Sweden: Visit 2021
CPT/Inf (2021) 20 | Section: 1/27 | Date: 30/07/2021
The main objective of the sixth periodic visit to Sweden was to review the measures taken by the Swedish authorities in response to the recommendations made by the Committee after previous visits. In this connection, particular attention was paid to the safeguards against ill-treatment of persons in police custody and the material conditions, regime and health care service in prisons and immigration detention. The delegation also examined the treatment, conditions and legal safeguards offered to psychiatric patients and residents of homes for young persons.
The Committee is pleased to report that the conclusion reached by the CPT after the 2015 visit – namely that persons deprived of their liberty by the Swedish police run little risk of being physically ill-treated – remains fully valid.
However, as regards the fundamental legal safeguards against ill-treatment by the police, namely the right of detained persons to inform a close relative or another third party of their situation (notification of custody), to have access to a lawyer, and to have access to a doctor, the Committee is concerned to observe remaining shortcomings regarding their implementation.
As on previous visits, the delegation found conditions of detention in all the police establishments to be on the whole fully adequate for the maximum periods of police custody (respectively, 96 and 8 hours).
Establishments for foreign nationals deprived of their liberty under aliens legislation
The delegation visited, for the first time, two closed migration detention centres run by the Swedish Migration Agency, in Åstorp and Ljungbyhed. The delegation did not receive any allegations of ill-treatment by staff; most of the foreign nationals interviewed indicated that the overall atmosphere in both centres was relaxed.
Material conditions in the two detention centres visited were of a high standard, including well-furnished and equipped day/recreational areas. The Committee recommends to further develop the offer of activities for foreign nationals who spend prolonged periods in detention centres. In particular, they should be offered some work and education/vocational training, preferably allowing them to acquire skills that may prepare them for reintegration in their countries of origin upon return.
As regards health care, the Committee calls upon the Swedish authorities to take measures to improve significantly the provision of health care to foreign nationals detained at Åstorp and Ljungbyhed Detention Centres (and, as applicable, in other detention centres), including ensuring adequate access to psychiatric care and psychological assistance.
The Committee is concerned by the fact that, despite its long-standing recommendation, foreign nationals detained pursuant to aliens legislation could still be held in prisons. The CPT must stress once again that, in those cases where it is considered necessary to deprive persons of their liberty under the aliens legislation, they should be accommodated in centres specifically designed for that purpose, offering material conditions and a regime appropriate to their legal situation.
During the 2021 periodic visit the CPT’s delegation focussed its attention on remand imprisonment and especially on the issue of restrictions. The delegation visited, for the first time, three remand prisons, in Helsingborg, Trelleborg and Ystad.
The CPT’s delegation received virtually no recent and/or credible allegations of deliberate physical ill-treatment of prisoners by staff in any of the prisons visited. Most of the inmates interviewed spoke positively about the staff, the general atmosphere was relaxed, and prison officers appeared to be generally professional and well-trained.
The Committee regrets to note that there is still no substantive improvement on the entire approach to restrictions for remand prisoners in Sweden and once again calls upon the Swedish authorities to take decisive steps to ensure that restrictions on remand prisoners are only imposed in exceptional circumstances which are strictly limited to the actual requirements of the case and last no longer than is absolutely necessary.
The regime for prisoners subjected to restrictions remained very impoverished. The regime for remand prisoners not subjected to restrictions was somewhat better, the main difference being that they had more work opportunities. The Committee reiterates its call upon the Swedish authorities to radically improve the offer of activities for remand prisoners. The aim should be to ensure that all such prisoners are able to spend at least 8 hours per day outside their cells, engaged in purposeful activities of a varied nature: work, preferably with vocational value; education; sport, recreation/association.
The Committee notes problems with securing an adequate access to medical consultations (both by general practitioners and by specialists, including psychiatrists and dentists) in the prisons visited and is also concerned that, despite the Committee’s long-standing recommendations on this subject, medical screening on arrival was still often delayed by up to 72 hours.
The delegation carried out first-time visits to the North Stockholm Psychiatric Clinic, the Regional Forensic Psychiatric Clinic in Karsudden, and the Regional Forensic Psychiatric Clinic in Sala.
The delegation received no allegations of any form of ill-treatment by staff in the psychiatric hospitals visited. On the contrary, most of the patients interviewed spoke positively of the staff, especially ward-based staff.
Living conditions in the hospitals visited were generally of a very good or excellent standard and provided a positive therapeutic environment. Staffing levels on the wards were sufficient to provide the necessary treatment and care.
The treatment available was based on an individualised approach, involving the drawing up of a written treatment plan for each patient (with the participation of the patient concerned) and its regular review.
The recourse to means of restraint (including seclusion) did not appear excessive in the hospitals visited and was well documented. However, the Committee is concerned to note that the practice of doctors authorising (or confirming) recourse to means of restraint by telephone, without actually seeing and examining the patient, has not stopped, despite the Committee’s recommendation on the matter following the 2015 visit.
As regards safeguards in the context of involuntary hospitalisation, the Committee reiterates its serious misgivings that in Sweden involuntary hospitalisation of a psychiatric patient continues to be construed as automatically authorising treatment without his/her consent. Despite the Committee’s repeated recommendations, the Swedish authorities have not taken measures to introduce a procedure whereby all psychiatric patients are placed in a position to give their free and informed consent to medical treatment and, if they require to be treated against their will, appropriate safeguards are put in place.
Homes for young persons
The CPT’s delegation visited, for the first time, the Sundbo Home for Young Persons in Fagersta and revisited the Bärby Home for Young Persons in Uppsala, first visited by the CPT in 2003.
The majority of the young persons interviewed by the delegation spoke positively about the staff. However, the delegation received a single allegation of physical ill-treatment, in Sundbo Home, where a staff member had allegedly punched a young person in the face and kicked him in the ribs.
Material conditions varied between the different units of the Homes but were generally of a good standard and offered a positive environment, despite the specific secure arrangements.
Staffing levels at both Homes appeared to be satisfactory to provide the care required; furthermore, the delegation gained a generally positive impression of the daily regime offered to young persons.
Based on the interviews with young persons, the staff, and the examination of records, the delegation gained the impression that the use of seclusion and separate care was not excessive in either of the Homes visited.
A. The visit, the report and the follow-up
1. In pursuance of Article 7 of the European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (hereinafter referred to as “the Convention”), a delegation of the CPT carried out a visit to Sweden from 18 to 29 January 2021. The visit had originally formed part of the Committee’s programme of periodic visits for 2020 but had to be postponed due to the temporary interruption (from March to July 2020) of the CPT’s visiting activities caused by the Covid-19 pandemic. It was the Committee’s sixth periodic visit to Sweden.
2. The visit was carried out by the following members of the Committee:
– Jari Pirjola, Head of delegation
– Vincent Delbos
– Ömer Müslümanoğlu
– Elsa Bára Traustadóttir
– Chila Van Der Bas.
They were supported by Borys Wódz (Head of Division) and Dalia Žukauskienė of the CPT’s Secretariat, and assisted by:
– Olivera Vulić, psychiatrist, former Chief of the Centre for Mental Health in Podgorica, Montenegro (expert)
– Nadia Alves (interpreter)
– Maria Hemph Moran (interpreter)
– Gerd Elisabeth Mattsson (interpreter)
– Louise Ratford (interpreter).
3. The list of police, immigration detention, prison, juvenile and psychiatric establishments visited by the Committee’s delegation can be found in the Appendix to this report.
4. The report on the visit was adopted by the CPT at its 105th meeting, held from 28 June to 2 July 2021, and transmitted to the Swedish authorities on 30 July 2021. The various recommendations, comments and requests for information made by the Committee are set out in bold type in the present report. The CPT requests the Swedish authorities to provide within six months a response containing a full account of action taken by them to implement the Committee’s recommendations and replies to the comments and requests for information formulated in this report.
 See https://www.coe.int/en/web/cpt/-/the-cpt-visits-fran-1 and https://www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-announces-periodic-visits-to-ten-countries-in-2021.
 The previous periodic visits took place in May 1991, February 1998, January/February 2003, June 2009 and May 2015. In addition, an ad hoc visit was carried out in August 1994. The CPT’s reports on these visits, as well as the responses of the Swedish authorities, have been made public at the request of the Swedish authorities and are available on the Committee’s website (https://www.coe.int/en/web/cpt/sweden). It is noteworthy that, as from 2016, Sweden has adopted an “automatic publication procedure” i.e. a general request to publish all future CPT’s visit reports and responses of the Swedish authorities.
B. Consultations held by the delegation and co-operation encountered
5. In the course of the visit, the delegation held consultations inter alia with Sweden’s four Parliamentary Ombudsmen (Elisabeth Rynning, Per Lennerbrant, Thomas Norling and Katarina Påhlsson) and staff of the OPCAT Unit of the Office of the Parliamentary Ombudsmen (National Preventive Mechanism).
Further, at the end of the visit, the delegation presented its preliminary observations to Morgan Johansson, Minister for Justice and Migration.
6. The delegation enjoyed excellent co-operation from the Swedish authorities, both prior to and during the 2021 periodic visit, despite the extraordinary circumstances caused by the pandemic of Covid-19.
Invariably, the delegation was granted rapid access to the places visited (including the ones not notified in advance) and was able to speak in private with persons deprived of their liberty, in compliance with the provisions of the Convention. Further, the delegation was given all the necessary documentation and additional requests for information made during the visit were promptly met.
The CPT wishes to express its particular gratitude for the efficient assistance provided in this context by the Committee’s Liaison Officer, Ms Signe Öhman from the Ministry of Justice.
C. Sweden’s response to the Covid-19 pandemic in places of deprivation of liberty
7. It must be stated from the outset that the CPT has serious reservations about certain aspects of the management of the Covid-19 pandemic in all types of closed institutions visited. In particular, the delegation noted the lack of systematic testing of both the detained persons (and patients) and staff, and the fact that most of the staff did not wear masks even when in close contact with persons deprived of their liberty (see also paragraphs 69 and 92 below).
In the Committee’s view, the aforementioned practices exposed persons deprived of their liberty (including psychiatric patients), many of whom had health conditions making them more vulnerable, to the avoidable degree of risk of getting very ill and maybe even dying of Covid-19.
While the CPT appreciates that Sweden has adopted its own epidemiological approach based on the freedom of personal informed choice, it wishes to stress that, unlike for the general population, persons held in places of deprivation of liberty have an only limited choice between exposure or lack of exposure to the infection risk. The Committee also reiterates the primary role of health care personnel in protecting and preventing Covid-19 exposure of their patients.
Further, the CPT wishes to refer to the Statement of principles relating to the treatment of persons deprived of their liberty in the context of the coronavirus disease (COVID-19) pandemic, issued on 20 March 2020, in which the Committee stressed inter alia that the relevant WHO guidelines must be respected and implemented fully in all places of deprivation of liberty.
The CPT would welcome the Swedish authorities’ further observations on this subject. Further, the Committee would like to be informed about the Covid-19 vaccination programme for staff and persons held in places of deprivation of liberty in Sweden.
 Admittedly, in their letter dated 21 April 2021, the Swedish authorities informed the CPT about new recommendations regarding testing and wearing of masks in places of deprivation of liberty, but these new rules did not really seem to change the situation insofar as testing remained voluntary (unless the person concerned displays symptoms suggestive of Covid-19) and there was still no recommendation for staff to wear a mask systematically while in a detention area.
 See https://www.coe.int/en/web/cpt/-/covid-19-council-of-europe-anti-torture-committee-issues-statement-of-principles-relating-to-the-treatment-of-persons-deprived-of-their-liberty-.
II. Facts found during the visit and action proposed
A. Police establishments
1. Preliminary remarks
8. There have been no major changes to the legal and regulatory framework governing the detention of persons by the police since the 2015 visit. It should be recalled here that, pursuant to the Code of Judicial Procedure (CJP), the maximum period during which criminal suspects may be held in police custody before being transferred to a remand prison is 96 hours. The prosecutor must be notified promptly when someone is apprehended (gripen) by the police, and the apprehended person must be interrogated as soon as possible. Immediately after this interrogation, the prosecutor must decide whether the person shall be arrested (anhållen) or released. A request by the prosecutor for an arrested person to be remanded in custody (häktad) by a court must normally be made on the same day as the decision to arrest, and in any case not later than on the third day after arrest.
Further, in the context of the preliminary investigation, the police may oblige a person not under arrest to stay with them for questioning for up to 6 hours, a period which may exceptionally be extended to 12 hours. This provision concerns persons who are not yet under suspicion (skäligen misstänkta) of having committed a crime, but who may become suspects, as well as witnesses. As regards persons under 15 years of age, the period of questioning is limited to a maximum of 6 hours.
The Police Act provides for other situations when the police may decide, on their own authority, to take persons into temporary custody (omhändertagits), such as minors found in circumstances which pose a serious and imminent threat to their health or development, persons who disturb the public order, and persons whose identity is unknown. The length of temporary custody is limited to 6 hours, but may be prolonged to 12 hours if it is particularly important that a person be identified. In addition, intoxicated persons may be taken into care (förvar) and held on police premises for up to 8 hours.
