibly immobilised, including that the time of the permanent guard’s observations appears
  • That management ensure increased focus on compliance with the rules on belt inspections, including that belt inspections are only postponed because a patient is sleeping if there is a medical assessment that it would be harmful to wake the patient and that a postponed belt inspection is carried out as soon as possible after the patient wakes up
  • That management ensure that external belt inspections are carried out in accordance with the applicable rules
  • That management ensure that the care staff are aware that they can stop a forced immobilisation when there is no longer a need for maintaining it
  • That management ensure that patients’ social guardians are given any information necessary in order for them to carry out their duties responsibly
  • That management ensure increased focus on the patient record showing if the patient does not want a follow-up interview as well as the reason for this
  • That a body search of a patient solely take place after the patient has given valid consent or on suspicion of medicines, drugs or dangerous objects in the department
  • That washing of patients’ clothes solely take place after the patient has given valid consent or within the scope of Section 2 b(1) of the Mental Health Act
  • That management ensure that use of detection dogs takes place in accordance with the applicable rules
  • That management ensure that seclusion in own room is only used after the patient has given valid consent and that the patient’s consent is obtained and documented in accordance with the relevant applicable rules and practices
  • That the house rules be adjusted so that it does not appear from them that a patient’s activities can be limited to their own room without the patient’s consent if the staff’s instructions are not observed

Forensic psychiatric bed units

Announced visit

Talks with 13 patients and 6 relatives, social guardians etc.

IMR and DIGNITY participated

General own-initiative case opened on the application of Chapter 5 b of the Mental Health Act

Recommendations:

  • That management ensure that treatment plans are drawn up in due time and contain the information required under the applicable rules
  • That management ensure that discharge agreements and coordination plans contain the information stated in item 8 of the Guidance Notes on Force
  • That management continue to ensure focus on preventing and reducing use of force
  • That management ensure that use of force protocols are completed in a way where the involved staff can be identified
  • That management ensure increased focus on comprehensive documentation in the patient record for starting forced immobilisation and maintaining it for the duration of the period, including that it contains separate grounds for starting and maintaining immobilisation with straps
  • That management ensure increased focus on the permanent guard keeping records at least every 15 minutes on the current condition of the person being forcibly immobilised, including that the time of the permanent guard’s observations appears and that the records contain an objective description of the patient’s current condition and behaviour
  • That management ensure that follow-up interviews are carried out and documented in accordance with the applicable rules and that it appears from the patient record if a patient does not want a follow-up interview as well as the reason for this
  • That management ensure that seclusion in own room is only used after the patient has given valid consent and that the patient’s consent is obtained and documented in accordance with the relevant applicable rules and practices
  • That management draw up a policy for handling violence and threatened violence etc. among patients, including for when a police report is to be made and how to follow up with patients involved

Forensic psychiatric bed units

Announced visit

Talks with 19 patients and 14 relatives, social guardians etc.

DIGNITY and IMR participated

Recommendations:

  • That management ensure that treatment plans contain the information required under the applicable rules
  • That management ensure that discharge agreements contain the information required under item 8 of the Guidance Notes on Force
  • That management ensure increased focus on comprehensive documentation in the patient record for maintaining forced immobilisation for the duration of the immobilisation period
  • That management ensure increased focus on the permanent guard keeping records at least every 15 minutes on the current condition of the person being forcibly immobilised
  • That management ensure increased focus on compliance with the rules on belt inspections, including that a belt inspection that has been postponed as an exception because the patient is asleep is carried out as soon as possible after the patient wakes up
  • That management ensure that the registrations in the use of force protocol do not give the impression that a belt inspection has been carried out while the patient was asleep
  • That management ensure that external medical assessments of the need to maintain a forced immobilisation are added to the patient’s record with information on whether there is deemed to be basis for continued forced immobilisation as well as the grounds for this
  • That management ensure that follow-up interviews are held and documented in accordance with the applicable rules, including that it is documented if a patient does not want a follow-up interview
  • That management ensure that seclusion in own room is only used after the patient has given valid consent and that the patient’s consent is obtained and documented in accordance with relevant applicable rules and practices

Detention facility

Unannounced visit

DIGNITY participated

Recommendations:

  • That management ensure that there are no plastic bags in the garbage bins in lavatories that are used by the detainees in detention cells or holding cells
  • That management ensure that all relevant items in the detention reports are completed, including in relation to the handing out of a leaflet with guidance on the right to complain, among other things

