Hauora Tairāwhiti (Gisborne Hospital) chief executive Jim Green said despite the safety policies and procedures in place, and the care and attention of staff on the ward, it wasn't enough on this occasion.
"On that day it broke down. We didn't have the adequate protections in place for that employee.
"That's something that we're very concerned about as an organisation and obviously as colleagues of that employee, but also for any other circumstances that might eventuate where the systems and processes that we've got in place may not be able to make sure that people are kept safe."
Te Whare Awhiora, or Ward 11 of Gisborne Hospital, is an eight-bed facility built in the 1980s.
It provides a safe place for people who are in mental distress or living with mental illness and who require 24-hour clinical care.
But Hauora Tairāwhiti and the Government have previously agreed the facility is "not-fit-for-purpose", and $18.8m has been earmarked for a new 11-bed facility expected to open in early 2024.
The hospital staff member and his family were supported following the incident and he was provided with treatment and rehabilitation to get back into work, Green said.
In reviewing the incident, Worksafe spoke to staff on the ward.
"They felt that staff were accepting of violence within the workplace," Green said.
WorkSafe advised the DHB to look again at reporting of violence to ensure all episodes were reported to help create a "more full picture", he said.
"If people are not reporting that there's some minor things that happen at three o'clock every afternoon, then how do you know that's not actually something that's part of a major more important thing that you could fix . . . that could reduce those things happening and escalating at 3.10pm."
Mental Health Foundation chief executive Shaun Robinson said a person's experience before entering a health service, the presence of alcohol or other drugs, and the state of health services could all contribute to incidents of violence.
Commenting on services generally, rather than the specifics of this incident, Robinson said mental health specialist services, inpatient services and emergency departments struggled with the lack of proper drug and alcohol detox services.
"It's not okay to just throw people who are dealing with addiction or coming down from alcohol or drug intoxication straight into a service that is primarily focused on dealing with people's mental distress.
"There can be a really dangerous mixing up of needs.
"In terms of the overall system, the lack of appropriate drug and alcohol services and detox is a major contributor to the risks, so it would be interesting to see how that gets looked at in this review."
He also described the constant overload on New Zealand's mental health system that goes back decades.
"You have overstressed, overcrowded, under-resourced services, staff who are often stressed, burnt out . . . and then whatever that person experienced on the way into the service, potentially add drugs and alcohol to that, and you've got potentially a very combustible situation.
"There can be a whole range of factors that lead to an incident like this."
Robinson was glad to hear the incident was being reviewed in the context of violence across the hospital, and not just in Te Whare Awhiora.
The DHB had policies and procedures in place around workplace violence that had been twice independently audited against a framework agreed on by DHBs and unions for the protection against violence in the workplace.
WorkSafe had asked the DHB to review these policies.
The improvement notice must be enacted by December.
Staff at Te Whare Awhiora include a psychiatrist, health officer, kaumātua, registered nurses, diversional therapist, psychiatric assistant, healthcare assistant, social worker, and access to allied and medical services as required.