It should be stressed as a positive fact that no violations of the above-mentioned time-limits for police custody have been observed by the CPT’s delegation in the course of the 2021 visit.
As for the detention by the police of foreign nationals pursuant to aliens legislation, reference is made here to the description of the applicable legal and regulatory framework in paragraph 18 below.
 See Chapter 24, Sections 8, 12 and 13 of the CJP.
 See Chapter 23, Section 9, of the CJP.
 See Sections 11 to 16 of the Police Act.
 See Section 7 of the Law on the Taking into Care of Intoxicated Persons.
9. The Committee is pleased to report that its delegation heard no allegations of deliberate ill-treatment by the police. In general, persons detained had no complaints about the way they had been treated while in police custody. Consequently, the conclusion reached by the CPT after the 2015 visit – namely that persons deprived of their liberty by the Swedish police run little risk of being physically ill-treated – remains fully valid.
10. This notwithstanding, it should be mentioned here that the delegation heard a few allegations of excessively tight handcuffing (including behind one’s back) upon apprehension, reportedly lasting for periods of up to 45 minutes.
The Committee recommends that the Swedish authorities remind all police officers that they should use no more force than is strictly necessary when carrying out an apprehension and, in particular, that whenever they deem it essential to handcuff a person at the time of apprehension or during the period of custody, the handcuffs should under no circumstances be excessively tight and should be applied only for as long as is strictly necessary.
 It should be noted that excessively tight handcuffing can have serious medical consequences (for example, sometimes causing a severe and permanent impairment of the hand(s)).
 Handcuffs had reportedly been removed after arrival at a police establishment or after the person concerned had declared that he had no (or no longer any) intention to oppose arrest.
3. Safeguards against ill-treatment
11. In the reports on its previous visits to Sweden, the Committee has repeatedly made a number of recommendations and comments as regards safeguards for persons detained by the police. The CPT has placed particular emphasis on three fundamental rights, namely the right of detained persons to inform a close relative or another third party of their situation (notification of custody), to have access to a lawyer, and to have access to a doctor. As stressed by the Committee, these rights should be enjoyed by all categories of persons, irrespective of their precise legal status, from the very outset of their deprivation of liberty (i.e. from the moment the persons concerned are obliged to remain with the police). It is equally fundamental that persons detained by the police be informed without delay of their rights, including those mentioned above, in a language they understand.
12. In this context, the CPT’s delegation was concerned to observe during the 2021 visit that, despite assurances to the contrary provided repeatedly by the Swedish authorities (in their response to the report on the 2015 visit and in several subsequent letters sent to the Committee), notification of custody remained frequently delayed in practice, almost systematically until the first court hearing and sometimes for the whole duration of police custody (i.e. 96 hours).
Police officers with whom the delegation spoke confirmed that this was a routine practice and that (in their perception) the matter was entirely in the hands of senior investigators in charge of the case (and sometimes also competent prosecutors).
Among both the police officers and detained persons interviewed by the delegation, there was a general expectation that a ban on notification of custody (referred to colloquially as “restrictions”) was unavoidable and more or less automatic in case of certain categories of criminal offences (e.g. drugs and weapons-related offences, large-scale smuggling, etc.).
The CPT wishes to stress once again that any delays in notification of custody should be highly exceptional, short (in any case, not longer than 48 hours), duly motivated in writing and authorised only by a prosecutor or a judge. The Committee calls upon the Swedish authorities to implement its long-standing recommendation that the possibility to delay the exercise of the right of notification of custody be more closely defined and made subject to appropriate safeguards, such as those enumerated above.
The CPT also reiterates its recommendation that detained persons be provided with feedback on whether it has been possible to notify a close relative or other person of the fact of their detention; this is still not systematically the case at present. Further, the relevant legislation and/or regulations should be completed so as to oblige the police to record in writing whether or not notification of custody has been performed in each individual case, with the indication of the exact time of notification and the identity of the person who has been contacted. A waiver of the right to notify a relative or a third party should be systematically signed by the person deprived of his/her liberty if he/she does not wish to exercise that right.
13. Regarding access to a lawyer, the situation observed during the 2021 visit was very similar to that described in the report on the 2015 visit, namely such access was as a rule granted at the beginning of the first formal interview by the investigating officer (which, in most cases, took place several hours or even the day after the actual apprehension). It was still highly exceptional for persons in police custody to benefit from access to a lawyer as from the very outset of deprivation of liberty (i.e. from the moment when they were obliged to remain with the police).
Admittedly, most detained persons told the delegation that the police had not insisted upon proceeding with initial questioning after they had refused to answer any questions without a lawyer being present. Nevertheless, the Committee again calls upon the Swedish authorities to take effective steps to ensure that the right of all detained persons to have access to a lawyer is fully effective as from the very outset of deprivation of liberty.
In addition, a record should be maintained of any request by a person deprived of his/her liberty by the police to see a lawyer and whether such a request was granted. A waiver of the right to legal assistance should be systematically signed by the person if he/she does not wish to exercise his/her right to access to a lawyer.
14. As for the access to a doctor for persons detained by the police, the situation was basically identical to that described in the report on the 2015 visit. Only the few largest police detention facilities had their own on-site health-care staff; in the other police establishments visited, whenever the custodial staff thought that a detained person’s health condition so required, recourse was had to outside medical services. It remained the case that it was for the (medically untrained) police officer (i.e. the duty officer) to decide whether calling for medical assistance was necessary and justified under the circumstances.
The CPT wishes to reiterate its view that access to a doctor for persons in police custody should be unfettered; police officers are not qualified to assess whether a detained person’s request to see a doctor is justified. Consequently, there should be a clearly established right of persons deprived of their liberty by the police to have access to a doctor. It is also important to stress here that for the Committee this right is not just about receiving health care but also preventing ill-treatment and, if necessary, documenting injuries – something that is still not done at present. The CPT reiterates its long-standing recommendation that the right of persons deprived of their liberty by the police to have access to a doctor be made the subject of a specific legal provision. Pending the adoption of such a provision, clear instructions should be issued to all police officers that they should never filter requests for medical assistance by persons in their custody.
15. Information on rights was systematically provided to persons in police custody, at the latest upon arrival at the police establishment. That said, despite the existence of an information sheet in
42 languages, the delegation’s impression (based on what it was told by detained persons and police officers) was that this was, in most cases, done orally. The aforementioned information sheets were generally only given to persons who did not speak Swedish.
The Committee recommends that the written information sheets (in an appropriate language) be systematically given to all persons apprehended by the police, including to Swedish speakers.
 Although, strictly speaking, the term “restrictions” applied more appropriately to persons (already) remanded in custody, see paragraph 32 below.
 See also Articles 5, 6 and 8 (and recitals 35, 36 and 38) of Directive 2013/48/EU of the European Parliament and of the Council of 22 October 2013 on the right of access to a lawyer in criminal proceedings and in European arrest warrant proceedings, and on the right to have a third party informed upon deprivation of liberty and to communicate with third persons and with consular authorities while deprived of liberty, OJ L 294, 6.11.2013, p. 1–12, https://eur-lex.europa.eu/eli/dir/2013/48/oj, which was due to be implemented in Sweden by 27 November 2016.
 See also Articles 3, para 1, and para 2(c), Directive 2013/48/EU of the European Parliament and of the Council of 22 October 2013 on the right of access to a lawyer in criminal proceedings and in European arrest warrant proceedings, and on the right to have a third party informed upon deprivation of liberty and to communicate with third persons and with consular authorities while deprived of liberty, OJ L 294, 6.11.2013, p. 1–12, https://eur-lex.europa.eu/eli/dir/2013/48/oj, which was due to be implemented in Sweden by 27 November 2016.
 See paragraph 18 of document CPT/Inf (2016) 1.
 E.g. a nurse was present at Malmö Police Department (capacity 53) every day for 3 hours in the morning and 2.5 hours in the evening (7 p.m. to 9.30 p.m.), weekends included.
 Falck Ambulans or, for “real” emergencies, 112.
 Although, admittedly, the very wording of the provision regulating the access to a doctor for persons in police custody suggested that a doctor should be called upon the request of the person concerned “unless it is obvious that it is unnecessary”.
 Persons were asked to confirm this fact with their signature, and a note of this was also made in the electronic records.
 It is to be acknowledged that written information on the rights of persons in police custody and on house rules was generally found to be posted inside the cells in the police establishments visited.
 See also Article 4, para 1 and 5, of Directive 2012/13/EU of the European Parliament and of the Council of 22 May 2012 on the right to information in criminal proceedings, OJ L 142, 1.06.2012, p. 1–10, https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=celex:32012L0013, which was due to be implemented in Sweden by 2 June 2014.
4. Conditions of detention
16. As on previous visits, the delegation found conditions of detention in all the police establishments (both in the cells for criminal suspects and in those for intoxicated persons) to be on the whole fully adequate for the maximum periods of police custody (respectively, 96 and 8 hours).
The (exclusively) single cells were sufficiently spacious (measuring approximately 8 m²), well-lit and ventilated, clean and in a good state of repair. The equipment of the cells for criminal suspects consisted of a sleeping platform, a mattress (with a blanket), a desk and a chair, as well as a call bell. Some of the cells had sanitary annexes (a toilet and a washbasin) and persons accommodated in cells without an annexe had ready access to clean and decent communal toilets (and showers). Cells for intoxicated persons had a washable mattress placed on the floor and a water fountain. The only possible point of concern was insufficient heating in the cells; in fact, a few of the detained persons interviewed by the delegation in police detention facilities complained that they had felt cold (especially at night). The CPT invites the Swedish authorities to look into this issue.
There were no problems with the provision of food and personal hygiene items, and daily access to the exercise yards was offered to criminal suspects if they stayed in the establishment for longer than 24 hours.
17. A pilot project, consisting of installing CCTV cameras in some of the cells (those used to accommodate persons believed to be at risk of harming themselves and those requiring additional surveillance on medical grounds) was ongoing at the time of the CPT’s visit to Malmö Police Department. In this context, the delegation was concerned to note that the cameras had been installed in such a manner that detained persons could be seen on control screens while using the in-cell toilets.
The Committee wishes to stress that, whenever it is deemed necessary to place a detained person under video surveillance, his/her privacy should be preserved when he/she is using a toilet, for example by pixelating the image of the toilet area. The CPT recommends that steps be taken accordingly at Malmö Police Department.
 See e.g. paragraphs 26 to 28 of the report on the 2015 visit, document CPT/Inf (2016) 1.
 It is to be recalled that the CPT’s visit took place in January.
B. Establishments for foreign nationals deprived of their liberty under aliens legislation
18. There had been no major changes to the legal framework for immigration detention since the 2015 visit. As previously, the maximum period of detention of an adult foreign national deprived of his/her liberty under aliens legislation was 12 months, except if he/she was expelled by a court decision because of a crime (as a rule after having served a prison sentence in Sweden) in which case there was no absolute time-limit for detention. Detention orders were reviewed every two weeks except for refusal of entry or expulsion orders, which were reviewed within 2 months from the date on which enforcement of the order had begun.
19. The delegation visited, for the first time, two closed migration detention centres (förvar) run by the Swedish Migration Agency, in Åstorp and Ljungbyhed.
Åstorp Detention Centre was located in a converted office and storage facility in an industrial estate on the town’s suburbs. Opened in 2011, it had the capacity of 80 places and was, at the time of the 2021 visit, accommodating 35 adult foreign nationals including five women.
Ljungbyhed Detention Centre, opened in 2019 on the premises of a former air force base fire station, had the capacity of 40 and was, at the time of the visit, accommodating fourteen foreign nationals, all of them male adults.
20. It is to be stressed that the delegation did not receive any allegations of ill-treatment by staff of the Åstorp and Ljungbyhed Detention Centres. Further, the delegation received no allegations and found no other indications of violence between detained foreign nationals. Most of the foreign nationals interviewed by the delegation indicated that the overall atmosphere in both centres was relaxed.
21. Material conditions in the two detention centres visited were of a high standard. Rooms were bright, airy and clean, suitably equipped (bunk beds with full bedding, lockers and wardrobes) and sufficiently spacious (e.g. rooms measuring 18 to 30 m² and accommodating up to three foreign nationals in Åstorp and up to four in Ljungbyhed). Detained foreign nationals could move freely within their living units and had unrestricted access to communal toilets and showers, as well as washing machines in which they could wash their own clothes (the bedding was washed by the establishments). Food, which was varied and reflecting the detained foreign nationals’ dietary needs, was served three times a day and there was an extra night snack at 10 p.m. as well as tea/coffee available at all times; furthermore, various snacks and drinks were available for sale from vending machines. There was no problem with access to adapted clothing (for those foreign nationals in need of it) and personal hygiene items.
22. As regards activities, both centres had well-furnished and equipped day/recreational areas with sofas, tables, chairs, TV/DVD and radio sets, some books and magazines in different languages and a range of board/computer games, as well as computers with the Internet. Further, there was access to fitness equipment and occasionally staff offered group activities such as bingo, cooking, painting, drawing, English classes, table football and table tennis competitions, etc.