Detention facility

Unannounced visit

Talk with one detainee

DIGNITY participated

Recommendations:

  • That management ensure that all relevant items in the detention reports are completed correctly, including in relation to the handing out of a leaflet with guidance on the right to complain, among other things
  • That management ensure that checks on detainees are conducted in accordance with the rules of the Executive Order on Detention and the Detention Proclamation
  • That management ensure that a doctor is summoned without undue delay in connection with detention placement in accordance with the rules of the Executive Order on Detention and the Detention Proclamation

Detention facility

Unannounced visit

DIGNITY participated

Recommendations:

  • That the Western Copenhagen Police ensure that the cell call system in the detention facility functions correctly
  • That management ensure that all relevant items in the detention reports are completed correctly, including that the names of the police officers who carried out a search are stated in the detention report
  • That completed detention reports are stored in their entirety by the police
  • That management ensure that checks on detainees are conducted in accordance with the rules of the Executive Order on Detention and the Detention Proclamation
  • That management ensure that a doctor is summoned without undue delay in connection with detention placement in accordance with the rules of the Executive Order on Detention and the Detention Proclamation

Forensic psychiatric bed units

Announced visit

Talks with 4 patients and 3 relatives, social guardians etc.

IMR and DIGNITY participated

Recommendations:

  • That management ensure that treatment plans contain the information required under the applicable rules
  • That management ensure increased focus on comprehensive documentation in the patient record for maintaining forced immobilisation for the duration of the immobilisation period, including that it contains separate grounds for starting and maintaining immobilisation with straps
  • That management ensure increased focus on the permanent guard keeping records at least every 15 minutes on the current condition of the person being forcibly immobilised, including that the time of the permanent guard’s observations appears
  • That management ensure increased focus on compliance with the rules on belt inspections, including that belt inspections are only postponed because a patient is sleeping if there is a medical assessment that it would be harmful to wake the patient and that a postponed belt inspection is carried out as soon as possible after the patient wakes up
  • That management ensure that external belt inspections are carried out in accordance with the applicable rules
  • That management ensure correct completion of the use of force protocol, including that the use of force protocol does not give the impression that a belt inspection has been carried out while the patient was asleep
  • That management ensure increased focus on follow-up interviews being held and that it appears from the patient record if the patient does not want a follow-up interview as well as the reason for this
  • That opening and checking of a patient’s mail solely take place on suspicion of medicines, drugs or dangerous objects in the department or after the patient has given valid consent and that the opening take place in the presence of the patient to the extent possible
  • That washing of patients’ clothes solely take place within the scope of Section 2 b(1) of the Mental Health Act or after the patient has given valid consent
  • That management ensure that the house rules contain the general rules that have been set out by management and that apply in the unit
  • That management ensure continued attention to discretion in relation to patient details when the staff are working in the shared environment 

Forensic psychiatric bed units

Announced visit

Talks with 9 patients and 4 relatives, social guardians etc.

DIGNITY participated

Recommendations:

  • That management ensure that treatment plans contain the information set out in the applicable rules
  • That management ensure that discharge agreements and coordination plans are drawn up according to the applicable rules, including that they contain the information required under item 8 of the Guidance Notes on Force
  • That management ensure increased focus on comprehensive documentation in the patient record for starting forced immobilisation and maintaining it for the duration of the period
  • That management ensure increased focus on the permanent guard keeping records at least every 15 minutes on the current condition of the person being forcibly immobilised
  • That management ensure increased focus on compliance with the rules on belt inspections, including that belt inspections are only postponed because a patient is sleeping if there is a medical assessment that it would be harmful to wake the patient and that a postponed belt inspection is carried out as soon as possible after the patient wakes up
  • That management ensure that use of force protocols are completed correctly on forced immobilisation, including that there is accordance between the use of force protocol and the other records, that the use of force protocol does not give the impression that a belt inspection has been carried out while the patient was asleep and that it is possible to identify the involved staff
  • That management ensure that – to the extent that manual restraint is used as a separate forcible measure – the use of force protocol contains the relevant information required under the applicable rules
  • That management – in cases where electrostimulation is carried out based on consent – ensure that the patients’ voluntary, informed consent is obtained and documented in accordance with the applicable rules
  • That management ensure that the notification requirements under Section 31 of the Mental Health Act are met
  • That management ensure that consent for routine urine tests is obtained and documented in accordance with the applicable rules
  • That management ensure that the house rules contain the general rules set out by management on the patients’ access to visits and, in that connection, that the rules on visits are clarified in accordance with the stated practice
  • That management ensure that consent for seclusion in own room is obtained and documented in accordance with the relevant applicable rules and practices

