- 80 252. The delegation was informed that isolation was imposed on the nursing staff's own initiative, without doctors' orders. Furthermore, the staff had no instructions as to the therapeutic object of this measure or concerning the exact procedure to be followed in the event of its application. On this subject, the staff declared that when a patient was put in an isolation room, the door was never locked and the patient was supervised by a staff member at all times. However, in pavilion Z, where all three rooms were occupied at the time of the visit, none of these rules were being observed. The delegation felt there was a serious risk of isolation being used by the staff as a punishment for what they might regard as patients' misbehaviour. Such an attitude would, of course, be unacceptable. 253. As to instruments of physical restraint, in the institutions visited in Athens and Rafina, the delegation observed that they were frequently applied and, furthermore, in a potentially dangerous manner. At the Attica State Mental Hospital, the standard method was to immobilise the patient by means of a padlocked strap on one arm and another strap on the opposite leg. This very incapacitating method was used even on elderly patients and constitutes a potentially dangerous procedure for an agitated patient. The delegation actually saw this method being applied in unit Tastsoglio E1 to a patient who had just been brought in by the police. This agitated patient's efforts to break free placed him in a painfully contorted position. What is more, the patient - wearing the same clothes and raincoat as on admission - was confined in full view of other patients in the unit. The delegation considered this situation harassing and degrading for the patient, as well as distressing for the unwilling onlookers. At the Attica State Mental Hospital for children, the delegation saw a girl whose limbs were secured to the bed with ligatures made of gauze bandages. The ligatures on one limb were obviously too tight and had caused circulatory disorders (cyanosis and hypothermia). The staff, alerted to this state of affairs by the delegation, were unaware of the ill-effects which could result from partial obstruction of blood circulation. 254. At Leros, the delegation observed no physical restraint of patients although it did see leather straps for that purpose. Admittedly, the patients' adverse clinical evolution had made them indifferent and apathetic so that there was seldom any cause to resort to physical restraint. 255. As was the case for isolation, in no establishment did the delegation find evidence of instructions issued to staff on the use of instruments of physical restraint, or of any guidance regarding the therapeutic expediency of such a measure. It was applied without medical supervision and without a written record being made. Such a situation, where the decision to use instruments of physical restraint is left to the discretion of a nursing staff which is untrained and numerically inadequate having regard to the number of patients in its care, leads the CPT to conclude that there is a serious risk of physical restraint being used in excess of requirements.