However, access to outdoor exercise (in sufficiently spacious and well-equipped yards with some exercise equipment and basketball hoops) was only granted for up to 2 hours per day. In the CPT’s view, detained foreign nationals should in principle have free access to an outdoor area throughout the day, i.e. at least two hours per day. The Committee recommends that the Swedish authorities take steps at Åstorp and Ljungbyhed Detention Centres (and, as applicable, in other detention centres) to increase detained foreign nationals’ daily entitlement to outdoor exercise in the light of the above remarks.
More generally, the CPT wishes to stress once again that the regime for persons deprived of their liberty pursuant to aliens legislation should reflect the nature of their deprivation of liberty, with limited restrictions in place and a varied offer of activities. The longer the period for which persons are held, the more developed should be the activities which are offered to them. The Committee recommends that further efforts be made to develop the offer of activities for foreign nationals who spend prolonged periods at Åstorp and Ljungbyhed Detention Centres (and, as applicable, in other detention centres). In particular, they should be offered some work and education/vocational training, preferably allowing them to acquire skills that may prepare them for reintegration in their countries of origin upon return.
23. Neither of the detention centres visited had its own on-site health-care staff. Instead, pursuant to agreements between the Swedish Migration Agency and respective local health-care centres, Åstorp Detention Centre was visited by a nurse from Monday to Friday (between 8 a.m. and 4 p.m.) and Ljungbyhed Detention Centre on Mondays, Wednesdays and Fridays. When the nurse was absent, staff of both detention centres relied on emergency services (Falck).
In order to see a doctor (whether a general practitioner or a specialist, including a dentist), detained foreign nationals had to write an application explaining the reasons for their request (in Ljungbyhed they were also asked to mark the part of the body where they had pain on a sort of “body chart”) and hand it to non-medical staff. This meant that the procedure criticised by the Committee many times in the past, whereby access to health care was filtered by non-medical staff, continued. It was thus hardly surprising that several interviewed foreign nationals complained about the lack of or delays in access to medical care (in particular, specialists). Furthermore, the arrangements in place remained problematic from the standpoint of the protection of medical confidentiality, also because prescribed medication (including psychotropic drugs) was distributed to detainees by medically untrained personnel.
Moreover, despite the CPT’s long-standing recommendation, there was still no systematic medical screening upon arrival at detention centres for foreign nationals. The Committee wishes to emphasise yet again that carrying out medical screening of all newly-arrived foreign nationals is in the interests of both detainees and staff, in particular for identifying those at risk of self-harm, screening for transmissible diseases and the timely recording of any injuries.
In the light of the above remarks, the CPT calls upon the Swedish authorities to take measures to improve significantly the provision of health care to foreign nationals detained at Åstorp and Ljungbyhed Detention Centres (and, as applicable, in other detention centres), paying due attention to medical confidentiality. Urgent steps should be taken to increase the times of presence of a nurse in both establishments and to improve access to general practitioners and specialists (including dentists). Further, steps should be taken to ensure that someone competent to provide first aid (which should include being trained in the application of cardiopulmonary resuscitation (CPR) and the use of defibrillators) is always present at both detention centres whenever the nurse is absent (including at night).
The Committee also reiterates its recommendation that all newly arrived detained foreign nationals benefit from a comprehensive medical screening (including screening for transmissible diseases and for signs of mental disorders) by a doctor or a fully qualified nurse reporting to a doctor as soon as possible after their admission.
24. As regards psychiatric and psychological care in particular, the CPT is concerned about possible mental health issues remaining undetected and/or not being addressed adequately. Given the numbers of detained foreign nationals transiting through both centres, their personal histories and the stress incurred by the prospect of deportation and sometimes prolonged detention, many of them inevitably presented symptoms of post-traumatic stress or other mental disorders (as was also acknowledged by the staff).
In both detention centres visited, access to psychiatric care was in fact limited to emergencies and psychological assistance was either unavailable (in Ljungbyhed) or only available upon request and with considerable difficulty (in Åstorp). The Committee recommends that steps be taken to ensure adequate access to psychiatric care and psychological assistance for foreign nationals at Åstorp and Ljungbyhed Detention Centres (and, as applicable, in other detention centres).
25. As for contact with the outside world, foreign nationals detained at both centres had reasonably good possibilities to receive visits, make telephone calls (including with their own mobile phones) and send and receive letters.
Further, detainees were provided with written information (available in a large number of languages) on their rights, including on the right to ex officio legal assistance (see paragraph 26 below), to appeal and to send confidential complaints to outside bodies. If required, access to (telephone) interpretation could be arranged easily.
External monitoring was carried out by staff of the OPCAT Unit (NPM) and, based on a Memorandum of Understanding with the Swedish Migration Agency, by the Swedish Red Cross.
26. Concerning access to a lawyer, the situation had not changed since the previous CPT’s visit. According to the Aliens Act, a detained foreign national has the right to a public counsel in cases concerning the enforcement of a refusal of entry or expulsion order if the alien has been held in detention for more than three days.
The Committee would like to recall once again that detained foreign nationals (whether or not they are asylum seekers) should – in the same way as other categories of persons deprived of their liberty – be entitled, as from the outset of their deprivation of liberty, to have access to a lawyer. The CPT reiterates its recommendation that the relevant legislation be amended so as to ensure that all persons held under aliens legislation (wherever they are detained) have an effective right of access to a lawyer as from the very outset of their deprivation of liberty and at all stages of the proceedings.
27. Both detention centres visited had isolation rooms for placement of persons for reasons of security (to protect them from harming themselves and to prevent them from harming others). Conditions in these rooms were on the whole adequate.
However, the CPT has misgivings regarding the whole concept and procedure for placement of detained foreign nationals in isolation. The placement was decided by the most senior staff member present at a given moment (usually the “team leader”) and there was no absolute time-limit in the Aliens Act (apart from the obligation to review the placement decision after 3 days). Likewise, there seemed to be no procedural safeguards in place such as the right to an oral hearing, to be informed of the reasons for the placement and to receive the placement decision in writing, to call witnesses and benefit from legal assistance, etc. While the Committee understands that placement in isolation was often decided because of the detained person being in an agitated/aggressive/self-aggressive condition (and, in such cases, especially if staff considered that there was a risk of suicide or self-harm, a nurse was contacted immediately or – in the absence of a nurse – a doctor from Falck was called and asked to come and see the person), the delegation found quite a number of instances where a detained foreign national had been held in the isolation room for prolonged periods (up to 3 weeks).
In the CPT’s view, whenever a person needs to be placed in an isolation room because of being agitated and/or aggressive to him/herself or others, such a placement should be of the shortest possible duration i.e. hours rather than days; if a detained person has not calmed down after such a short period, he/she should be medically assessed with the view to a transfer to an appropriate health-care facility. If, on the other hand, the placement takes place on de facto disciplinary and/or administrative grounds (because a detained person has violated the house rules and/or did not get along with other detainees), this would seem to be contrary to the current Swedish legal framework and should thus not take place at all.
More generally, it should be recalled here that, according to the Committee, any placement in isolation for disciplinary and/or administrative reasons would in any case have to have a legally set time limit (e.g. up to 14 days) and the placement procedure would have to comprise all the safeguards referred to above.
The Committee recommends that the legal framework and the practice of placement of detained foreign nationals in isolation be reviewed in the light of the above remarks and, furthermore, be brought into conformity with the standards set out by the CPT in document CPT/Inf (2011) 28-part2. The comments and recommendations made by the Committee in paragraphs 50 and 51 below are applicable mutatis mutandis.
28. The Committee is concerned by the fact that, despite its long-standing recommendation, foreign nationals detained pursuant to aliens legislation could still be held in prisons. It appeared that such a transfer (decided by the Swedish Migration Agency at the Headquarters level in coordination with the Swedish Prison and Probation Service, Kriminalvården) was sometimes de facto a form of ultimate measure to deal with “difficult” or “challenging” detainees held in detention centres.
The CPT must stress once again that, in those cases where it is considered necessary to deprive persons of their liberty under the aliens legislation, they should be accommodated in centres
specifically designed for that purpose, offering material conditions and a regime appropriate to their
legal situation. The Committee calls upon the Swedish authorities put an end to the practice of placing persons detained under aliens legislation in prisons.
 For a reminder, according to Chapter 10, Section 1, of the Aliens Act, an alien who is over 18 years of age may be detained in a special detention centre if: a) his/her identity is unclear; b) detention is necessary for the investigation of his/her right to stay in Sweden; c) it is likely that he/she will be refused entry or be expelled, or this is necessary for the enforcement of an existing refusal of entry or expulsion order. In most cases, detention orders are issued by the police and the Swedish Migration Agency (Migrationsverket); in some cases, it is the Migration Court or, exceptionally, the Swedish Security Service (Säkerhetspolisen, SÄPO).
 Minors could not be detained for more than 72 hours, unless there were exceptional grounds for a prolongation for another 72 hours (Chapter 10, Section 5, of the Aliens Act).
 See paragraph 22 below.
 As one of the measures to deal with the Covid-19 pandemic, the Migration Agency had taken a decision to use only half of the available places in Åstorp, keeping the other half for isolation and quarantine of any detained foreign nationals with suspected or confirmed Covid-19 infection.
 Half of which unused based on the analogous decision of the Migration Agency as in the case of Åstorp Detention Centre.
 Every detained foreign national received 24 SEK per day.
 In Ljungbyhed detainees received tablets (with an Internet connection), which they could use to watch movies, consult different websites, accede to social media and make VoIP calls (see also paragraph 25 below).
 In Åstorp the indoor gym was exclusively reserved for women during 2 hours per day.
 The mean stay at Åstorp Detention Centre was said to be approximately 30 days but several foreign nationals (especially former inmates from countries such as Morocco and Afghanistan) had been there for much longer (between 6 months and a year and 9 months). In Ljungbyhed one foreign national had been detained for 10 months, and several others for between 5 and 8 months.
 There were no set working hours; the time of attendance by the nurse depended on the number of persons registered for consultation.
 See e.g. paragraph 36 of the report on the 2015 visit, document CPT/Inf (2016) 1.
 See e.g. paragraph 37 of document CPT/Inf (2016) 1.
 Regarding the contents of medical screening, the procedure to be followed and the recording and reporting of injuries, reference is made here to the comments and recommendations in paragraph 45 below, which are applicable mutatis mutandis also to detention centres for foreign nationals.
 Only teleconsultations were possible due to the ongoing Covid-19 pandemic and an appointment had to be made through the local outpatient health centre (vårdcentral), which reportedly could take a long time.
 Visits (up to one hour at a time) were unrestricted in frequency, the only requirement being to fix a time in advance and provide identification details of the visitors. After having been completely suspended between March and October 2020 due to the Covid-19 pandemic, visits were authorized again but under modified conditions (using a specially adapted room with a glass separation). Further, foreign nationals were encouraged to use VoIP calls instead of visits to the extent possible, and apparently this was met with much understanding considering that VoIP calls (up to one hour per session) were free of charge, detained foreign nationals were unaccompanied by staff and allowed to call relatives and friends anywhere in the world.
 Detained foreign nationals could use a special (locked) complaint box or could send complaints online or through their lawyers.
 Visits by the Swedish Red Cross had been suspended since the start of the Covid-19 pandemic and temporarily replaced by individual VoIP calls with detained foreign nationals.
 See paragraph 90 of CPT/Inf (2009) 34.
 A person who is to be returned under the Dublin Regulation and who is detained has the same right to a public counsel.
 The rooms were well lit and ventilated, clean, spacious enough (8 to 12 m²) and equipped with a mattress placed on the floor and a call bell. Persons placed in these rooms had access to a secure toilet and a shower and, if they stayed longer and were calmer, to a secure area with a sofa and a TV set. They were also allowed outdoor exercise in a separate small yard once they have calmed down.
 While such prolonged placements were rare, it was not uncommon for detained foreign nationals to spend several days in an isolation room.
 Solitary confinement of prisoners. Extract from the 21st General Report of the CPT, published in 2011 (https://www.coe.int/en/web/cpt/solitary-confinement). See, in particular, paragraphs 56, 57 (procedural safeguards) and 62 – 63 (role of health-care staff).
 See e.g. paragraph 72 of the report on the 2015 visit, document CPT/Inf (2016) 1.
 There were reportedly between 100 and 120 placements per year, and (for example) the delegation learned that four foreign nationals had been accommodated at Helsingborg Remand Prison (see paragraph 29 below) for periods of up to 4 months.
 Examination of the records of placements in isolation rooms at Åstorp and Ljungbyhed Detention Centres revealed that a transfer to a prison often followed a prolonged placement of a detainee in an isolation room.
1. Preliminary remarks
29. During the 2021 periodic visit the CPT’s delegation focussed its attention on remand imprisonment (häktet) and especially on the issue of restrictions. The delegation visited, for the first time, three remand prisons, in Helsingborg, Trelleborg and Ystad.
