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Health & Human Services

Critical Incident Investigation

A Workplace, Conduct & Risk case study

Our role

OCM has personnel experienced in providing critical incident investigations (Safety and Security) for the government and private sectors. It is crucial to identify and understand the contributing factors to any incident to ensure that appropriate mitigation controls are in place to minimise the risk of harm to staff, contractors and persons affected by the workplace activities.

OCM were engaged to conduct a fact-finding investigation into the events, decision making and subsequent management of an elderly dementia patient at a suburban community health facility. During a social event, the patient was able to abscond and was later found deceased. The investigation considered the actions of nursing staff and centre management to identify the failures and causal factors leading to the incident.

Our role

The investigation was complex and our planning carefully considered the traumatic affect the incident had on the staff, family and other patients. The investigation reconstructed the events leading to, during and after the incidents in a detailed chronology support through evidence from witnesses and collected from the incident scene. In the conduct of the investigation, OCM investigators worked closely with subject matter experts and emergency service such as the NSW Police Force. Procedures and protocols were examined along with documentary evidence to establish the validity of actions and practices exercises by the health facility. The investigation found that appropriate risk assessment practices were not in place and the risk of dementia patient absconding was not mitigated through any effective control. Recommendations from this investigation included establishing appropriate risk assessment protocols and an audit of existing care plans. Additional actions include the physical risk assessment of existing related facilities and training for staff to ensure awareness of their obligations under Work Health and Safety Act and Regulations NSW (2011).

For other Workplace, Conduct & Risk case studies refer to A Data Breach Investigation, Department of Justice Taskforce, Parramatta Square Redevelopment, Investigation into suspected Employee Misconduct, Investigation of a Public Interest Disclosure.