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Worker stabbed by patient during cooking activity

Date of incident: September 2012
Notice of incident number: 2012166700158
Employer: Forensic hospital

Incident summary

A worker was conducting a one-to-one therapeutic cooking activity with a psychiatric patient, who had a history of violence. They were alone in a small kitchen where the worker had to get on one knee to access the knife. When the patient was handed the knife, he stabbed the worker. The worker sustained injuries from the attack as well as a defensive wound.

Investigation conclusions
Cause

  • Psychiatric patient with access to a knife stabbed a worker: A psychiatric patient stabbed a worker during a cooking activity that was provided as a reward in a behaviour modification program.

Underlying factors

  • Incomplete violence risk assessment: The employer had completed only a draft violence risk assessment for the site, which did not include consideration of location and circumstances where the work occurred. Given the patient's history, careful consideration should have been given to the location in which work was to occur, and under what circumstances, to minimize the risk of injury from violence.
  • Ineffective controls to minimize the risk of injury from violence: Policies, procedures, and work environment arrangements were not developed to minimize the risk of injury from violence. A patient with a known history of violence was given access to a large unsecured knife with which he stabbed the worker.
  • Lack of effective training: The worker had not received training sufficient to ensure his own safety. Other workers responsible for supervision and management were not trained in their responsibilities related to the Workers Compensation Act or the Occupational Health and Safety Regulation.
  • Ineffective supervision: Without training about the regulations applicable to the work being supervised, the supervisors and manager could not provide effective supervision to ensure the safety of the workers under their supervision or other workers at the site.
  • Lack of a written agreement defining health and safety responsibilities: Two employers had oversight responsibilities for health and safety at this worksite, but no written agreement existed stipulating the parameters of those responsibilities. Thus, it was unclear as to how the employers would ensure the health and safety of all workers at the site. The employer that was the prime contractor by default at this work location did not implement a system to coordinate health and safety or to ensure compliance with the regulations.
  • Failure by the employer with oversight responsibilities to ensure the health and safety of workers: The employer with oversight responsibilities at this worksite did not ensure the health and safety of other workers, including those employed by the prime contractor, who were present at this workplace.

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Publication Date: Sep 2012 Asset type: Incident Investigation Report Summary NI number: 2012166700158