Detention facilities

The police station in Nuuk
The municipal bailiff in Kulusuk
The municipal bailiff in Kuummiit
The police station in Tasiilaq
The police station in Ilulissat
The municipal bailiff in Oqaatsut

Announced visits

Talks with 2 remand prisoners

DIGNITY participated

Own-initiative case opened with the Ministry of Justice concerning remand prisoners’ stays in police detention facilities and municipal bailiffs’ checking on detainees

Own-initiative case opened with the National Police concerning the police’s use of atemi strikes

Recommendations to the Commissioner of Police in Greenland:

  • That management ensure that the furnishing of detention rooms during remand prisoners’ stays is in accordance with the rules
  • That management ensure that the local guidelines for checking on detainees in ‘Greenland Police’s Action Card on detention placements in Greenland’ clearly state when and how to check on detainees and who is responsible for the individual checks, including for documentation of the conducted checks
  • That management ensure that there is a fixed procedure for how to document municipal bailiffs’ use of detention facilities and that the procedure is complied with
  • That management ensure that the cell call system in the detention facility in Tasiilaq works
  • That management ensure that procedures are drawn up for ongoing self-monitoring of the physical conditions and the electronic equipment in the police detention facilities, including in relation to cell call systems, camera surveillance and fire detectors working, and not least that shortcomings that affect the detainees’ safety are remedied as soon as possible  
  • That management ensure that detainees in detention facilities with cell call systems are informed clearly of how the buttons on the cell call system work
  • That management ensure that municipal bailiffs receive one-on-one training in accordance with the orders of the day on the municipal bailiffs’ tasks, training and equipping
  • That management ensure that all municipal bailiffs have received first aid training
  • That management consider drawing up a written leaflet with the information set out in Section 17 of the Executive Order on Detention, which can be handed out when a detainee leaves the detention facility
  • That management ensure correct and comprehensive documentation in detention cases, including in relation to notification of the custodial parent and the social services department in cases with minors and in relation to detainees receiving guidance in accordance with the rules in the Executive Order on Detention when they leave the detention facility
  • That management ensure that detainees are checked on in accordance with the applicable rules and that the checks are documented
  • That management ensure focus on the immediate summoning of a doctor or an ambulance if a detainee harms or tries to harm themselves, in accordance with the relevant guidelines
  • That management again initiate dialogue with the healthcare sector about handling of detainees who are suicidal
  • That management enter into dialogue with the social guardian coordinator in order to ensure a sufficient number of social guardians 

Correctional institutions

The Correctional Institution in Tasiilaq
The Correctional Institution in Nuuk (unit A)
The Correctional Institution in Ilulissat
The Correctional Institution in Aasiaat
The Correctional Institution in Qaqortoq

Announced visits

Talks with 27 inmates

IMR and DIGNITY participated

Own-initiative case opened with Greenland’s Prison and Probation Service concerning the placement of male and female inmates in the same unit in the Correctional Institution in Nuuk

Recommendations to the management of Greenland’s Prison and Probation Service:

  • That the management of Greenland’s Prison and Probation Service, together with the local correctional institution managements, follow the development in the number of placements in disciplinary solitary confinement in the correctional institutions and analyse the causes of the development
  • That management consider drawing up written guidelines for searches of inmates that involve undressing
  • That management implement a fixed procedure for screening of whether inmates are suicidal on arrival
  • That management consider the possibilities of offering new inmates in all correctional institutions a health check or health talk on arrival
  • That management ensure increased focus on compliance with the Prison and Probation Service’s instructions on medicines management, including removal of expired medicines and documentation of medication given, as well as draw up written instructions for the officers on handling of PRN medication
  • That management continue on an ongoing basis to pay attention to opportunities for providing occupation, including education, for inmates who do not have access to occupation outside the correctional institution 

Recommendation for the Correctional Institution in Nuuk: 

  • That management ensure special attention to hierarchies between inmates with, respectively, West and East Greenlandic backgrounds in order to implement measures that can prevent and reduce harassment, bullying and exploitation among the inmates.

Recommendation for the Correctional Institution in Tasiilaq::

  • That management ensure that inmates who are placed in solitary confinement as a disciplinary measure are not subjected to other restrictions than the restrictions that follow from the applicable rules.

