What happened
In October 2019 the Health and Safety Executive served Hywel Dda University Health Board with two Improvement Notices and seven material breaches, on violence and aggression including lone working.
The board covers Pembrokeshire and west Wales. The notices named the staff groups where the HSE found the risk was not managed: district nursing, community mental health teams, and the mortuary and estates maintenance staff at Prince Philip Hospital.
No assault on a named worker is recorded. The failure was in the arrangements around them.
The outcome
No prosecution followed.
The board’s plan went to its Health and Safety Assurance Committee on 14 May 2020: a Violence and Aggression Control Group, a dedicated case manager, better links with Dyfed Powys Police, and a trial of Skyguard, a personal safety device with an SOS function, issued to community nursing teams in Ceredigion at £5.21 per device per month.
On 19 October 2021 an HSE inspector confirmed in writing that the extended Improvement Notices had been complied with.
What went wrong
The board’s March 2020 data recorded 68 incidents across hospital sites and patients’ homes: 37 physical assaults, 11 episodes of aggressive or threatening behaviour and 16 of verbal abuse. Fourteen needed police, and four led to an arrest or summons.
The reporting was inconsistent. Many incidents had no perpetrator named. Some were submitted up to eight days late. One recorded a pharmacy worker being spat at by a patient with Covid-19 from a care home where the risk process was not clear or owned.
Then the training. The board’s audit found 1,188 staff needed the two day course on behaviours that challenge in older adults: 99 courses. The team had no trainer capacity to deliver them in twelve months, and the board’s own paper said so.
What it teaches
An improvement notice is a written finding that an employer’s arrangements are not adequate. It binds the board, not the worker, and it does not create trainers.
Most services can produce a training need. Fewer can say how many courses and trainers it takes, and fewer still will write down that the number does not fit the year.
The second lesson is reporting. Thirty seven assaults in a month is a number a board can act on. A log where many incidents have no perpetrator named, and some arrive a week late, is not. For a lone worker, the report is often the only record they were on their own, which makes the route part of the control.
An SOS button is a control only if it is issued, carried, charged and answered.
Questions for the room
- Which parts of your service would not appear on a lone working list, and would surprise you? Mortuary and estates were on this one.
- Your last incident report: does it name who did it, and how late did you send it?
- If your service costed its training need in courses and trainers, would the number fit the year?
- Who answers when you press the SOS, and how quickly?
Evidence and limits
Confidence: confirmed. Two of the three cited sources were read in full, the board’s papers of 14 May 2020 and 15 November 2021. The third, the HSE notices register, is recorded in the pack as unreadable, so the notice wording is not quoted here.
The figures above are the board’s own, from its May 2020 paper.
No individual is named, and none is described as injured in the material read.
Our lone working training covers what a workable lone working arrangement has to contain, and how to test it.
Sources
- Hywel Dda University Health Board, Management of Violence and Aggression and Lone Working update, 14 May 2020 · https://hduhb.nhs.wales/about-us/governance-arrangements/board-committees/health-and-safety-committee-hsc/hsc/hsc-14-may-2020/item-2-4-management-of-violence-and-aggression-lone-working-update/
- Hywel Dda University Health Board, HSE Enforcement Action Update, 15 November 2021 · https://hduhb.nhs.wales/about-us/governance-arrangements/board-committees/health-and-safety-committee-hsc/health-and-safety-committee-meeting-15-november-2021/item-2-4-health-and-safety-executive-hse-enforcement-action-update/
- HSE public notices register, recorded in the pack as unreadable · https://resources.hse.gov.uk/notices/search/search.asp?CO=%2CAND&EO=%3D&SF=SIC&SN=F&ST=N&SV=86101
Reviewed 20 October 2026.