On January 5, 2011, Mr Fenwick died of a stab wound to the chest while defending a female colleague who was attacked after the patient stole a knife from within the hospital.

In her inquest findings handed down in Orange court yesterday, Ms Forbes said she was satisfied doctors in charge of the patient’s care had acted appropriately and she referred to testimony provided by an expert, independent witness. 

Nurses looking after the patient on the morning of the attack wrote notes that said the patient was “pleasant and polite”.

“There were no signs as to what was coming,” Ms Forbes said.

The patient had gained access to a knife because a lock was broken but since the death an internal audit, an external audit and a Work Cover audit had made recommendations to ensure it was impossible for patients to access cutlery. 

The patient had made a threat to another patient earlier in the year but in Ms Forbes’s findings she said it was common for patients to make threats in mental health facilities and staff had no evidence to suggest he would carry out a threat. 

In Australia and New Zealand, a death of an employee at a mental health facility at the hands of a patient had only occurred once in 25 years. 

“It’s not really a systemic problem,” Ms Forbes said. “But it is important to reflect on the circumstances surrounding the death because some would argue one death is one too many.”

Ms Forbes said the manner of Mr Fenwick’s death demonstrated how he was clearly a courageous man. 

“The bravery, courage, kindness and caring demeanour are all exemplified by this act,” she said. 

Since Mr Fenwick’s death, Bloomfield Hospital has implemented a range of procedures such as increasing the staff-to-patient ratio and keeping all cutlery behind a metal sheet accessible only with a key carried by staff.