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Nurse assaulted by patient in psychiatric care facility

Date of incident: April 2015
Notice of incident number: 2015157580019
Employer: Public health care provider

Incident summary
A registered nurse was performing her regular duties in a secured area of a tertiary psychiatric care facility when she was physically assaulted by a patient with a history of aggressive behaviour and assaults. Several other nurses intervened and stopped the assault. The nurse sustained serious injuries.


Investigation conclusions


  • Nurse was injured after exposure to a known workplace hazard. The high risk of violence from the patient had been identified and was well understood by the staff at the psychiatric care facility. When the nurse came into close proximity to the patient, she was physically assaulted while performing her normal duties.

Contributing factors

  • Hazard control inappropriate for level of risk. The patient’s records and an assessment conducted at the psychiatric care facility indicated that the patient presented a high risk of aggression and could inflict serious injury on staff. Previous to this incident, the patient had assaulted a fellow patient and workers at the facility. After both assaults, planned Code White procedures were used whenever workers were required to leave the secure nurse station and were exposed to the potential of further violence from the patient. (Code White procedures are a control measure intended to mitigate the duration and exposure of aggression or potential aggression from patients to workers.) On the day of the incident, however, the planned Code White procedures were not instituted, and the nurse was permitted to work unaccompanied in close proximity to the patient as she performed her regular duties, such as dispensing medication and providing care to other patients. Without the presence of many nurses as specified in the planned Code White procedures, the risk of violence on the part of the patient was not controlled. Once the assault began, it was stopped only after several other nurses intervened.
  • Mitigation measures did not perform as expected. The nurse’s training in physical manoeuvres for dealing with a violent person was not augmented by practical experience. When the assault began, the nurse was forced to immediately adopt a defensive posture and was unable to use any of the tactics learned in the classroom. Similarly, the duress badge she wore proved to be of no benefit because the nurse’s hands were completely occupied with her self-defence, and she simply could not press the duress badge to summon help.
  • Inadequate supervision. Given the patient’s past violent behaviour, high-level management at the psychiatric care facility was involved in developing and updating the patient’s care plan, and supervisory support was provided to the affected workers. After the patient had spent time in seclusion for two violent incidents at the facility, there was little change made to the behaviour management strategies that staff were to follow after the patient was released from seclusion. Thus, the same hazardous situation resulting in violence by the patient was allowed to develop repeatedly. After the first instance of violence, the care plan should have been revised and supervisory oversight instituted to ensure that workers did not approach the patient unaccompanied.

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Publication Date: Feb 2019 Asset type: Incident Investigation Report Summary NI number: 2015157580019