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FATALITY ASSESSMENT AND CONTROL EVALUATION (FACE) PROGRAM

A Psychiatric Technician Dies from a Patient Assault at a Forensic Psychiatric Facility

California Case Report: 10CA009

SUMMARY

A psychiatric technician died after she was strangled by a patient at a forensic psychiatric facility. The patient assaulted the victim while the victim was walking alone across the large, open grounds of the facility Secure Treatment Area (STA)). The victim carried a personal alarm that was not able to transmit a signal inside to security personnel or treatment team staff from the STA grounds. At the time of the assault, security personnel were at the entrance to the STA but nowhere else within the grounds. The alleged assailant had been admitted to this facility in 1999 after conviction for violent assault and being declared not guilty by reason of insanity. He had a long, documented history of assault and verbal abuse to other patients and staff. The alleged assailant's unrestricted grounds pass had been suspended by his treatment team on two occasions because of physical and verbal assaults within three weeks prior to this incident. However, the treatment team restored his grounds pass and he was on the grounds of the STA without supervision on the day of the incident. The CA/FACE investigative team determined that, to prevent future occurrences, forensic psychiatric facilities should develop and implement a comprehensive written workplace violence injury prevention program.

A Psychiatric Technician Dies from a Patient Assault at a Forensic Psychiatric Facility [PDF 100 KB]

 
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