Helsingborg Remand Prison was a relatively recent purpose-built establishment (opened in 2010) located opposite Helsingborg Police Department in an area close to the city centre mostly occupied by commercial, office and service enterprises. With an official capacity of 120, the prison was accommodating, at the time of the visit, 114 adult remand prisoners including 19 women. Almost all the inmates were on restrictions. The average stay was said to be approximately 3 months but several inmates had been accommodated there for much longer periods, up to 7 months and even, in one case, almost 2 years.
Trelleborg Remand Prison was a compact establishment located in the city centre. At the time of the visit, it was operating at its full official capacity (33 places). All but six of the adult male remand prisoners were on restrictions. The average stay was said to be approximately 3 months but one inmate had been there since April 2020.
Ystad Remand Prison, opened in 1985, enlarged in 1994 and renovated extensively in 2015, was located on the outskirts of Ystad and physically formed a part of the larger campus also comprising the prison (anstalt) for sentenced women (with which it shared some premises and services, including the health care unit, the visiting premises and the observation/isolation cells). With an official capacity of 34, the prison was at the time of the visit accommodating 38 remand prisoners (adult men only), which meant that some of the standard single cells had had to be converted into double cells. Unlike in Helsingborg and Trelleborg, there were no inmates on restrictions. The average stay was said to be approximately 6 months but in rare cases inmates could remain at Ystad Remand Prison for up to a year.
30. Regrettably, overcrowding observed at Ystad Remand Prison was not unique in the Swedish prison system; in the recent years, it had begun affecting, to varying extents, numerous establishments for inmates on remand throughout the country.
The Minister of Justice and Migration, Mr Morgan Johansson, attributed this to his Government’s determination to clamp down on violent and/or organised crime. He referred inter alia to the policy decision that prosecutors should systematically request courts to remand in custody persons suspected/accused of violent offences (especially when those offences involved the use of firearms).
At the same time, the Minister referred to several measures that the Swedish authorities planned in order to shorten the time inmates spent on remand, including amendments to the Code of Judicial Procedure (CJP) that would make it possible to admit during court proceedings evidence obtained in the course of the investigation and to combine the detention hearings and hearings on the merits (which would speed up court proceedings). Other amendments, introducing strict time-limits for remand in custody, were partially approved by the Parliament (Riksdag) on 7 April 2021, although the maximum time-limit for remand in custody during the investigation stage had finally been set at 9 months instead of the 6 months proposed by the Government; an extension of this time-limit will only be possible if there are special grounds to do so (e.g. if the offence is particularly difficult to investigate because it is a part of an organised or gang-related crime).
While taking due note of these amendments, the CPT recommends that further efforts be made by the Swedish authorities to combat prison overcrowding, including making wider use of measures alternative to remand in custody (such as electronically surveyed house arrest, obligation to report and travel bans). Further, the Committee would like to receive updated information about the draft amendments to the CJP referred to above.
31. The CPT was also informed about efforts being made to expand the prison estate, including the reopening of a previously closed prison, converting another prison that had been used for staff training purposes and, in the longer term, construction of new prisons in Kalmar, Trelleborg and Västerås. The objective was to have 2.000 additional prison places by 2029. The Committee would like to be informed about the implementation of these plans.
32. The CPT stressed in the report on its 2015 visit that the entire approach to restrictions for remand prisoners in Sweden had to change fundamentally. Unfortunately, no substantive improvement had taken place since the 2015 visit (the official statistics communicated to the delegation suggested that the percentage of remand prisoners on restrictions had been more or less stable between 2017 and 2020, oscillating between 55 and 65% of the total population of remand prisoners). It remained the case in the remand prisons visited during the 2021 visit (especially at Helsingborg Remand Prison) that some remand prisoners spent months with no (or hardly any) contact with their families and with extremely limited opportunities to interact with other human beings.
In this context, the Swedish authorities informed the Committee of planned legislative amendments aimed at reducing the recourse to restrictions. According to those draft amendments, prosecutors would have to explain in their requests to the courts which precise restrictions they would like imposed, why and for how long, and the courts would be obliged to examine the specific need for each type of restriction (i.e. ban on association, media, electronic communication, letters, visits and telephone calls) and its duration. Further, it was proposed to amend the legislation so as to entitle every remand prisoner (whether on restrictions or not) to spend time with another person for at least two hours every day (4 hours for juveniles). The CPT requests to be provided, in the Swedish authorities’ response to this report, with an update on the adoption of the aforementioned legislative amendments.
More generally, the Committee again calls upon the Swedish authorities to take decisive steps to ensure that restrictions on remand prisoners are only imposed in exceptional circumstances which are strictly limited to the actual requirements of the case and last no longer than is absolutely necessary. Further, fully individualised reasons why restrictions have been imposed should always be recorded in writing and open to legal challenge.
 See paragraphs 32 and 37 below.
 There was a tunnel under the car park connecting both buildings.
 There were also four foreign nationals detained pursuant to the Aliens Act, see paragraph … above [aliens].
 The prison could also accommodate women but it was reportedly a rare event (a few times per year).
 See paragraph 42 below.
 See paragraph 53 below.
 See paragraph 50 below.
 See paragraph 35 below.
 Once sentenced, they would be transferred to an establishment for sentenced prisoners (anstalt).
 See https://www.prisonstudies.org/country/sweden.
 In their letter dated 13 January 2021, the Swedish authorities informed the CPT that there was a shortage of approximately 600 places in remand prisons. The number of inmates had somewhat gone down by comparison with the period before the start of the Covid-19 pandemic but Directors of the three remand prisons visited were convinced that this was a temporary relief and that the problem would worsen again after the pandemic.
 At present only the evidence presented in court is admissible.
 Three months for juveniles.
 The entry into force of these new provisions has been set for 1 July 2021.
 As a matter of fact, the wide recourse to restrictions on remand prisoners’ regime and contacts with the outside world had been an issue of the CPT’s concern since the very first visit by the Committee to Sweden (in 1991) and had also been the main subject of the high-level talks between the CPT and the Swedish authorities in 2016, see www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-holds-high-level-talks-in-sweden.
 See also paragraphs 37, 38 and 52 below.
 Unlike presently, when the court gives the prosecutor a general permission to impose restrictions (and these are then reviewed by court every two weeks, at the same hearing during which the prolongation of remand custody is examined).
33. The CPT’s delegation received virtually no recent and/or credible allegations of deliberate physical ill-treatment of prisoners by staff in any of the prisons visited. Most of the inmates interviewed spoke positively about the staff, the general atmosphere was relaxed, and prison officers appeared to be generally professional and well-trained.
However, at Helsingborg Remand Prison the delegation heard two recent allegations referring to the use of excessive force (pushing, pulling by handcuffs) by custodial staff when transferring an inmate to the observation cell; in one of these cases, the inmate concerned also alleged having been abused verbally by the custodial officer.
The Committee recommends that the management of Helsingborg Remand Prison delivers to custodial staff the clear message that any use of excessive force and any verbal abuse vis-à-vis prisoners (as well as any other form of disrespectful or provocative behaviour) will not be tolerated.
34. The delegation gained the impression that inter-prisoner violence was not a frequent occurrence in the establishments visited; steps were taken by staff to prevent such incidents and to address them adequately if and when they did occur.
 See paragraph 50 below.
3. Conditions of detention
a. material conditions
35. In the three remand prisons visited the material conditions were generally good, despite the fact that (as already mentioned in paragraph 29 above) the number of inmates accommodated at Ystad Remand Prison exceeded the establishment’s official capacity.
The cells, each measuring between approximately 8-9 m² (in Helsingborg and Trelleborg) and 12 m² (in Ystad) were suitably equipped, access to natural light was generally adequate and the artificial lighting and ventilation was sufficient. Inmates had ready access to well-equipped and clean communal toilet, washing and shower facilities (the latter every day or every second day).
Overall, prisoner accommodation areas were clean and in a good state of repair. The provision of food and personal hygiene items does not call for any particular comment either.
36. Remand prisoners were allowed one hour of outdoor exercise every day. That said, the Committee is concerned by the fact that exercise yards at Helsingborg Remand Prison were located on the roof and were of an oppressive design (high walls and frosted glass which obstructed any outside view).
The CPT recommends that the Swedish authorities take steps to ensure that outdoor exercise facilities in all remand prisons are less oppressive in design (e.g. allowing a horizontal view) and, as far as possible, located at ground level.
 But the living space per inmate was still within the CPT’s minimum standard. That said, see document “Living space per prisoner in prison establishments: CPT standards” (CPT/Inf(2015)44, https://www.coe.int/en/web/cpt/living-space-prisoners).
 Bed with full bedding, table or desk, chair, locker, shelves, television, call bell, and (in some cells) a fully screened sanitary annexe comprising a toilet and a washbasin. At Ystad Remand Prison, the 8 cells converted from single to double occupancy had a bunk bed instead of a bed.
 On a more positive note, the yards were equipped with benches and shelters against inclement weather.
37. The regime for prisoners subjected to restrictions remained very impoverished. Apart from daily outdoor exercise (see paragraph 36 above), they had access to a gym for periods of up to an hour three times a week. There were hardly any other organised out-of-cell activities and inmates spent most of their day in their cells, watching TV/DVDs, listening to the radio, reading books or newspapers, and playing board or electronic games.
The prison administration continued the practice of submitting a request to the prosecutor to find out whether a remand prisoner could be granted limited association time with another inmate.
If approved, the prisoner concerned would be able to take outdoor exercise and use the gym together with another inmate (restriktionsgrupp) or associate in a cell (samsittning) for one or two hours per day.
Some prisoners subjected to restrictions were given the opportunity to work for a few hours per day. The work included cleaning, laundry or simple folding and packaging performed inside the cell. Further, young prisoners (aged under 21) were provided with some schooling (by outside teachers) and offered access to activity rooms with table tennis and table football.
38. The management and staff in the remand prisons visited made efforts to minimise the negative consequences of prolonged isolation for prisoners subjected to restrictions. Each of the remand prisons visited had staff whose task was “to break isolation”. The staff member would spend some time with a prisoner watching a movie and discussing it afterwards, playing computer or board games, or playing table tennis, table football or volleyball with the inmate. While it was appreciated by the prisoners, many of the inmates interviewed by the delegation complained that isolation and the almost total lack of human contact due to the restrictions had a serious impact on their mental wellbeing.
39. The regime for remand prisoners not subjected to restrictions was somewhat better, the main difference being that they had more work opportunities (e.g. 26 inmates out of the total of 38 had a paid job at Ystad Remand Prison).
Further, prisoners not subjected to restrictions benefited from (more) association time: they could take their outdoor exercise, play some sports and use the gym together with other inmates, and associate in a well-furnished recreation area for several hours per day. At Ystad Remand Prison, cells were unlocked from 8 a.m. to noon and from 1 to 5 p.m.
40. In the light of the delegation’s findings described in paragraphs 37 to 39 above, the Committee reiterates its call upon the Swedish authorities to radically improve the offer of activities for remand prisoners. The aim should be to ensure that all such prisoners are able to spend at least 8 hours per day outside their cells, engaged in purposeful activities of a varied nature: work, preferably with vocational value; education; sport, recreation/association.
 In the presence of staff.
 Without staff presence.
 Up to 40 prisoners daily at Helsingborg Remand Prison and up to 25 at Trelleborg Remand Prison.
 There were e.g. seven such prisoners at Helsingborg Remand Prison.
 A “häktesplan” (an individual plan for the time spent in remand prison) was drawn up and used to plan the time spent for each inmate depending on the his/her needs.
 Assembling EUR-pallets, packaging, laundry and cleaning.
4. Health-care services
41. As had been the case in the past, prisons in Sweden did not have their own health-care services; the responsibility for providing health-care to inmates rested with the general health-care services which were decentralised (run by the regional and local authorities) and with which every regional prison directorate and each particular establishment had agreements on the regional/local level.
Whilst this system no doubt had several advantages, such as ensuring health care staff’s professional independence, good opportunities for skills improvement and career advancement, the oversight of the quality of care and the continuity of care (before, during and after imprisonment), the CPT’s impression is that the absence of a specific prison health-care organisation resulted in a certain lack of understanding of specific health-care needs of prisoners and in persisting lacunas in the provision of health care to inmates.
42. In particular, there were problems with securing an adequate access to medical consultations (both by general practitioners and by specialists, including dentists) in the prisons visited. For example, a general practitioner generally only visited every prison once a week, with access to a doctor limited to emergencies (Falck or 112) for the rest of the time.
It was reportedly difficult and time-consuming to obtain an appointment with a specialist (since the procedure required first a meeting with the nurse, then a referral to the GP who would in turn refer to a specialist) and access to a dentist had become even more problematic since the start of the Covid-19 pandemic.
Consequently, the burden of providing health care to prisoners rested primarily with the nurses (generally present in the establishments during normal office hours on working days, but not at night or on weekends) who – although well qualified and experienced – could not be expected to replace doctors.
The CPT recommends that steps be taken to improve inmates’ access to doctors (both general practitioners and specialists including dentists) in the prisons visited, in the light of the above remarks; in particular, there should be a doctor specifically appointed to be in charge of the health-care service in each prison. The Committee also reiterates its recommendation that someone qualified to provide first aid (which should include being trained in the application of cardiopulmonary resuscitation (CPR) and the use of automated external defibrillators) is always present, including at night, in the prisons visited (and, as applicable, in all the other penitentiary establishments); preferably this person should be a nurse.
