In July 2023, the GEV received a notification from the work and rehabilitation center that a serious unexpected incident had occurred at the site of the center, which is operated as a work place for disabled individuals. In the notice and the accompanying incident description, it was stated that an employee of the work and rehabilitation center (hereafter: B), had known another employee of the work and rehabilitation center with violence with the result that employee A fell backwards and hit the ground with his head. Also, employee B had attempted to know other employees and instructors of the work and rehabilitation center. It was stated that the entire group had received crisis help following the incident.

On September 22, 2023, GEV initiated an investigation of the serious unexpected incident in accordance with Article 12, paragraph 3 of the Act on GEV. The purpose of the investigation of GEV according to the abovementioned legal provision is to seek explanations of the serious unexpected incident that can be used to prevent similar incidents from occurring and thus improve the safety of services provided at the work and rehabilitation center. In the investigation of the case, a thorough data collection took place.

The study of GEV showed that there was no one-size-fits-all explanation in the work of the work and rehabilitation center for the serious unexpected incident. On the other hand, the study specifically looked at the synergistic factors that contributed to the fact that employee B could recognize another employee with violence and show threatening behaviour towards other employees as well as instructors. It is the conclusion of GEV that there is not a simple explanation behind the serious unexpected incident but the explanation can be attributed to the following factors:

According to GEV, nothing in the work of B’s employee on the day in question gave the instructor and/or department manager of the facility clear reason to be especially careful of B, as B had never before shown threatening behavior or violent behavior towards colleagues. Furthermore, nowhere in the data obtained during the investigation is stated that instructors should or should have been aware that B could lose control of his temper and know of colleagues with violence.

In the opinion of GEV, the staffing was not adequate on the day of the incident. Even though the staffing was not in accordance with the needs and the burden of care of the employees on the day in question, it cannot be claimed that more instructors on duty would have prevented the serious unexpected incident. However, in the opinion of GEV it is clear that more instructors on duty could have both reduced the severity of the incident, i.e. it could possibly have been possible to overpower the employee B earlier than was the case and prevented B from showing other people threatening behaviour.

According to the GEV, the premises that housed the operations of the station at the time of the incident were extremely unsuitable for the operations that took place there. The premises were both small and restricted to those who used the service and these restrictions led to conflicts in communication between users of the service.

In view of improvements made by the municipality responsible for the operation of the work and rehabilitation center on the synergistic factors considered in the GEV investigation, it was not considered necessary to carry out an initiative check alongside the GEV investigation of the serious unexpected incident.

In the name of the Welfare Quality and Regulatory Authority,

Herdís Gunnarsdóttir Director.