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HomeMy WebLinkAboutKostadinova 16-11-28IN THE MATTER OF AN ARBITRATION BETWEEN: ONTARIO PUBLIC SERVICE EMPLOYEES UNION, LOCAL 548 (hereinafter referred to as the “Union”) -and- COTA HEALTH (hereinafter referred to as “Cota” or the “Employer”) AND IN THE MATTER OF A GRIEVANCE CONCERNING ANTOANETA KOSTADINOVA ARBITRATOR: Derek L. Rogers APPEARANCES FOR THE UNION: Ian McKellar, Counsel Adrienne Lei, Counsel Antoaneta Kostadinova, Grievor APPEARANCES FOR THE EMPLOYER: Robert Hickman, Counsel Donald Chiro, Advisor to Cota A hearing in this matter was held in Toronto, Ontario on May 3, September 19 and 20, and October 28, 2016 DECISION 1. This case involves allegations that Cota was in breach of its collective agreement with the Union and also of its obligations under the Occupational Health and Safety Act, R.S.O. 1990, c. O.1 (“OHSA”) in relation to risks to which the Grievor was exposed in the performance of her duties as a case manager. 2 The Grievance 2. Ms. Kostadinova’s grievance challenged the sufficiency of Cota’s reaction to incidents that involved two of its clients: the first, a male identified at the hearing and here as Client A, was alleged to have sent a text message to another Cota client in which he either threated to rape or expressed a desire to rape the Grievor, and the second, another male designated as Client B, who assaulted the Grievor during a home visit ten months later in February 2016. 3. The text of the grievance, dated February 26, 2016, reads as follows: I grieve that the employer is breaching the collective agreement in particular articles 3, 17 and the Occupational Health and Safety Act (Ontario) . . . by failing to properly protect me from unwanted harassment & violence in the workplace. This led to physical violence on my person and psychological distress resulting from an inadequate response to a text message directly threatening my safety. Proper safety measures were not implemented when concerns were brought to COTA’s attention by me nor was a risk assessment completed. 4. The grievance form indicated that the settlement that Ms. Kostadinova desired was: Full redress including: 1. I be provided proper compensation for lost sick days I have and will endure due to the mental stress of dealing with harassment/violence at work. 2. Punitive damages against COTA for failing to adequately protect my person at work and their negligence. 3. Any other appropriate remedy or sanction/order against COTA for breaching the CA/OHSA etc. At the conclusion of the hearing, the Union submitted that there should be a declaration of Cota’s breach of its OHSA and collective agreement obligations, and awards of “general damages” referable to the period of April 2, 2015 to February 2, 2016, together with punitive damages. There was no formal objection to the arbitrability of the grievance insofar as it related to events discovered months before submission of the Grievor’s complaint. 5. Article 3 of the collective agreement addresses management rights and Article 17 records the parties’ mutual desire “to maintain high standards of health and safety in the operation” and the commitment “to cooperate in . . . the reasonable 3 promotion of a safe and healthy work environment in accordance with the Occupational Health and Safety Act”. Background 6. Cota is a not-for-profit organization that, among other activities, provides a range of assistance to individuals with mental health and related challenges, including efforts to secure housing for its clients. 7. Ms. Kostadinova has completed eleven years service with Cota, and at the material times was working as a case manager in the Hostel Outreach Program (“HOP”) assisting homeless clients with serious mental health issues. Clients would typically enter the HOP through facilities such as Seaton House and referrals by probationary officers and the like. The Grievor had been one of ten case managers assigned to the HOP when she started work in the program in 2008, but a reorganization in January 2015 resulted in a 50 percent reduction in the number of HOP case managers. 8. Ms. Kostadinova testified that she normally had 16 clients and she reported to a manager, Jeannette Krueger. She would meet with her manager approximately once very two months for a formal “supervision” session of up to 90 minutes duration; however, as the two worked in and from the same office, they had frequent opportunities for conversations. Case managers had team meetings every second Tuesday, and minutes were kept of those interactions. On the opposite weeks, the team would meet for a psychiatric consultation with a mental health professional. Ms. Kostadinova’s evidence was that those meetings were not minuted. 9. Case managers are expected to attend weekly drop-ins that are held for HOP clients on Wednesdays. They also saw their clients at individual meetings they would schedule to take place at hostels, in coffee shops, at service provider offices, and, when the clients were housed in their own dwellings, at clients’ homes. 