43. The delegation also noted that, as previously, prisoners had to make a written request to see a health-care professional (explaining the reasons for the request) to the (non-medical) custodial staff, and medication (including psychotropic drugs) continued to be distributed by the medically untrained custodial officers. Both practices – incompatible with the principle of medical confidentiality – have been criticized many times in the past. The CPT recommends that they finally be discontinued.
44. Despite the Committee’s long-standing recommendations on this subject, the delegation observed in the three prisons visited that medical screening on arrival (consisting essentially of a questionnaire, without a proper medical examination) was still often delayed by up to 72 hours. Moreover, several prisoners (especially at Helsingborg Remand Prison) alleged that upon admission they had not been medically screened and the delegation noted that prisoners transferred from other penitentiary establishments were often not medically screened upon admission at all, unless they themselves requested to see a nurse. Such an absence of medical screening on admission was of particular concern in the context of the ongoing Covid-19 pandemic.
The CPT again calls upon the Swedish authorities to take effective steps to ensure that a comprehensive medical screening (comprising the screening for transmissible diseases such as tuberculosis and – on a voluntary basis – HIV and hepatitis) of newly arrived prisoners is carried out systematically within 24 hours from arrival.
45. The Committee is also concerned by the fact that its repeated recommendations on the recording and reporting of injuries observed on prisoners have remained largely unimplemented; in particular, injuries were usually poorly recorded (if recorded at all) and were not reported unless the prisoner concerned consented to this. There was thus a real risk that some medical evidence of ill-treatment could be lost because the inmate concerned would be afraid to consent, and therefore ill-treatment would remain undetected (or would be very difficult to prove).
The CPT once again calls upon the Swedish authorities to amend the relevant legislation and review the existing procedures in order to ensure that whenever injuries are recorded which are consistent with allegations of ill-treatment made by a prisoner (or which, even in the absence of allegations, are indicative of ill-treatment), the report is immediately and systematically brought to the attention of the competent authorities (e.g. the prosecutor), regardless of the wishes of the prisoner. The results of the examination should also be made available to the prisoner concerned and his or her lawyer; the health-care professional should advise the prisoner concerned that the writing of such a report falls within the framework of a system for preventing ill-treatment and that the automatic forwarding of the report does not substitute for the lodging of a complaint in proper form.
The Committee also wishes to recall that any record drawn up after such an examination should contain:
(i) an account of statements made by the person which are relevant to the medical examination (including his/her description of his/her state of health and any allegations of ill-treatment or inter-prisoner violence);
(ii) a full account of objective medical findings based on a thorough examination;
(iii) the doctor’s observations in the light of i) and ii), indicating the consistency between any allegations made and the objective medical findings.
The record should also contain the results of additional examinations performed, detailed conclusions of any specialised consultations and an account of treatment given for injuries and of any further procedures conducted.
The recording of the medical examination in cases of traumatic injuries should be made on a special form provided for this purpose, with “body charts” for marking traumatic injuries that will be kept in the medical file of the prisoner.
In addition to this, all injuries should be photographed in detail and the photographs kept, together with the “body charts” for marking traumatic injuries, in the prisoner’s individual medical file. This should take place in addition to the recording of injuries in the special trauma register.
46. As regards the psychiatric care and the psychological assistance, both remained very problematic, as acknowledged by the management and staff in the prisons visited. This was of particular concern given the presence of inmates with mental health-related issues and the impact of restrictions on the mental well-being of the remand prisoners concerned.
The CPT recommends that steps be taken to improve access to psychiatric care and psychological assistance for prisoners; in particular, regular visits by a psychiatrist and access to psychological assistance should be ensured at Trelleborg and Ystad Remand Prisons. Similar measures should be taken, if and as required, in all other prisons in Sweden.
47. Inmates’ addiction to substances (mainly alcohol and drugs) remained a challenge for the Swedish prison system, as acknowledged by both the management and staff in the prisons visited. In this context, the delegation noted that detoxification was offered by nurses at Helsingborg Remand Prison; further, inmates who had initiated opioid agonist therapy prior to incarceration were allowed to continue the therapy in prison. The delegation was also informed that Alcoholics Anonymous and Narcotics Anonymous meetings had previously been held regularly in the prisons visited but had been suspended since the beginning of the Covid-19 pandemic. Other than this, there were still no harm-reduction measures and only very limited psychological assistance was available.
The Committee must reiterate its view that the management of prisoners with a substance use problem must be varied – eliminating the supply of drugs into prisons, dealing with drug use through identifying and engaging drug users, providing them with treatment options and ensuring that there is appropriate through care, developing standards, monitoring and research on drug issues, and the provision of staff training and development – and linked to a proper national prevention policy. This policy should also highlight the risks of HIV or hepatitis B/C infection through drug use and address methods of transmission and means of protection. It goes without saying that the multi-disciplinary task of drawing up, implementing and monitoring the programmes concerned must be performed by prison staff in close co-operation with health-care personnel and other (psycho-socio-educational) staff involved. 
The CPT reiterates its recommendation that the Swedish authorities develop and implement a comprehensive policy for the provision of assistance to prisoners with substance use problems (as part of a wider national strategy) including harm reduction measures.
48. The Committee has serious misgivings regarding arrangements for urine tests at Ystad Remand Prison. Inmates suspected of substance use were obliged to urinate strip naked in the presence of several custodial staff (apparently to avoid substitution of samples). Not surprisingly, prisoners concerned felt that these conditions were humiliating (and at least one inmate had been placed for 3 days in an observation cell for having refused to undergo this procedure).
The CPT recommends that the existing arrangements for urine testing at Ystad Remand Prison (and, as applicable, in all prisons in Sweden) be reviewed; other means could and should be found to reconcile the legitimate aim of combating the use of prohibited substances with the inherent dignity of the persons concerned. Every reasonable effort should be made to minimise embarrassment; prisoners who are undergoing a urine test should not normally be required to remove all their clothes at the same time, e.g. a person should be allowed to remove clothing above the waist and redress before removing further clothing.
49. As already mentioned in paragraph 41 above, the Committee is of the view that the persistence of lacunas in the provision of health care to prisoners is at least partly due to the fact that the specificity of health-care needs of the prisoner population is not duly recognised by the Swedish authorities, in particular by the Ministries of Justice and Health and Social Affairs. The organisation of prison health-care services, their interaction with outside clinics and hospitals (especially psychiatric) and the job descriptions and training of health care professionals working with prisoners do not sufficiently reflect this specificity. Furthermore, the absence of a clear structure and chain of responsibility, specific to the health-care service provision in prisons, has a negative impact on the quality of care.
In the light of the above-mentioned findings, the CPT requests the Swedish authorities to transmit to the Committee, in their response to this report, a detailed action plan (comprising precise tasks, agencies responsible, deadlines and financial allocations) for the provision of health care in prison. This will require putting in place genuine co-ordination, at both the senior and the operational levels, between the Ministries of Justice and Health and Social Affairs, and developing specific protocols for the provision of primary and specialist health care in prisons, reflecting particular health-care needs of the prisoner population.
 With the Ministry of Health and Social Affairs and the National Board of Health and Welfare (Socialstyrelsen) performing an expert and supervisory role.
 By Socialstyrelsen and, in case of a suspected breach of standards, by the Medical Responsibility Board (Hälso- och sjukvårdens ansvarsnämnd).
 See also paragraph 49 below.
 Twice a week for half of a working day in Helsingborg.
 Several interviewed prisoners alleged that they had been obliged to wait for weeks to see a dentist.
 The nurse at Trelleborg Remand Prison attended on the basis of 75% of a full-time equivalent.
 See e.g. paragraphs 83 and 84 of the report on the 2015 visit, document CPT/Inf (2016) 1.
 Especially whenever an inmate arrived at the prison on a Friday.
 See paragraph 7 above.
 Reference is also made here to more detailed standards contained in the substantive section of the CPT’s 23rd General Report (“Documenting and reporting medical evidence of ill-treatment”), in particular in paragraphs 73 to 82 (document CPT/Inf (2013) 29, https://www.coe.int/en/web/cpt/medical-evidence-ill-treatment).
 Only Helsingborg Remand Prison was visited by a psychiatrist on a regular basis (once a week); in the other prisons psychiatric care was in fact limited to emergencies (and any care could only be provided at an outside psychiatric ward).
 A psychologist visited Helsingborg Remand Prison two – three times a week but there was no access to psychological assistance for remand prisoners in Trelleborg and Ystad.
 As confirmed by the health-care staff, especially in Helsingborg. See also paragraph 32 above.
 I.e. methadone treatment.
 See paragraph 46 above.
 See also “Drug Dependence Treatment: Interventions for Drug Users in Prison”, UN Office on Drugs and Crime, www.unodc.org/docs/treatment/111_PRISON.pdf.
 See paragraph 50 below.
 See paragraphs 42 to 47 above.
5. Other issues
50. There is officially no isolation as a disciplinary sanction in Swedish prisons. Instead, prisoners who pose a danger to themselves or others (or to the property) may be placed in an observation cell, by a decision of the establishment’s Director or duty officer (when the Director is absent) and for an unspecified period.
Conditions in the observation cells (some of which were fitted with a bed to which a 5-point leather fixation belt could be attached) were found to be generally adequate in the prisons visited. Having said that, concerning the very concept of observation cells and the procedure of placement in them, reference is made to the comments and recommendation in paragraph 27 above, which apply mutatis mutandis also to prisons.
51. The delegation was told that a nurse or a doctor (a general practitioner or a doctor employed by Falck) had to be informed immediately and had to physically come and see any prisoner placed in an observation cell if the reason for the placement was attempted suicide and/or self-harm and, especially, whenever fixation was applied. In all other cases, the nurse (or doctor) was merely informed.
In this context, the Committee wishes to emphasise once again that health-care staff should be very attentive to the situation of all prisoners placed under conditions akin to solitary confinement, whether for preventing self-harm or for reasons of security and good order. Health-care staff should visit prisoners immediately after placement and thereafter, on a regular basis, at least once per day, and provide them with prompt medical assistance and treatment as required.
The CPT reiterates its recommendation that the Swedish authorities take steps, including if required of a legislative nature, to review the role of health-care staff in the context of placement of prisoners in observation cells. In so doing, regard should be had to the European Prison Rules (in particular, Rule 43.2) and the comments made by the Committee in its 21st General Report.
Regarding the use of fixation in prisons, the CPT wishes to stress once again that, in principle, restraint beds should not be used in a non-medical setting.
The Committee also reiterates its remarks on this subject made in paragraph 91 of the report on its 2015 visit, which states as follows:
“The CPT fully recognises that it could be necessary, on rare occasions, to resort to mechanical means of restraint in a prison. However, in the Committee’s opinion, the approach to mechanical restraint in prisons should take into consideration the following principles and minimum standards:
– regarding its appropriate use, mechanical restraint should only be used as a last resort to prevent the risk of harm to the individual or others and only when all other reasonable options would fail satisfactorily to contain those risks; it should never be used as a punishment or to compensate for shortages of trained staff; it should not be used in a non-medical setting when hospitalisation would be a more appropriate intervention;
– any resort to mechanical restraint should be immediately brought to the attention of a medical doctor in order to assess whether the mental state of the prisoner concerned requires hospitalisation or whether any other measure is required in the light of the prisoner’s medical condition (as opposed to certifying the individual’s fitness for restraint);
– the equipment used should be properly designed to limit harmful effects, discomfort and pain during restraint, and staff must be trained in the use of the equipment; metal cuffs should never be used;
– the duration of mechanical restraint should be for the shortest possible time (usually minutes rather than hours); the exceptional prolongation of immobilisation should warrant a further review, including a new medical assessment; immobilisation for periods of days at a time cannot have any justification and would amount to ill-treatment;
– persons subject to mechanical restraint should receive full information on the reasons for the intervention;
– the management of any establishment which might use mechanical restraint should issue formal written guidelines, taking account of the above criteria, to all staff who may be involved;
– a special register should be kept to record all cases in which recourse is had to means of restraint; the entry should include the times at which the measure began and ended, the circumstances of the case, the reasons for resorting to the measure, the name of the person who ordered or approved it, and an account of any injuries sustained by the prisoner or staff;
– further, the inmate concerned should be given the opportunity to discuss his/her experience, during and, in any event, as soon as possible after the end of a period of restraint. This discussion should always involve a senior member of the health-care staff or another senior member of staff with appropriate training.”
52. As for inmates’ possibilities to maintain contact with the outside world, reference is made to the comments and recommendation in paragraph 32 concerning restrictions.
Prisoners not subjected to restrictions had generally adequate possibility to receive visits (even though visits had been stopped for some time due to the Covid-19 pandemic and had only restarted recently), make telephone calls and write and receive letters. Further, as a means to compensate for the lack of visits during the aforementioned ban, prisoners with small children were given access to video meetings (using VoIP); the CPT welcomes this and invites the Swedish authorities to extend this possibility to all other inmates (especially those whose relatives and friends live far away) and to make it permanent (not just during the pandemic).
