Visit Report – Agder prison, Mandal unit

Table of contents

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• Visit report Agder prison Mandal unit 2025.pdf

I.Visit to Mandal – investigation into the use of security cells

The Parliamentary Ombud’s mandate to prevent torture and inhuman treatment

People who are deprived of their liberty are vulnerable to violations of the prohibition against torture and inhuman treatment. The Optional Protocol to the UN Convention against Torture requires states to establish a body to prevent people deprived of their liberty from being subjected to torture and other cruel, inhuman or degrading treatment or punishment. This mandate is fulfilled in Norway by the Parliamentary Ombud’s National Preventive Mechanism (NPM).

In prisons, the use of security cells and restraint beds are coercive measures that involve a high risk of inhuman or degrading treatment. The NPM has therefore examined the use of these coercive
measures in selected prisons.

The NPM’s visit to Agder Prison, Mandal Unit

The Parliamentary Ombud’s NPM visited Mandal Prison from 24 to 26 March 2025. The prison was not notified in advance. During the visit, the team inspected the security cells and the corridor with the restraint bed, conducted 21 interviews with prisoners and staff in the prison and with staff in the municipal health service, and collected extensive documentation from both the prison and the health service.

We examined the use of both security cells and restraint beds during the period 1 January 2024 to 26 March 2025. During this period, the prison issued 16 decisions on the use of security cells and none on the use of a restraint bed.

Mandal Prison

Agder Prison, Mandal Unit (hereafter Mandal Prison), housed 87 prisoners at the time of the visit. The prison has 100 high-security places for men and opened in 2020.

It consists of five buildings. It has two security cells and one restraint bed, located next to the health unit and a residential unit called S+. The security-cell section has its own staff office and a dedicated exercise yard.

The restraint bed was in the same section as the security cells. S+ is a smaller residential unit with three reinforced cells and a shared living area with a kitchen that was linked to Unit S. Unit S was used for remand prisoners subject to court restrictions and for prisoners who had difficulties living in the ordinary residential units.

Health unit

Lindesnes Municipality is responsible for providing primary health-care services to the prisoners. The health service in the prison consists of two doctors, five nurses and a physiotherapist, several of them in part-time positions. The health unit is open on weekdays from 7:30 a.m. to 3:00 p.m.

Outside these hours, the prison must contact the municipal emergency service.

II. Summary

Placement in a security cell is a coercive measure that exposes the prisoner to a high risk of inhuman or degrading treatment.

The Parliamentary Ombud’s NPM therefore examined the use of security
cells in Agder Prison, Mandal Unit. During the investigation period, 1 January 2024 to 26 March 2025, the prison made 16 placements in a security cell.

Burdensome physical conditions

The two security cells were in a separate section, apart from the other units. The cells were small.

The lighting conditions and the possibility of looking out were relatively good, however the acoustics were very poor, which made it difficult to talk and hear inside the cell.

With few sensory stimuli, staying in the cell was burdensome for prisoners.

Deficiencies in the care of prisoners placed in a security cell

Prisoners described the stay at the security-cell as distressing and difficult. The prison did little to actively reduce the harmful effects of security-cell placement, which was particularly serious for prisoners with long and repeated placements. In seven cases, 10 hours or more passed before the
prisoner was offered food, and in three cases it took nearly a whole day.

There was no running water in the cells, making it impossible to maintain personal hygiene.

Serious weaknesses in security-cell decisions and continuation reviews

The prison’s decisions to use the security cells had serious shortcomings. Grounds for placement often lacked an explanation of why the measure was strictly necessary and which less intrusive measures had been attempted first. Nor did they include an assessment of whether the intervention was proportionate for the individual prisoner. Taken together, these deficiencies made it difficult to verify the legality of the decisions.

The prison is obliged to reassess continuously whether the legal conditions for continued placement are met. In some cases, more than 20 hours passed between assessments. Many were weak, and several placements were so poorly justified that their legality was questionable.

No assessments were made at night. In some cases, the prison did not end the stay until the prisoner had apologised for their behaviour, which is not consistent with the law. Overall, this created a clear risk that prisoners remained in a security cell even after the strict legal conditions were no longer met. The prison must work actively to terminate the measure as soon as possible, bearing in mind that the placement itself may affect a prisoner’s ability to co-operate or communicate.

Placements with a particularly high risk of inhuman or degrading treatment

Two prisoners had repeated and prolonged stays in a security cell. The documentation lacked assessments of how these stays affected them, even though such consideration is central to assessing proportionality.

In one case, the prison assumed that the prisoner wanted to be placed in a security cell. A prisoner’s wish is not a legal ground for such placement and may indicate isolation-related harm.

The prison made too little effort to bring these placements to an end. Both prisoners remained in a security cell despite being calm, and 18–23 hours passed between each continuation assessment. The prison carried out no systematic evaluation of its use of security cells, which is particularly concerning for repeated or lengthy placements.

Need to strengthen health-care follow-up in the security cell

In seven of the 16 placements, no health check was carried out by medical staff. Five of these placements lasted more than 12 hours, and two lasted more than 60 hours. One prisoner, who had five stays in a security cell, received a health check only once.

III. Recommendations

Decision on security-cell placement

• The prison must ensure that a security cell is used only when strictly necessary, less intrusive measures have been attempted or assessed, and the intervention is proportionate.
• The prison must document a concrete justification showing that all statutory criteria for using a security cell are met, and the prisoner should be given an opportunity to be heard.
• The prison should not use a security cell to prevent or manage self-harm or attempted suicide.

Follow-up of prisoners in a security cell

• The prison should ensure that an individual assessment is always made, and documented, when handcuffs are used, a body search is performed, or clothing is removed in connection with security-cell placement.
• The prison should ensure that prisoners in a security cell are provided with adequate food.
• The prison should ensure that it is possible to maintain personal hygiene in a security cell, regardless of whether the prisoner requests it.
• The prison should ensure that health personnel are notified immediately of every placement in a security cell.
• The prison should strengthen follow-up of prisoners in a security cell to prevent isolation-related harm. Follow-up should help end the placement as quickly as possible.
• The municipality should ensure daily supervision and follow-up of prisoners placed in a security cell, and that this is documented in the medical record.
• The municipality should ensure that every placement in a security cell is recorded in the medical file, even when no health visit has taken place, and that the record includes concrete information about the physical conditions, the intrusiveness of the measure and any use of force.

Assessment of continuation or termination

• The prison should work actively to end a security-cell placement as soon as possible.
• The prison should ensure that ongoing assessments are made of whether the legal conditions for continued placement are met, and that these assessments are documented at least every six hours.
• The prison must ensure that a security-cell placement ends immediately once the statutory conditions are no longer met.

Security-cell placements with a particularly high risk of inhuman or degrading treatment

• The prison should introduce special measures to prevent prolonged and repeated use of the security cell.

Preventing the use of security cell

• The prison should strengthen its efforts to evaluate and prevent the use of security cells and involve prisoners in this work.