A vicious attack by a mental health patient while being specialled by an AiN highlights systemic deficiencies in managing violence in our hospitals.

Three nurses and an elderly patient were stabbed with scissors and attacked with air mattress equipment during an assault at Royal Prince Alfred Hospital on 4 May.

There had been clear escalating behaviour from the patient leading to the attack with two previous code blacks in the couple of hours before the incident.

The patient’s family had also raised concerns about her agitated behaviour when they had seen her the day before.

In the third incident she assaulted three nurses and one patient with scissors. She grabbed the scissors, stabbed one nurse in the back when she was on the ground, and the other two in the chest and in the arm. She then went into another room and stabbed an elderly patient in the face.

The only duress button available was in the nurses’ station. The attacker was being specialled at the time by an agency AiN. The other staff on shift were new graduates.

An investigative report of the incident by Safework found that the nurses were “exposed to serious risk to their health and safety from patients displaying escalating violent behaviour such as attempting to strangle a nurse, accessing and swinging air mattress equipment, verbal aggression, grabbing nurses’ hair, accessing and using scissors to harm others”.

Safework issued an “improvement notice” and directed RPA to implement a safe system of work which should include:

• the availability of suitably skilled staff for the patient’s medical needs
• the selection and location of the room in which the patient is placed (should be visible) from the nurses’ station
• the access to equipment and other objects which may be used as weapons towards others
• the selection of control measures for managing the patient’s violent behaviour such as medication, restraint and/or the appointment of a security special.

An incident that was foreseeable

NSWNMA President O’Bray Smith, says: “You have to ask the question of whether the incident was foreseeable when there were two previous code blacks.”

“The special should have been someone who had done the training. I think at a very minimum you would have expected a nurse with mental health training to be looking after her. Someone who knows de-escalation, who is more aware of an escalating patient.”

O’Bray says the nurses deserve the highest praise for their bravery and selflessness during and after the attack.

“Once the incident was over the patient was banging her head against the floor. Even though she had just attacked them, they just turned around and went to help her and to stop her from harming herself.

“It’s a testament to how they coped that straight away afterwards they were looking after the patient,” she said.

O’Bray says there are many lessons to be learned from the incident.

“I’ve heard that at other hospitals they put patients like that on the mental health unit and have an RN with them from medical or surgical as the special rather than putting them on a medical ward and having an AiN special them.

“In a lot of incidents the after-hours management or the staff are blamed but when the ‘F’ word applies to recruitment and there are overtime bans how can we expect them to provide the necessary care?”

O’Bray says that since the then-health minister Jillian Skinner initiated a roundtable on hospital violence in 2016 the issue has been neglected.

“I think the initial response was really good. We had increased security. I’d have to applaud the security department at RPA. They are exceptional. They are fantastic with patients. They respond quickly. But I don’t think that has happened across NSW.

“As for training the staff – I haven’t done it and I don’t think many staff have. It has just fallen over. When you have a large hospital, with a large ED, mental health wards, plus a massive neuro and maternity – you have high-risk areas and just having extra security isn’t enough.

“I think the roundtable was good in theory but I haven’t seen what really came out of it apart from more security.”

The system failure that led to a multiple stabbing attack at RPA

After clearly escalating behaviour from the patient – with two code blacks – an AiN from an agency rather than an RN was allocated as a special.

• Of the three nurses injured two were new graduates and one was an EN, which raises concerns about the level of experience and appropriateness of skills mix on the ward at the time.
• Despite the known aggression risk, no personal duress devices were issued to staff working close to the patient, with only a fixed point alarm available on the unit, not readily accessible from the patient’s room.
• The duress alarm only alerted security and not the other nurses working in the area.
• There was insufficient training for the nurses working with patients with a high incidence of aggression: no practical de-escalation, breakaway or restraint training.
• There was no appropriate system for managing scheduled mental health patients with physical 
health needs.