Further, the Committee reiterates its long-standing recommendation that the Swedish authorities adopt precise legal provisions concerning the visiting entitlement for prisoners (to ensure that all prisoners, irrespective of their legal status and category, are entitled to least an hour of visiting time per week).
53. Due to the ongoing Covid-19 pandemic, the Swedish Prison and Probation Service had decided to temporarily use visiting facilities with a physical separation (generally a plexiglass screen) between the inmates and their visitors. While acknowledging that it may be necessary for the time being to use such facilities, the CPT hopes that as soon as the epidemiological situation permits the previous general rule of allowing visits to take place under open arrangements (without a separation) will be reinstated, and closed visits will again become an exception only applied in individual cases where there is a clear security concern.
54. In the three remand prisons visited, the delegation noted with concern that procedures making it more difficult and delaying inmates’ access to a telephone were still in place. In particular, it was still not allowed to call a number which was not attached to a nominal subscription (abonnemang). Further, persons whom an inmate wished to call continued to be required to provide their written consent, which could take weeks to arrange (especially when the persons concerned lived abroad).
The Committee reiterates its recommendation that the Swedish authorities seek ways to ensure that prisoners have access to a telephone without disproportionate restrictions and delays.
55. Overall, the delegation noted that external complaints mechanisms were well known and understood by inmates in each of the prisons visited; further, information on complaints procedures and more generally on prisoners’ rights and house rules was readily available in a variety of languages.
By contrast, the prisons visited still seemed to lack a formalised internal complaints procedure. Consequently, the CPT reiterates its recommendation that the Swedish authorities ensure that prisoners are able to make written internal complaints at any moment and place them in a locked complaints box (to which only the establishment’s Director and/or designated deputy has the key) located in each accommodation unit. All written complaints should be registered centrally within a prison before being allocated to a particular service for consideration. In all cases, internal complaints should be processed expeditiously (with any delays duly justified in writing) and prisoners should be informed within clearly defined time periods of the action taken to address their concerns or of the reasons for considering the complaint not justified. In addition, statistics on the types of internal complaints made should be kept as an indicator to the management of areas of discontent within the prison.
 The delegation noted that such placements were relatively frequent in two of the three prisons visited: there had been (in 2020) 270 placements at Helsingborg Remand Prison and 178 placements in Ystad (although the latter figure concerned both remand prisoners and sentenced female inmates from the adjoining “anstalt”). By contrast, observation cells had only been used 13 times in 2020 at Trelleborg Remand Prison.
 Examination of the relevant records in the prisons visited revealed that, although in most cases placements were of a short duration (a day or two), some inmates had spent lengthy periods in observation cells e.g. up to 20 days at Ystad Remand Prison.
 Cells measured approximately 8 m², were equipped with a mattress, a call bell, CCTV and an observation window (through which staff could check on the situation of the inmate) and were clean, well-lit and ventilated. Inmates had access to secure toilet and washing facilities and, if they stayed longer than a day, could take a shower and go outdoors in special secure yards.
 And the practice of their use, which appeared to sometimes comprise placements on de facto disciplinary and/or administrative grounds.
 See paragraphs 62 and 63 of document CPT/Inf (2011) 28-part2 (https://www.coe.int/en/web/cpt/solitary-confinement).
 Which, admittedly, appeared very rare and exceptional in the prisons visited (8 instances between 1 January 2017 and 1 January 2021 at Helsingborg Remand Prison, and no cases in the two other remand prisons for at least 2 years).
 Remand prisoners who were not on restrictions could normally receive visitors once a week for up to an hour and 45 minutes at a time; however, due to the limited number of adapted premises (see paragraph 53) the duration of each visit had temporarily been reduced to 45 minutes maximum.
 Once a week for up to 20 minutes.
 Although prisoners were still allowed physical contact with their children aged below 12.
 In particular, the possibility to contact the Parliamentary Ombudsmen (and the OPCAT Unit) as well as the Medical Responsibility Board (for health-care related complaints).
 If needed, it was easy to arrange telephone interpretation. It is also noteworthy that many staff members had a migration background and corresponding linguistic skills.
D. Psychiatric establishments
1. Preliminary remarks
56. The delegation carried out first-time visits to the North Stockholm Psychiatric Clinic, the Regional Forensic Psychiatric Clinic in Karsudden, and the Regional Forensic Psychiatric Clinic in Sala.
57. The North Stockholm Psychiatric Clinic, with an official capacity of 139, was, at the time of the visit, accommodating 99 adult patients – 34 male and 65 female; 57 of them were civil involuntarily detained patients. The hospital’s catchment area is central Stockholm, as well as its western and north western parts. The hospital also provides Stockholm county’s only psychiatric emergency department for adults.
Regarding diagnoses, about a third of patients suffered from psychotic disorders and another third from personality disorders, with other diagnoses including organic and affective disorders. The average stay was 11.7 days for voluntary and 23.1 days for involuntary patients.
58. The Regional Forensic Psychiatric Clinic in Karsudden, built in the 1960s, is located in woodland outside of Katrineholm town in Södermanland county. It is the largest forensic psychiatric hospital in Sweden, with a catchment area covering the counties of Stockholm, Gotland and Sörmland. The hospital mainly accommodates patients sentenced to compulsory treatment but can also provide treatment to patients from penitentiary institutions or closed youth care establishments.
With an official capacity of 143, at the time of the CPT’s visit, the hospital was accommodating 133 adult patients – 98 male and 35 female; all of them sentenced to compulsory treatment. The main diagnosis among the patients was schizophrenia in its various forms, followed by affective and personality disorders and developmental disorders. The average stay in the hospital was five years, although some patients stayed for 20 -25 years.
59. The Regional Forensic Psychiatric Clinic in Sala, which opened in 2011, is located outside of Sala town in Västmanland county. Its priority catchment area is Västmanland county, however, the hospital may accommodate patients from throughout Sweden. The hospital mainly accommodates patients sentenced to compulsory treatment but can also provide treatment to patients from penitentiary institutions or closed youth care establishments.
With an official capacity of 55, at the time of the CPT’s visit, the hospital was accommodating 51 adult patients – 46 male and five female; one male patient had been transferred to the hospital from a remand prison. Patients suffered from psychotic disorders including substance induced psychosis, affective disorders, and developmental disorders. The average length of stay was four and a half years.
60. It should be stressed at the outset that no allegations were heard by the delegation of any form of ill-treatment by staff in the psychiatric hospitals visited. On the contrary, most of the patients interviewed spoke positively of the staff, especially ward-based staff. As for inter-patient violence, this did not appear to be a significant problem in the hospitals visited.
 In 2019, the hospital completed a seven-year renovation project which considerably improved the environment for patients and staff. The capacity of the hospital increased from 127 to 143.
2. Living conditions
61. Living conditions in the hospitals visited were generally of a very good or excellent standard and provided a positive therapeutic environment. Patients were accommodated in spacious and well-equipped single-occupancy rooms with fully partitioned sanitary annexes. The rooms were personalised and furnished with a bed, bedside table, chair, table, and wardrobes/shelves. Patients also had access to pleasantly furnished communal areas on the wards (equipped with TV sets and computers with internet access).
62. All the wards in the hospitals visited were mixed gender; in the forensic hospitals, a number of wards often accommodated only one or two female patients. However, there were no women-only day rooms or separate accommodation areas for female patients. From interviews with staff and patients in the forensic hospitals, the delegation noted that, in some cases, this could be a source of additional stress to female patients. In the Committee’s opinion, mixed gender wards in forensic hospitals should be equipped with a women-only day room for female patients who wish to avoid interactions with male patients. The CPT recommends that the Swedish authorities take measures to address this issue.
63. At North Stockholm Psychiatric Clinic, there was no dedicated secure outdoor exercise area for patients which meant that involuntary patients did not always have access to daily outdoor exercise; when and if allowed by the doctor after a daily assessment, some of these patients could only walk around the hospital territory accompanied by the staff, when available.
In the Committee’s view, all patients should benefit from unrestricted daily access to the open air, unless there are clear medical contraindications or treatment activities require them to be present on the ward. If necessary, freely accessible and appropriately secure outdoor exercise areas should be installed (which should be reasonably spacious and equipped with a means of rest and a shelter against inclement weather). The CPT recommends that the Swedish authorities provide the North Stockholm Psychiatric Clinic with a designated appropriately secure outdoor area for involuntary patients.
 The rooms were approximately 10-12 m² in size; at North Stockholm Psychiatric Clinic, some rooms were double occupancy.
 At North Stockholm Psychiatric Clinic, the sanitary facilities were shared between two rooms.
3. Staff and treatment
64. The North Stockholm Psychiatric Clinic employed 13 full-time psychiatrists (two further positions were vacant) and 20 junior doctors in training. The nursing staff consisted of 135 nurses (plus 16 vacant posts) and 196 auxiliary nurses. Further, there were four occupational therapists, seven social workers and one physiotherapist. The Hospital did not employ psychologists; due to a relatively short hospitalisation, patients met with the psychologists in the outpatient clinics, after discharge.
The Regional Forensic Psychiatric Clinic in Karsudden was staffed with eight full-time psychiatrists, 66 nurses (six of them part-time) and 355 auxiliary nurses (126 of them part-time). Further, there were five psychologists (of whom one was part-time), three social workers, seven occupational therapists, one addictions therapist and one physiotherapist.
The Regional Forensic Psychiatric Clinic in Sala employed four full-time psychiatrists (one further position was vacant), 33 nurses (plus three vacant posts) and 91 auxiliary nurses. As regards other staff qualified to provide therapeutic and rehabilitative activities, the hospital employed four psychologists, two occupational therapists, three social workers, an addictions therapist, and a family therapist.
Staffing levels on the wards in all hospitals visited were sufficient to provide the necessary treatment and care.
65. The treatment available was based on an individualised approach, involving the drawing up of a written treatment plan for each patient (with the participation of the patient concerned) and its regular review.
In forensic settings, in addition to pharmacotherapy, patients were offered a range of therapeutic and rehabilitative activities (e.g. individual psychotherapy, supportive and group therapy, special education, work therapy, life skills training, art, sports, etc.). In the civil setting, due to normally short periods of stay, the key aim was to address a patient’s immediate needs by pharmacological treatment and counselling offered by psychiatrists and other staff.
66. At Karsudden forensic hospital, the delegation interviewed a patient who had committed sex offences and who was receiving anti-androgen treatment (so-called “chemical castration”) at the time of the visit. According to the patient, this treatment was based on a treatment plan drawn up after an individual psychiatric and somatic assessment; the patient was informed in advance of possible side-effects and gave verbal consent. However, written consent to the treatment was not obtained.
The Committee wishes to stress that, as a matter of principle, anti-androgen treatment should be given on a purely voluntary basis. Free and informed written consent of the patient concerned should be obtained prior to the commencement of anti-androgen treatment, it being understood that consent may be withdrawn at any time; in addition, the patient should be fully informed of all the potential effects and side-effects of the treatment, as well as the consequences of refusal to undergo such treatment. No patient should be put under pressure to accept anti-androgen treatment.
The CPT recommends that the Swedish authorities take steps to ensure that the aforementioned precepts are effectively followed in practice as regards patients receiving anti-androgen treatment in all psychiatric establishments.
67. All the hospitals visited occasionally resorted to electroconvulsive therapy (ECT), as a last-resort measure to treat severe and life-threatening conditions; it was usually carried out at nearby clinics. It was reportedly always applied with anaesthesia and muscle relaxants and was administered by specially trained staff. However, despite the Committee’s previous recommendations, the patients’ written consent was still not sought before undergoing this therapy.
The CPT calls upon the Swedish authorities to take steps, without any further delay, to ensure that patients’ free and informed written consent is always sought before resorting to ECT (and that this be reflected in the relevant documentation).
68. As regards somatic care, at North Stockholm Psychiatric Clinic, patients were physically examined upon arrival by a psychiatrist on the ward. The somatic care in the forensic hospitals visited was reportedly provided by visiting doctors based on agreements with outside clinics.
69. Regarding the Covid-19 pandemic and the response to it of the hospitals visited, the delegation was extremely concerned to find that, unlike in the other hospitals visited, the ward-based staff at Karsudden forensic hospital did not wear any personal protective equipment (PPE), reportedly due to an absence of any regional recommendations to do so.
In the Committee’s opinion, not wearing proper PPE, i.e. at least a surgical mask, in a closed health-care environment during the Covid-19 pandemic, is placing patients at potentially serious risk of harm to their health, or even death. Social distancing might not always be ensured in psychiatric hospitals and psychiatric patients might not always be able to fully understand the risks of Covid-19 and to protect themselves, so it is entirely the duty of the authorities and, more directly, of the hospital staff, to take all possible measures to protect the health of the patients in their care.
The Committee also regrets to note that despite the fact that hospital staff are key vectors of infection, almost nothing was being done, to a differing degree in every hospital visited, to minimise the risk – there was no testing of patients upon admission or returning from home leave, no regular testing of the staff and no testing of contact cases when a patient or a staff member had tested positive.
In this regard, reference is made to the remarks and request made in paragraph 7 above.
