What happened
On 25 March 2009 a 55-year-old community psychiatric nurse was sent alone to the home of a 58-year-old patient in the Tranent and Haddington area of East Lothian. The patient had a long history of psychiatric illness.
The patient attacked her from behind. She broke free and got out of the house.
The patient had tried to attack another NHS employee with a blade before this visit.
The outcome
On 11 September 2013 NHS Lothian pleaded guilty at Haddington Sheriff Court to two charges, one under the Health and Safety at Work etc. Act 1974 and one under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995: a breach of the general duty to employees, and a failure to report the incident in time.
Sheriff Peter Braid fined the board £32,000, payable within 28 days. The attack happened in March 2009 and was not reported to the HSE until eight months later. The legal requirement was ten days.
The sheriff placed principal fault on the local departmental manager for the community mental health team, who had not carried out risk assessments or kept training current. The board’s own fault was that it did not audit whether its procedures were followed.
What went wrong
There was no proper risk assessment for the team’s community caseload. Only two of the team’s twelve members had up to date training for dealing with violent patients. And the board had no system for emergencies, so a worker in trouble inside a house had nothing to trigger.
The reporting failure is separate. An incident that goes unreported for eight months cannot be counted, and a risk that is not counted does not reach anyone with power to change a rota or a training plan.
What it teaches
A known history of violence plus a missing risk assessment is the classic lone home visit failure, and it is decided in an office before the visit. The question is not whether the nurse could have defended herself. The question is why she was sent.
Allocation is the control. A visit to a patient with a history of violence should be allocated against a written, current assessment, and with whatever it says is needed: a second worker, police support, a different venue, a planned exit. Where no assessment exists, the decision defaults to sending one person.
Training numbers are the second control, and they are testable. Two of twelve is a figure a manager could have known before the attack. So is an incomplete training register.
Questions for the room
- Who owns the risk assessments on your community caseload, and could you produce tomorrow’s?
- How many of your team are current on violence training, and who holds that number?
- You are in that house. Not fighting, but calling for help. What is there in your service to trigger?
- Which of your incidents is sitting unreported, and who watches the reporting clock?
Evidence and limits
Confidence: confirmed. Three independent outlets were read, BBC News, Nursing Times and Croner, and they agree on the facts, the charges and the fine.
They differ on one point. Nursing Times describes the patient as a woman, while the BBC and the court coverage do not give the patient’s gender, and the vault record describes a man. This page says “the patient” and prints no gender.
The pack names the nurse and the record does not, so she is not named here. The sources do not say what time of day the visit was made, or who knew where she was.
Our lone working training covers how a risk assessment decides whether a visit goes ahead, and with whom.
Sources
- BBC News, September 2013 · https://www.bbc.co.uk/news/uk-scotland-edinburgh-east-fife-24048084
- Nursing Times, 13 September 2013 · https://www.nursingtimes.net/archive/health-board-fined-after-nurse-attacked-by-patient-13-09-2013/
- Croner, 2013 · https://app.croneri.co.uk/feature-articles/nhs-board-fined-after-nurse-attacked
Reviewed 20 October 2026.