Date of incident: January 2015
Notice of incident number: 2015145500005
Employers: Regional health authority; Home care services company

Incident summary
A community health worker (employed by a regional health authority) and a caregiver (employed by a home care services company) were providing home support to an elderly couple in a private residence. While the workers were moving the wife with a lifting device from a bed to a wheelchair, the husband, who had dementia, woke up. The workers did not see him leave the room and then re‑enter the bedroom with a kitchen knife. He stabbed the community health worker in the chest. Both workers also experienced psychological trauma.

Investigation conclusions

Cause

• Workers not told about male client’s dementia diagnosis: The regional health authority knew that the male client had been diagnosed with dementia; however, the community health workers had not been told. Care plans by the regional health authority and the home care service provider did not include a shift report or exchange of information. The male client had exhibited a potential for violence prior to the incident. The elderly male with dementia stabbed the community health worker after waking up and seeing her and the caregiver attending to his spouse.

Underlying factors

• Incomplete risk assessments: Risk assessments completed by the regional health authority prior to the couple returning home from hospital were incomplete. Not all information in the possession of the regional health authority was considered in its totality when providing information and instructions to workers. When there was increased tension and agitation, including violent incidents and threats of violence in the home, there was no reassessment of risk. The regional health authority did not minimize the risk to workers by ensuring that complete risk assessments, ongoing training in violence prevention, and appropriate instruction and information were given to workers.
• Inadequate training, instruction, information, and supervision: The community health worker did not receive adequate training, instruction, information, and supervision after being hired. The regional health authority’s written commitment to ongoing training was not fulfilled. The community health worker had not taken the current violence prevention training program. The community health workers and the caregivers were not informed sufficiently about the diagnosis and behaviours of the male client. As a result, the workers did not recognize events that were occurring as potential predictors for aggressive or violent behaviour by the male client. In addition, there was no formalized shift report between the two providers of care in the home.

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