The visit involved the remand unit and a unit with disciplinary and solitary confinement places, the association unit and the treatment unit

Announced visit

Talks with 18 inmates

DIGNITY participated

Recommendations:

  • That management – to the extent that double cells are used – focus on ensuring a suitable composition of inmates in the cells, including in relation to the inmates’ condition
  • That management ensure that the prison’s instructions and practice for summoning a doctor on placement in an observation cell are in accordance with the Executive Order on Exclusion from Association
  • That management clarify the prison’s internal instructions for searching and for changing of clothes on placement in an observation cell so they are in accordance with the stated practice and the Executive Order on Exclusion from Association
  • That management ensure correct completion of the security cell reports, including that they contain information on the prison’s deliberations on medical checks and that they are accurate in relation to whether a medical check has been carried out
  • That management ensure that security cell reports contain documentation of an ongoing assessment of the need for the kind of immobilisation used on the detainee
  • That the inmates are made aware that violence and threats are reported to the police
  • That management ensure that inmates can make cell calls in order to go to the toilet, and that both inmates and staff know that it is fully acceptable that inmates make cell calls in order to go to the toilet
  • That management ensure that the spokesperson system is administered in accordance with the applicable rules
  • That management focus on ensuring that the rules on duration of occupation are met
  • That management on an ongoing basis pay attention to opportunities for providing more occupation options in the remand unit
  • That management ensure that work refusal is handled in accordance with the applicable rules
  • That management ensure that the house rules are brought in accordance with applicable rules

Remand unit

Announced visit

Talks with 4 inmates

DIGNITY participated

Recommendations:

  • That management ensure that the provisions in the house rules on the right to complain are brought in accordance with the applicable rules, including that guidance is given to the relevant extent on the possibility of judicial review, and that the house rules otherwise reflect the actual conditions in the remand unit
  • That management ensure increased focus on the remand unit’s uniformed staff knowing the remand unit’s procedures regarding contact with healthcare staff and division of healthcare responsibilities
  • That management ensure that the rules on dental care for inmates are met
  • That management continue on an ongoing basis to pay attention to opportunities for providing cell work and shopwork

Remand unit

Announced visit

Talks with 7 inmates

DIGNITY participated

Recommendations:

  • That management ensure use of interpreters to the necessary extent
  • That management ensure that the provisions in the house rules on the right to complain are brought in accordance with the applicable rules, including that guidance is given to the relevant extent on the possibility of judicial review, and that the house rules otherwise reflect the actual conditions in the remand unit
  • That management ensure that the rules on dental care for inmates are met
  • That management continue on an ongoing basis to pay attention to opportunities for providing cell work
  • That management look into the possibilities for offering additional education to the inmates

Local prison

Unannounced visit

Talks with 14 inmates

IMR and DIGNITY participated

Recommendations:

  • That management ensure that staff knock on inmates’ cell doors before opening – unless for control purposes
  • That management ensure use of interpreters to the necessary extent
  • That management consider changing the visiting times so that there are more available when it is possible to have visits from children attending school
  • That management look into the possibilities for offering additional education to the inmates
  • That management ensure that the inmates are offered occupation in accordance with the Executive Order on Occupation
  • That management look into the possibilities of handing out inmates’ sleep medication later in the evening in order to take the inmates’ circadian rhythm into account

Bed units

Announced visit

Talks with 11 patients and 8 relatives, social guardians etc.

DIGNITY participated

Recommendations:

  • That management ensure that follow-up interviews are carried out and documented in accordance with the applicable rules, including that several forcible measures are only discussed during the same follow-up interview if they are part of the same episode, and that it can be documented which specific forcible measures the follow-up interview concerns
  • That management ensure that additional follow-up interviews are offered and that it appears from the patient record if the patient does not want an additional follow-up interview
  • That management ensure that use of force protocols are completed in a way where the involved staff can be identified
  • That management ensure increased focus on comprehensive documentation in the patient record for starting forced immobilisation
  • That management ensure increased focus on the permanent guard keeping records at least every 15 minutes on the current condition of the person being forcibly immobilised, including that the time of the permanent guard’s observations appears
  • That management ensure correct completion of the use of force protocol, including that the use of force protocol does not give the impression that a belt inspection has been carried out while the patient was asleep
  • That a search of a patient’s body or belongings solely take place after the patient has given valid consent or on suspicion of medicines, drugs or dangerous objects in the department, and that staff do not monitor when the patients open their mail without legal basis