What happened
In 2006 an experienced community psychiatric nurse visited a client at home. He thought the man might turn violent, so he took a colleague with him. He then took the client out for a walk while the colleague stayed in the house to talk to the client’s wife.
On the walk the client spotted a neighbour in a doorway and asked if he could have a word. The nurse heard him ask the neighbour whether he had a knife, and waved his arms through a window to signal no. Ten seconds later the client came out of the house with a knife about six inches long, turning the blade in his palm “like it was a badge of honour”. He approached the nurse, lunged at him and grabbed his shoulders, looking at his neck.
The nurse turned, pulled his arm out of his baggy coat to unbalance the man and break the grip on his shoulders, and ran.
The outcome
In court the client claimed no memory of the incident. He was found guilty and given a suspended sentence, his defence having argued successfully that a recent cancer diagnosis reduced his culpability.
The nurse took a few days’ leave and said he felt well supported by his employer and by police victim support. He then pressed for a panic alarm linked to a control centre, saying: “We were reduced to using stupid code words like ‘Have you fed the parrot?’ It’s ridiculous that community staff are reduced to thinking of such inappropriate solutions.”
What went wrong
The assessment was right, and the visit still failed. Two staff went out, then split, and the walk put the nurse in the street with the client and no colleague within reach.
The danger came from a third party. The client was handed a weapon by a neighbour, ten seconds after asking for one, while the nurse watched through a window. No visit plan covers a man who can borrow a knife from the house next door.
The team’s fallback was a code word, which assumes somebody is listening on a phone the worker can still use.
What it teaches
A correct risk assessment is necessary and not sufficient. Much of what is called lone working is two staff who separate during the visit, and two staff who separate are two lone workers.
The plan needs an abandon-the-visit trigger, written down before the visit starts, and it needs to treat third parties as a risk in their own right: neighbours, relatives, passers-by, any of whom may hand over a weapon.
The kit matters more than the phrasebook. A panic alarm to a control centre, with a recorded response, is a control. “Have you fed the parrot” is a hope. The coat was a control too: baggy enough to pull an arm free with a man’s hands on his shoulders.
Questions for the room
- If the danger comes from a third party, who is assessing that, and when?
- What is your abandon-the-visit trigger, and is it written where you can find it mid-visit?
- Are you relying on code words and a mobile, or on an alarm linked to a control centre?
Evidence and limits
Confidence: confirmed. One source was read in full: a Nursing Times case study published in October 2008, covering a 2006 incident. It is his own first-person account and the only source in the pack. No court report or employer document was available, so the sequence is his recollection and the legal outcome is as he describes it. His name was changed and is not used here; the location is given only as England.
Our lone working training covers visit planning where the risk comes from outside the client.
Sources
- Nursing Times, October 2008 · Lone Worker Case Study (name changed at the subject’s request; incident 2006)
Reviewed 20 October 2026.