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Residential care workers and resident assaulted by another resident

Date of incident: July 2016
Notice of incident number: 2016163050023
Employer: Residential social service facility

Incident summary

At a residential care home, two workers and a resident were assaulted by a second resident. All three of the people who were assaulted sustained injuries that required medical attention at a hospital.

Investigation conclusions


Known risk of violence to workers was not minimized: Acts of violence against workers performing their job duties at the residential care home were frequent and were a known hazard in the workplace. The employer had trained its workers and implemented hazard controls to address the issue, but these efforts failed to constitute an effective system that minimized the risk of violence. This failure resulted in a serious incident in which two workers and one resident were injured and required medical treatment.

Underlying factors

Ineffective training and supervision: The resident who attacked the workers and the other resident in this incident had a history of aggressive behaviour resulting from a medical condition. The employer had a structured plan in place that was intended to address and minimize the risk of violence to workers specific to the unique issues presented by this resident. This mitigation plan depended on strict adherence to performance-based protocols being consistently applied by trained, supervised workers. The overall effectiveness of the plan was undermined by an inconsistent approach to training and supervision. As a result, workers were not adhering to all of the protocols, and supervisors were not routinely correcting and retraining workers.

Workplace culture normalized the risk of violence: The workplace safety structures intended to promote the detection and resolution of workplace hazards did not recognize issues of workplace violence as a priority. At least 10 previous incidents in the year prior to this incident involved aggression from the resident. Despite these previous incidents, the employer’s incident reporting and workplace inspection programs and the joint occupational health and safety committee did not react effectively when presented with clear data about a serious workplace hazard. Investigations and follow-up actions might have prevented dangerous workplace conditions from developing, but procedures continued unchanged until the workers and the other resident were injured.

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Publication Date: May 2017 Asset type: Incident Investigation Report Summary NI number: 2016163050023