Date of incident: June 2013
Notice of incident number: 2013166880111
Employer: Building management company

Incident summary

A resident with a history of mental illness had recently moved into a single-room occupancy hotel run by a building management company. Various agencies were providing support services. During the night shift, the resident told front desk workers that he intended to kill one of the afternoon shift workers. The threat was documented in the logbook and read by the afternoon shift workers. Later, the afternoon shift worker who had been threatened was taking a break outside. The resident followed him out and stabbed him twice in the back. The injured worker managed to run back inside the hotel, closing the door, which automatically locked behind him. The worker was treated in hospital for stab wounds and released the same evening.

Investigation conclusions

Cause

• Resident with mental illness stabbed worker: A resident with a history of mental illness uttered death threats against a worker. The resident took an opportunity to follow the worker outside the building, where he stabbed him with a knife, causing injuries.

Underlying factors

• Inadequate communication: There was a breakdown in communication at several levels. Information about the resident's mental health symptoms was not shared with the building management company, and front desk workers did not inform management or service partners of the death threats.
• Inadequate risk assessments: The orientation and training of front desk workers was informal and did not include a comprehensive practice for conducting risk assessment of residents. Specifically, the injured worker made assumptions regarding risk that were based on his limited knowledge of the resident. This put him at direct risk of harm, as a result of mistaken beliefs. The employer did not ensure that appropriate risk assessments were conducted effectively, and the employer allowed workers to make personal judgments based on their limited knowledge of the resident.
• Lack of violence prevention program: Although the employer's occupational health and safety program was under development, it had no provision for a violence prevention program. Had this element been incorporated, it is possible that risk assessments, procedural communication, and other requirements would have been taken into consideration and become part of the overall program. This shortfall led to workers not having the training or the tools necessary to conduct adequate risk assessments for the prevention of violence in the workplace.

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