Nurses and allied health workers' lives were put at risk by a failure of safety protocols, according to the ACT's workplace safety watchdog.
The ruling follows four assaults on nurses or allied health workers carrying out home visits in March.
Canberra Health Services (CHS) chief executive Dave Peffer said the assaults were serious.
"Serious enough to require medical assessment…we did offer occupational violence leave, and that was certainly taken up,"
Mr Peffer said.
The incidents occurred during home visits as part of the Hospital in the Home and Belconnen Recovery Service programs run by CHS.
The staff involved have since returned to work.
The assaults were severe enough that CHS was required by law to report them to the workplace safety watchdog WorkSafe ACT.
A WorkSafe investigation into the incidents found:
"The situations resulted in physical and psychological harm to the affected workers and had serious potential to result in the death of a person."
"That's the finding of WorkSafe, and we don't step away from that at all," Mr Peffer said.
"We've taken that on board, and that's why we've been working so closely with the regulator to improve our practices."
Years of raising safety concerns
However, Community and Public Sector Union (CPSU) ACT Regional Secretary Maddy Northam said she wasn't surprised to hear about the assaults, because members had been raising safety concerns for years.
She said allied health workers attempting to provide hospital level care in patients' homes often encountered "really scary situations".
"We've had members who have had the front door opened and the patient or a family member may be holding a machete or a knife or an axe or chain,"
Ms Northam said.
"There are firearms present, guns, bows and arrows."
She said members' reporting such incidents had not lead to change.
"CPSU members at Canberra Health Services have been raising pretty serious safety concerns about home visits for more than two years now," Ms Northam said.
Improvement and prohibition notices
As part of its assessment of the assaults, WorkSafe issued six improvement notices and one prohibition notice to CHS in March in relation to home visit safety protocols.
These notices list changes and improvements CHS are required to make under the Work Health and Safety Act.
WorkSafe found the risk assessments used for home visits were "ineffective", the alarm systems "unsafe" and required a series of changes in order to better protect staff.
CHS has now undergone those mandatory changes and the safety notices have been lifted.
A CHS spokesperson said some of the actions taken included strengthening the risk assessment tool, mandatory training for staff before a home visit and ensuring staff have a duress device and that their manager always knew where they were.
However, Ms Northam said CPSU members felt let down.
"Our members are really disappointed that it took an unprecedented prohibition notice from WorkSafe to actually get CHS to listen."
'Almost impossible to foresee'
Mr Peffer said safety issues had been raised over the past few years but denied it was the WorkSafe notice that finally brought about action.
"I acknowledge that these have been issues that have been raised throughout the years, and to be fair to the to many of our teams, they have adjusted their processes," he said.
"Occupational violence is something we've been working on for a long time, for many years. It didn't start when these incidents occurred, and certainly it won't end tomorrow.
"Some of the situations where assaults have occurred it is almost impossible to foresee that that would have happened."
In 2024 there were six assaults on nurses and allied health workers in the home care programs run by CHS.
More broadly, there were 43 instances of occupation violence across CHS services.
In March Mr Peffer, in a regular update to staff, wrote: "Team, that's 43 too many. As an organisation we've let our team members down — and for that I am deeply sorry."
More than sorry
Australian Nursing and Midwifery Federation ACT Branch secretary Carlyn Fidow said its members had also raised safety concerns several times over many years.
She said an apology wasn't enough.
"Nurses and midwives — they don't want to hear apologies for it after the fact," Ms Fidow said.
"They want to see some action. They want to know that their employer is going to do something to address the assaults in a timely manner.
"Over many years, we have continued to raise safety concerns which lead to potential risk of assaults.
"It shouldn't take a WorkSafe notice to get some action."
