1. Summary in English

In 2020-21, the county governors conducted an audit concerning patients who are unable to give consent and do not wish to receive essential healthcare. They also investigated whether healthcare is, wherever possible, being provided without coercion. The audit considered whether:

1. Resistance to healthcare from patients is being picked up.
2. Resistance from patients is being followed up through confidence-building measures.
3. The ability of patients to give consent is being assessed, and the persons responsible for healthcare provision are assessing whether the healthcare should be provided through coercion.
4. Coercive healthcare is being continuously evaluated while it is being provided.

The audit was conducted in nursing homes and among home-based services in a total of 55 municipalities. The audit was conducted in the form of a system audit and self-assessments, with a total of 30 system audits and 27 self-assessments.

What did we find?

Regulatory breaches were identified in 19 of the 30 system audits. All but two municipalities found deviations from one or more of the requirements in their self-assessments. 

The breaches indicate that the regulations set out in Chapter 4 A of the Patient and User Rights Act are not sufficiently well-understood and are not being adequately incorporated into the services concerned. Among other things, we found that:

• Resistance to healthcare from patients is not always picked up.
• The ability of patients to give consent is not always assessed.
• Patients often receive confidence-building measures, but they are inadequately planned, followed up and evaluated by healthcare professionals.
• Patients do not always receive a decision concerning compulsory healthcare when they need one.
• The patient's decision concerning coercion is not always evaluated.
• Patients encounter healthcare professionals with insufficient knowledge and competence in applying the regulations, and a lack of agreed practice.
• Patients encounter services where it is not always clear who is responsible for the healthcare.
• Patients encounter services with unclear guidelines and an inadequate overview of risk areas.

A serious consequence of these circumstances is that patients are being subjected to unlawful coercion when healthcare is provided. Examples of this emerged during the audit. If there is no decision on the use of coercive measures, the patient has no decision to appeal against and is in reality not covered by due process. A lack of understanding regarding how the regulations are to be practised also puts patients at risk of not receiving essential healthcare, even when they meet the conditions for coercion.

The purpose of providing essential healthcare to patients who do not have the capacity to give consent and guarantees of due process to patients who receive healthcare through coercion is thus not being fulfilled.

The findings of this audit were also identified during the audit of coercive somatic healthcare during the period 2011-2012 ("Doubts over coercion", report from the Norwegian Board of Health Supervision 5-2013). The Norwegian Board of Health Supervision considers it a serious matter that the same failings that were discovered on that occasion still exist ten years later. The Norwegian Board of Health Supervision believes there is reason to question whether the authorities are providing sufficient professional guidelines and support for the continuing need for competence development within the area of coercive somatic healthcare. The Norwegian Board of Health Supervision will follow up the report and the audit’s findings through a closer dialogue with the relevant competent authorities.

The Norwegian Board of Health Supervision makes the following recommendations to the municipalities:

• Municipalities must ensure that employees possess the requisite knowledge and expertise to ensure that patients are not subjected to unlawful coercion or put at risk of not receiving essential healthcare. This entails a responsibility not only to provide training and guidance, but also to monitor to ensure that competence-enhancing measures are implemented and that such measures result in health professionals being confident in the application of the regulations.

• Municipalities must ensure the clear delegation of responsibilities, tasks and authorities within the area of coercive somatic healthcare. It must be clear who is responsible for the healthcare provision, and municipalities must ensure that employees are aware of the delegation of responsibilities and tasks.

• Municipalities must ensure that the necessary information is continually recorded in the patient's medical records and facilitate a good flow of information between the healthcare professionals involved and the person responsible for the healthcare.

Ongoing improvements are necessary to ensure that patients receive essential health-related assessments and healthcare.  Municipalities must use information concerning their own practices, identify risks and implement and monitor to ensure that measures that they implement are having the desired effect.