 The plan for a forensic patient, for example, covered the following aspects: physical health, mental health, social situation, psychological well-being, physical activity, addictions, risk assessment of reoffending, privileges, etc.
 In this regard, the delegation was very impressed with a new activities building at Karsudden forensic hospital, due to open in the spring of 2021, offering patients a wide range of activities, including training kitchens and “training apartments” (for patients to “rehearse” autonomous living), a music studio, a physiotherapy room, workshops, secondary education classes, canine therapy, etc.
 After a patient’s immediate crisis had subsided, they were discharged and could receive continued help and support via an outpatient clinic.
 At the time of the visit, every county in Sweden had different recommendations regarding the wearing of PPE in health-care establishments, varying from a requirement in Stockholm county for clinical staff to wear both surgical masks and visors to, e.g., Sörmland county, where clinical staff were not required to wear any PPE at all.
 Reportedly, at Sala forensic hospital, there was testing of contact cases (both among patients and staff) as well as of patients upon their return from long-term leave.
4. Means of restraint
70. The recourse to means of restraint (including seclusion) did not appear excessive in the hospitals visited and was well documented. Mechanical restraint (using specially designed magnetic belts) was generally applied for brief periods (of up to a few hours), with a staff member continuously present. Seclusion, in most cases, did not last more than a day. Debriefing of the patient following the application of the means of restraint was mandatory. As required by the law, the Health and Social Care Inspectorate (IVO) was informed every time a decision was taken to extend mechanical restraint for more than four hours and seclusion for more than eight hours.
Generally, all means of restraint had to be ordered by a doctor; in Sala forensic hospital, the delegation was informed that a nurse could exceptionally decide on mechanical restraint or seclusion and subsequently inform a doctor.
71. However, the Committee is concerned to note that the practice of doctors authorising (or confirming) recourse to means of restraint by telephone, without actually seeing and examining the patient, has not stopped, despite the Committee’s recommendation on the matter following the 2015 visit. Reportedly, the relevant legislation requires a doctor to examine the patient only if there is a need to prolong the measure of restraint (mechanical restraint for more than four hours, seclusion for more than eight hours).
In the Committee’s opinion, every resort to means of restraint should always be expressly ordered by a doctor after an individual assessment, or immediately brought to the attention of a doctor with a view to seeking his/her approval. To this end, the doctor should examine the patient concerned as soon as possible.
The CPT reiterates the recommendation that the Swedish authorities take measures, without further delay, to ensure that decisions regarding the application of means of restraint (or its continuation) are taken only after the doctor has personally seen and examined the patient; relevant legislation should be amended, if necessary.
72. At Karsudden forensic hospital, a relatively small number of patients were being subjected to prolonged segregation in their own rooms, reviewed by the psychiatrist every 72 hours. The segregation measures were individualised, based on risk assessment and applied in a differentiated manner, with most patients being segregated for only part of the day and being able to interrupt their segregation several times during the day (i.e. to go to a computer room, take outdoor exercise with staff, have meals together with others, etc.).
73. At the aforementioned establishment, the delegation had some concerns regarding the design of the seclusion suites, namely the vestibule between the two seclusion rooms, where staff would normally sit during the seclusion of a patient, which, in addition to a window into a seclusion room itself, also had a large (almost floor to ceiling, approximately 40 cm wide) window into the sanitary annexe, giving the staff a totally unrestricted view of a secluded patient using the shower or toilet.
In the Committee’s view, such an arrangement unnecessarily challenges patients’ privacy and dignity. The view into such a sanitary annexe should normally be obscured, e.g. by covering the window with a blind or a curtain which the staff could exceptionally open, when required, based on an individual assessment of the patient’s risk of self-harm or other damage. The CPT recommends that the Swedish authorities take measures to address this issue.
 Reportedly, a representative of IVO visited patients kept in segregation for longer than 30 days.
5. Safeguards in the context of involuntary hospitalisation
74. Involuntary psychiatric hospitalisation and treatment in Sweden is governed by two legal acts: the Compulsory Mental Care Act (LPT) and the Forensic Mental Care Act (LRV). The LPT provides the legal framework for civil involuntary hospitalisation of persons who refuse to consent to necessary psychiatric care or who are judged incapable of participating in such care voluntarily, whereas the LRV concerns forensic psychiatric patients sentenced to compulsory treatment pursuant to the Criminal Code, following forensic psychiatric assessment carried out by the National Board of Forensic Medicine. There are two types of forensic procedures: the standard one (LRV) under which the hospitalisation of a person who has committed a punishable act is decided by an administrative court but their release may be decided by a psychiatrist; and a reinforced one (LRV-SUP), under which both the placement and their release (as well as any temporary leave) may only be ordered by a court.
For patients hospitalised pursuant to the LPT, there was an initial review by the administrative court after four weeks, then after four months, and afterwards every six months; for forensic patients hospitalised pursuant to the LRV, the court review was every six months, but for those whose hospitalisation was based on the LRV-SUP, discharge from the hospital also necessitated separate court proceedings. It is noteworthy that an obligatory psychiatric expert opinion (independent of the establishment in which a patient was placed) was provided in the context of the review of the measure of involuntary hospitalisation; the Committee welcomes this development.
Based on interviews with patients and staff and the examination of patients’ files in the hospitals visited, the delegation gained the impression that the applicable legal provisions were duly followed in practice.
However, there are some issues that the Committee finds concerning in the context of involuntary hospitalisation which are presented below.
75. At North Stockholm Psychiatric Clinic, the delegation noted that voluntarily hospitalised patients were not required to sign a form on admission attesting to their voluntary status.
In the Committee’s view, all voluntary patients should be required to sign such a form upon admission. This form should expressly state that voluntary patients are free to leave the establishment and to refuse treatment that they do not wish to take or participate in. Further, patients who are not able to give their valid consent to their hospitalisation should be assessed in order to establish whether they fulfil the criteria for involuntary admission. The CPT recommends that the Swedish authorities take steps to ensure that these precepts are respected in all the psychiatric hospitals of the country.
76. As regards the involuntary medical treatment of patients who are hospitalised against their will, the CPT must once again reiterate the importance of distinguishing the need for involuntary hospitalisation from the need for a specific medical treatment. As already explained several times in the past, the Committee has serious misgivings that in Sweden involuntary hospitalisation of a psychiatric patient continues to be construed as automatically authorising treatment without his/her consent. Despite the Committee’s repeated recommendations, the Swedish authorities have not taken measures to introduce a procedure whereby all psychiatric patients are placed in a position to give their free and informed consent to medical treatment and, if they require to be treated against their will, appropriate safeguards are put in place.
During the 2021 visit it was found that the practice continued whereby doctors obtained patients’ verbal consent to treatment, but there was no written proof that such informed consent had been given. Further, a patient’s refusal or subsequent withdrawal of consent to treatment did not result in an external independent psychiatric review as to whether treatment could be provided against the patient’s will.
77. Therefore, the CPT once again calls upon the Swedish authorities to introduce at all psychiatric establishments in Sweden, without further delay, a procedure whereby patients’ free and informed consent to treatment is actively sought and every patient capable of discernment is given the opportunity to refuse treatment or any other medical intervention. The relevant legislation should be amended so as to stipulate the fundamental principle of free and informed consent to treatment, as well as to clearly and strictly define the exceptional circumstances that may cause any derogation from this principle.
The relevant legislation should also be amended so as to:
– require an external psychiatric opinion, entailing examination of the clinical records (including the proposed written treatment plan) and consultation with the patient, with the relevant psychiatrist and clinical staff involved, in any case where a patient does not agree with the treatment proposed by the hospital’s doctors. The contested treatment(s) should then only be applied in the case of a written concurring external psychiatric opinion;
– provide patients with the possibility to appeal against a proposed treatment to an independent outside authority and to receive the respective decision within an appropriately short timescale.
It should further be ensured that the patient’s consent or refusal to treatment is in any case recorded prior to its commencement.
78. The delegation gained a positive impression of patients’ possibilities to maintain contact with the outside world. Patients at North Stockholm Psychiatric Clinic could generally retain their mobile phones and had free access to the internet; patients in the two forensic hospitals visited could freely use phones on the wards, as well as book time to use computers (with some websites restricted).
At the time of the CPT’s visit, visits to patients were banned at North Stockholm Psychiatric Clinic and Sala forensic hospital due to the Covid-19 pandemic. The Committee recommends that the Swedish authorities review the total ban on visits to patients in psychiatric hospitals, instituted in response to the Covid-19 pandemic, and take steps to ensure that patients can receive such visits in safe conditions, respectful of requirements for physical distancing and with the deployment of PPE as indicated.
79. At Sala forensic hospital, the delegation met a patient who was legally considered as a remand prisoner and was subjected to restrictions, due to which he was reportedly not allowed to participate in any activities or use the telephone (except for contacting his lawyer), the gym, the library or the computer room; he was also required to wear a green prison uniform. The Committee reiterates its view expressed in the report on the 2015 visit that such an approach vis-à-vis persons with severe mental disorders (necessitating a period of hospitalisation and treatment) is discriminatory, potentially humiliating and highly likely to be detrimental to their mental health and treatment prospects; the imposition of such restrictions on such patients should be avoided and decisions restricting access to activities with therapeutic benefits in hospitals, should be individually decided upon and clinically based.
80. According to the management of Sala forensic hospital, there were a few patients who no longer needed to be hospitalised but who required supported residential accommodation in the community, which was not available at the time; at Karsudden forensic hospital, there were also, reportedly, three such patients.
The Committee notes the adoption, in 2018, of the Act on collaboration regarding discharge from inpatient health care. Reportedly, the aim of this law is to strengthen co-operation between the social services, the municipally funded health-care system and the region-funded outpatient care system, so as to assist persons in need of further health care/support after their discharge from inpatient care. The law seeks to ensure that a person is discharged as soon as it has been assessed that their inpatient care is no longer necessary.
In the Committee’s view, involuntary placement in a psychiatric establishment should cease as soon as it is no longer required by the patient’s mental state. The CPT would like to be informed about the measures being taken to transition this group of patients from all psychiatric hospitals in the country to appropriate care structures in the community.
 One such patient had reportedly been waiting to be discharged for the previous three years, a few more had been waiting between five to ten months.
 The new law regulates increased co-ordination around the patients’ needs, including increased collaboration between care providers, better co-ordination procedures when a patient receives a so-called co-ordinated individual plan, and certain payment responsibilities between the regions and the municipalities.
E. Homes for young persons
1. Preliminary remarks
81. In Sweden, compulsory care for young persons with psychosocial problems is provided in special residential homes under the authority of the National Board of Institutional Care (Statens institutionsstyrelse, or SiS). SiS provides care and treatment where voluntary interventions have proved insufficient and compulsory care is therefore necessary.
Under the Care of Young Persons Act (LVU), an administrative court may, upon application by the local social services, order compulsory care for a young person aged 12–21 years’ old whose health or development is at risk as a result of the situation at home, substance abuse/addiction, criminal activity or other socially damaging behaviour. The duration of the compulsory care is not fixed, but its continuing need is reviewed by social services every six months.
Further, by virtue of the Secure Youth Care Act (LSU), a district court may sentence a young person aged 15-20 years old, who has committed a serious criminal offence, to secure youth care in a designated institution; such placements can last between 14 days and four years.
SiS is supervised by several bodies, including the Health and Social Care Inspectorate, the Swedish Schools Inspectorate, and the Parliamentary Ombudsmen (JO).
82. The CPT’s delegation visited, for the first time, the Sundbo Home for Young Persons in Fagersta and revisited the Bärby Home for Young Persons in Uppsala, first visited by the CPT in 2003.
83. The Sundbo Home, established approximately a century ago, is located in a green area by a lake, 8 km outside the town of Fagersta in Västmanland County, in central Sweden. With an official capacity of 39, at the time of the visit, the Home was accommodating 32 boys (12 under LVU placement and 20 under LSU placement). The residents were aged between 16 and 19 years and came from all over Sweden. The Home consists of 6 units (5 secure local and 1 open remote), each in a separate one-storey building:
– Nygård – 8 places, a unit mostly for LSU placements, focusing on addictions and violence;
– Persbo – 7 places, an assessment unit for LSU placements;
– Sjögården – 5 places, a unit for LVU placements, focusing on trauma and addiction treatment;
– Strandgården – 8 places, a unit for the most challenging young persons;
– Wengen – 6 places, a unit for the treatment of anti-social behaviour;
– Räddningstjänsten – 5 places, an open phasing-out unit located 40 km from the Home.
84. The Bärby Home, opened in 1959, is located 12 km outside the city of Uppsala. With an official capacity of 51, at the time of the visit the Home was accommodating 37 boys (32 under LVU placement and 5 under LSU placement). The residents were aged between 15 and 20 and came from all over Sweden. The establishment consists of 5 secure units, each in a separate one-storey building:
– Garanten – 7 places, a unit for young sex offenders;
– Höjden – 8 places, an assessment/admission unit;
– Klockbacka – 8 places, a unit for the most challenging young persons;
– Sirius – 21 places, a unit for addiction treatment;
– Tunet – 7 places, a unit for young sex offenders.
85. The majority of the young persons interviewed by the delegation spoke positively about the staff. However, the delegation received a single allegation of physical ill-treatment, in Sundbo Home, where a staff member had allegedly punched a young person in the face and kicked him in the ribs. Furthermore, in Bärby Home, a young person complained that he had been insulted by a staff member in a racist manner. Both incidents had been reported to the administration by the young persons concerned and the necessary actions had reportedly been taken.
While taking due note of the above, the CPT recommends that the Swedish authorities regularly deliver a clear message to staff in the homes for young persons that all forms of ill-treatment, including verbal abuse, are not acceptable and will be punished accordingly.
86. Violence between young persons did not appear to be a major problem in the Homes visited; the young persons interviewed by the delegation said that they felt safe and that staff were always nearby and intervened quickly if necessary.
 There are 22 special residential homes that can accommodate up to 700 young persons in total. All the institutions provide care to young persons with psychosocial problems, drug addiction and/or criminal behaviour who are placed into these institutions under LVU.
Six of the 22 homes also accommodate young persons who have committed serious criminal offences and are placed in secure youth care on LSU grounds.
In addition, SiS operates 11 residential homes for substance abusers which treat adults with serious problems relating to abuse of alcohol, drugs and/or prescription drugs. Here, care is provided under the Care of Substance Abusers Act (LVM).
 According to the statistics provided by the Swedish authorities, in 2020 there were 1,113 young persons (405 girls and 708 boys) who had received care in residential homes under LVU.
 In Sweden, the age of criminal responsibility is 15 years. Young people can be sentenced to prison only in very special circumstances, and for those under 21 years’ old the maximum sentence is 10 years’ imprisonment.
Young persons can only be sentenced to secure youth care if the crime was committed between the ages of 15 and 18 years. However, the sentence can be served up to the age of 21 years. Most of those sentenced to secure youth care are boys. The majority have committed serious violent crimes: robbery, aggravated assault, rape, manslaughter, or murder.
 According to the statistics provided by the Swedish authorities, in 2020 there were 61 young persons (all boys) cared for in residential homes under LSU.
 See the report on the visit at https://www.coe.int/en/web/cpt/sweden.
 Two more were absent at the time of the visit – having absconded and not yet been found.
 The unit re-opened with a new name and new staff in November 2019, after it had been closed for a year following the inspection of the Parliamentary Ombudsman which had reported allegations of physical ill-treatment by the staff.
 Three more were absent at the time of the visit – they had absconded; two of them had still not been found, one had recently been found and was due to be returned shortly.
 Sirius unit was divided into 4 sub-units – 3 places for admission/detoxication (usually lasting one week), 7 places in the ‘motivation’ sub-unit (an 8-week placement), 7 places in the sub-unit for persons needing more extensive addiction treatment, and 4 places for phasing-out in the semi-open Bågen sub-unit, located some 20 km away.
2. Living conditions
87. Material conditions varied between the different units of the Homes but were generally of a good standard and offered a positive environment, despite the specific secure arrangements; the living areas were in a good state of repair and clean. Every young person had his own personalised room (with a sanitary annexe) which was of sufficient size (11 m² or more), adequately furnished, well ventilated, and had good access to natural light. The common areas in each unit comprised of open-plan kitchens, a dining table, sofas and television sets.
In addition, both establishments had schoolrooms, hobby-workshops, a gym and a sports hall, and a well-equipped sports ground.
 Units for the most challenging young persons were surrounded by a high barbed wire fence: at Bärby Home, the Klockbacka and Sirius units, at Sundbo Home the Strandgården unit.
3. Staff and regime
88. Staffing levels at both Homes appeared to be satisfactory to provide the care required. At Bärby Home, the number of staff present on the units varied from three to four (e.g. Tunet and Garanten units) to six in Klockbacka unit. At Sundbo Home, there were usually three or four staff members in units like Wengen or Persbo and seven staff members in Strandgården, the unit for the most challenging young persons. At both establishments, each resident was assigned a contact person from amongst the staff.
As regards other multi-disciplinary staff, Bärby Home employed three nurses, five psychologists, three addiction therapists, and an occupational therapist. At Sundbo Home, there were two nurses and four psychologists; reportedly, an external occupational therapist was recruited, when necessary.
89. The delegation gained a generally positive impression of the daily regime offered to young persons. In the morning, residents attended classes in small groups, the afternoon (after 3 p.m.) being reserved for sports activities (gym, football, basketball, weight training, yoga), arts (music room, art studio), recreation (fishing, billiards), etc. Vocational training was also provided, e.g. carpentry, welding, vehicle maintenance, driving a forklift, etc.
Individual care plans had been prepared for each resident and were regularly updated; young persons were involved in the development of such plans. The support provided to residents included individual and group therapy provided by psychologists (including cognitive behavioural therapy (CBT) and dialectical behavioural therapy (DBT)), aggression replacement training (ART), relapse prevention (RP), and motivational interviewing (MI). Treatment of addictions was based on the 12-step Minnesota programme as well as the educational programme developed by SiS and adapted for young persons.
 Although the contact person helped with practical matters, such as buying clothes, their key function was to assist in communication with family and social workers.
 The delegation was informed that due to the Covid-19 pandemic some of the activities had been suspended.
 All young persons had a treatment planner or LSU co-ordinator who had an overall picture of the need for care and treatment and was responsible for ensuring that the planned treatment was carried out.
 A treatment method for substance addictions, behavioral addictions and compulsions developed in the USA in the early 1950s, see https://www.hazeldenbettyford.org/articles/the-minnesota-model.
4. Health care
90. As regards health care, Bärby Home was visited by a general practitioner and a psychiatrist once a week. Sundbo Home was visited by a psychiatrist once every two weeks and visits to a general practitioner were arranged if needed.
The delegation was informed that, following SiS guidelines, the first medical examination upon admission took place within two weeks. Examination of medical files revealed that it usually did not take that long but it was never carried out within 24 hours of admission. There was also no mandatory medical examination of young persons re-admitted to the establishment after an escape.
Further, there was no systematic screening for transmissible diseases (including sexually transmitted ones) and no review of the young persons’ vaccination history.
91. In the Committee’s view, all juveniles deprived of their liberty should be properly interviewed and physically examined by a health-care professional as soon as possible after their admission to a place of detention; save for in exceptional circumstances, the interview/examination should be carried out on the day of admission.
If properly performed, such medical screening on admission should enable the establishment’s health-care service to identify young persons with potential health problems (e.g. drug addiction, suicidal tendencies, etc.). The identification of such problems at a sufficiently early stage will facilitate the taking of effective preventive action within the framework of the establishment’s medico-psycho-social programme of care.
The CPT recommends that all young persons, including those re-admitted after an escape, are given a comprehensive medical examination by a health-care professional as soon as possible, and no later than 24 hours after their admission; the examination procedure should include screening for transmissible diseases.
Further, all juveniles accommodated in homes for young persons should be included in the national immunisation programme and an individual vaccination plan should be set up for each juvenile upon admission.
92. Regarding the Covid-19 pandemic and the response to it of the Homes visited, the delegation was very concerned to note that staff working in close contact with detained young persons did not wear any personal protective equipment (PPE) at Bärby Home, and at Sundbo Home they only wore face shields which, according to the WHO, do not provide equivalent protection against infection. There was also no Covid-19 testing of young persons upon admission, no regular testing of the staff, and no testing of contact cases when a young person or a staff member tested positive.
In this regard, reference is made to the remarks and request made in paragraph 7 above.
 The benefit of an expeditious examination upon re-admission following an escape can be demonstrated by an example from Sundbo Home from January 2021 where, following an examination by a nurse the day after the re-admission, a young person had been sent to hospital, where a suspicion of a fractured shoulder had been confirmed.
5. Means of restraint
93. Section 15c of the Care of Young Persons Act (LVU) authorises the use of seclusion, if it is absolutely necessary, when a young person is behaving violently or is so intoxicated that he/she presents a danger to himself/herself or others. The young person in seclusion must be under the continuous supervision of staff and should be able to call for staff assistance at any moment.
The Committee welcomes the 2018 amendments to the LVU and LSU which shortened the maximum allowed time for seclusion from 24 to four hours (but for no longer than is absolutely necessary).
The law requires a doctor or a nurse to give an urgent opinion on the application of seclusion. If a doctor or a nurse so requests, seclusion must be discontinued immediately. Following the application of means of restraint, the young person concerned must be offered a debriefing.
94. During the interviews with the health-care staff in both Homes, the delegation was informed that when a decision to seclude a young person was taken by the Director or the person in charge, a nurse was consulted by telephone to assess whether there were any reasons why seclusion should be discontinued. Outside regular working hours, such a consultation was provided by one of the three nurses from Bärby Home on call.
Based on the interviews with young persons, the staff, and the examination of records, the delegation gained the impression that the use of seclusion was not excessive in either of the Homes visited and lasted 30 to 45 minutes on average, also that a debriefing following the seclusion took place regularly. The majority of the units had one or two seclusion rooms, measuring some 6 or 7 m² and equipped with mattresses placed on the floor.
95. Section 15d of the Care of Young Persons Act also authorises the segregation (‘separate care’) of a young person, preventing him or her from associating with other residents, if required due to his or her special care needs, his or her safety or the safety of other individuals. A decision on separate care must be adapted to the young person’s individual care needs, is taken by the Head of the institution, and reviewed on a weekly basis.
Both Homes had well-equipped separate care suites (a living room, a bedroom, and adjacent sanitary facilities). Residents placed in separate care were prevented from participating in group activities but continued their schooling with teachers on an individual basis, had exercise outside accompanied by a staff member and could invite staff to spend time with them.
The delegation gained the impression that the use of separate care was not excessive in either of the Homes visited and that its application was regularly reviewed as required by the law. At the time of the visit, there was no one in separate care at Bärby Home and three young persons in separate care at Sundbo Home.
 Identical provisions of the Secure Youth Care Act regulate the seclusion of young persons detained under LSU.
 Upon such a call, a nurse was obliged to check the online seclusion form which was attached to every resident’s personal medical file and had relevant health information entered during the first medical examination upon admission (the form was regularly updated after any change to mental and/or somatic health issues). The other issues examined also included information on the person’s breathing, whether he/she was subjected to any violence, whether there were any injuries, etc.
 Nurses from Bärby Home were the only ones who had access to the medical files of all the young persons accommodated in SiS institutions all over the country and were thus mandated to provide consultation outside of working hours.
 At Bärby Home, 15 young persons had been placed in seclusion in 2020 (from a total of 41 cases), at Sundbo Home, 22 young persons had been placed in seclusion in 2020 (from total of 59 cases).
 Two separate care suites in two units in Bärby and three separate care suites in one unit in Sundbo.
 At Bärby Home, 50 young persons had been placed in separate care in 2020; at Sundbo Home, 47.
 One in separate care for a week, another for two weeks, another for the last two months (during an interview with the delegation, the young person concerned stated that he had requested to be put in separate care for his own safety due to perceived possible retaliation from a victim’s family).
6. Other issues
96. As regards young persons’ contact with the outside world, the arrangements were fully satisfactory. The residents had free access to phones and computer tablets in the units (residents in Sundbo Home were also allowed to use their own mobile phones for one hour per day and had at least one hour of internet access per day. Every unit had a visit room and visits could be arranged any day of the week; permission for home leave was also regularly granted.
97. Every unit had information brochures, in several languages, which provided young persons with the relevant information on their rights, the institutions’ daily routines, and the avenues of complaint.
98. Some of the young persons interviewed informed the delegation that during occasional body searches they had to undress fully when being strip-searched by the staff.
The CPT considers that a strip-search is a very invasive and potentially degrading measure and should only occur when absolutely necessary and based on justifiable risk. When carrying out such a search, every reasonable effort should be made to minimise embarrassment and maintain as much dignity as possible; detained persons who are searched should not normally be required to remove all their clothes at the same time, e.g. a person should be allowed to remove clothing above the waist and put the clothes back on before removing further clothing.
The CPT recommends amending the current practice used in homes for young persons when carrying out strip-searches to bring it into line with the precepts set out above.
 At Sundbo Home, there were also two visiting facilities where a family could stay overnight, either together with the young person concerned or not.
 Day leave to a neighbouring town had been temporarily suspended due to the Covid-19 pandemic.
APPENDIX List of the establishments visited by the CPT’s delegation
– Norrmalm Police Department, Stockholm
– Södermalm Police Department, Stockholm
– Solna Police Department, Stockholm
– Avesta Police Department
– Malmö Police Department
– Ystad Police Department
– Helsingborg Remand Prison
– Trelleborg Remand Prison
– Ystad Remand Prison
Migration Agency establishments
– Migration Agency Detention Centre, Åstorp
– Migration Agency Detention Centre, Ljungbyhed
– Regional Forensic Psychiatric Clinic, Karsudden
– Regional Forensic Psychiatric Clinic, Sala
– North Stockholm Psychiatric Clinic
Homes for young persons
– Bärby Home for Young Persons, Uppsala
– Sundbo Home for Young Persons, Fagersta