10. An extensive job description for the case managers speaks to their responsibilities in connection with the assessment of clients, their goals and needs, the provision of assistance in acquiring shelter, food, income and clothing, and in accessing primary health and psychiatric care. The document also identified compliance “. . . with all Health and Safety policies and procedures to ensure every reasonable precaution is taken for the protection of workers and clients and that 4 their health and safety concerns or incidents are responded to promptly” as a case manager’s responsibility. 11. Cota has published policies that recognize issues that were relevant to the situations raised by this grievance. Its policy entitled “Prevention of Workplace Harassment and Violence”, in place at the material times, included the following acknowledgement and undertaking: Cota recognizes that many of the individuals we support live with mental health and/or cognitive challenges which may affect their awareness and ability to deal with matters that relate or can lead to harassment or violence. Client action resulting in Worker harassment or violence will be evaluated on an individual basis to assess the capacity of the client to effectively manage and/or control acts leading to harassment or violence. Appropriate courses of action will be developed and implemented Cota’s policy identified “violence perpetrated by a client against a Worker” as a source of workplace violence and added: By virtue of the nature of our services and the target populations we support, it is recognized that Cota Workers may occasionally experience harassing, aggressive and/or threatening behaviour from clients. . . . When encountering these behaviours from clients: • The Worker is to inform the client that his/her harassing behaviour is not welcome, explain why and encourage change through teaching/counseling when possible • When this is ineffective and the behaviour has the potential or has escalated to aggression, threats or violence, the Worker is to: ü Take all necessary immediate precautions to ensure his/her personal safety (e.g. stop visit, call for assistance, etc.) in accordance with service or location-specific Safety Protocols ü File an Occurrence Report . . . . ü Bring the client challenges forward for team discussion and/or consultation with his/her manager. When warranted, service delivery changes can be employed to improve/safeguard management of harassing or violent client behaviours 5 12. The policy expressly addressed work refusals as follows: “A Worker can refuse to work if he/she has reason to believe he/she may be endangered by workplace violence” and the policy required workers “to immediately and formally identify any known workplace hazards that may pose safety risks in relation to harassment or violence in the workplace to their respective managers”. In instances when “hazards presenting risks in relation to workplace harassment or violence are identified”, the policy dictated that “managers are expected to ensure immediate action is taken to minimize the risk (e.g. adjust schedules, increase safety protocols)” and provided that: “Corrective action will be implemented up to and including temporary withdrawal of support to client or possible discharge [of the client] from service”. 13. Case managers received specific “Safety Protocols for the Cota HOP Team” in a document that was detailed and explicit in many of the elements it addressed. Of particular relevance to the Grievor’s issues with Client B were the following directions: When you have concerns about the potential for violence against yourself or others, discuss the situation with your Manager and evaluate whether Cota should continue to provide service to the person. . . . Home visits are an integral part of the program to ensure homeless clients succeed in new housing. Staff safety supersedes this program expectation. To manage home visits safely, HOP team members are expected to: . . . • not complete a home visit with client if circumstances appear to be potentially unsafe (i.e., client and/or guests is/are using substances, threatening or inappropriately dressed). . . . HOP team members are not to enter a client home or dwelling if they feel any type of threat. 14. Cota’s case managers are required to document all of their interactions with clients and do so by way of “case notes” that become part of each client’s record with Cota and thus provide a resource available to any other Cota workers whose duties necessitate their having any dealings with another’s client. Ms. Krueger’s evidence was that she expected a case manager’s notes to “report on observations such as client behaviour, what they are exhibiting” and that she made clear to case managers that the notes comprised “a client chart” and “ a means of communicating to other staff”, adding: “In the event you leave, the notes must give a clear reflection 6 of what is in the file”. Ms. Kostadinova appeared to have been diligent in her record keeping and Ms. Krueger testified that she had not raised any deficits in the Grievor’s note taking. The Underlying Events The Text Message Threat 15. The first incident raised by this grievance involved Client A, an individual who was the client of one of the Grievor’s male co-workers, designated here as RG. The incident was noted by RG in his case notes for Client A under the caption “4/1/2015: v incident of texting to another client with sexual assault intent towards a female staff”. In summary, Ms. Kostadinova’s client had received a text message from Client A and her client displayed the text to the Grievor at the client drop-in on Wednesday, April 1, 2015. RG’s notes included the following: I was asked to discuss a matter with co-worker Antoaneta. It lead to a discussion with one of her clients [redacted] who had received a text from [Client A] a couple of days previously. I am not sure of the exact wording but it was ‘Don’t you want to rape Antoaneta?’ I confronted [Client A] and he indicated a friend of his actually did the text. 16. RG initiated an Occurrence Report in which he set out the following description of the incident: “Client . . . showed inappropriate text from another client [Client A] to his worker [Ms. Kostadinova]. This text was threatening to do an inappropriate and illegal act ‘rape’ of the worker Antoaneta Kostatinova [sic]”. 17. Ms. Kostadinova’s evidence was that she had been aware of Client A from his attendances at the drop-ins, and that he had exhibited what she described as “intimidating behaviour”. Her testimony was that the text message shown to her read: “I’m going to rape Antoeneta”. 18. RG reported the incident to Ms. Krueger and the Grievor had a subsequent conversation with their manager. She and Ms. Krueger testified that they discussed Ms. Kostadinova’s reaction to the text message. Ms. Krueger’s evidence was that she asked Ms. Kostadinova whether she felt at risk and her response was: “I don’t feel threatened by him, I am not scared of him. He cannot do this kind of stuff”. The Grievor testified that even though Client A had a history of being intimidating to others, she “did not feel any immediate concern, but did feel violated by the threat”. Ms. Kostadinova conceded on cross-examination that Cota had communicated to Client A that his behaviour was unacceptable, that it was criminal, and that he could be charged; however, it was also her evidence that she had expressed concern that Cota did not have a protocol that addressed situations involving direct threats such as that presented by Client A’s text message. 7 19. Notwithstanding his excuse that the text had been sent by someone using his device, Client A had offered apologies. RG and Ms. Krueger conferred and, in summary, it was decided that Client A would be barred from having any contact with Ms. Kostadinova and from attending the drop-ins. In addition, Cota involved the Toronto Police Service by requiring Client A to meet with them and a community relations officer. Client A was warned by the officer that the incident had been noted and, according to Ms. Krueger, that he would be charged with uttering threats if anything of that nature occurred again. 20. Ms. Krueger’s evidence-in-chief was delivered, on consent, as a written statement that ran to 12 pages. In her statement, Ms. Krueger referred to a team meeting – “(consult with Psychiatrist)” – on April 10, 2015 at which “the incident and the outcome was [sic] discussed”. Ms. Krueger’s statement then asserted that the Grievor had “accepted invitation to meeting” and added: “I cannot recall if she attended”. In the following paragraph, Ms. Krueger stated: This incident was never raised at subsequent team meetings. AK did not raise the matter again after the April 10 team meeting. My recollection is that this was discussed at a team meeting on April 10 and I believe AK was present. 21. On April 10, 2015 Ms. Krueger completed the Occurrence Report initiated by RG on April 2, 2015. Her entries referred to meetings on April 2, 7 and 9, 2015, but failed to mention any meeting or discussion of the incident on April 10th. 22. On cross-examination, Ms. Kostadinova questioned whether she was present at a team meeting on April 10, 2015 and she responded to the proposition that the incident was raised then by saying: “I still say it wasn’t to my knowledge”. A second witness called by the Union, Ms. Kostadinova’s colleague MB, testified that she could not remember whether the incident had been discussed at a team meeting. 23. The Grievor maintained that she was upset both by the incident and by the failure of Cato to take seriously her contention that its arrangements were deficient as it had no developed protocol to deal with the situation presented by Client A’s text message. 24. Notwithstanding the representations that Client A had been barred from the drop-ins, he attended on at least two occasions in May and July 2015. Ms. Krueger was asked in cross-examination what follow up had been done to ensure that Client A was not attending the drop-ins. Her answer was that she “assumed it would be followed through with; no one reported that he was attending”. Ms. Krueger confirmed that nothing came of the occurrence report regarding the threat against the Grievor other than the directive that Client A was not to attend drop-ins. 25. Ms. Kostadinova testified that the she felt that Cota had not taken the incident with Client A seriously. It was her view that the incident and her concern 8 about the absence of a relevant protocol had been “swept under the carpet”. Her evidence was that she was disillusioned regarding how safety was addressed, and that she felt like a “sitting duck”. She allowed that she experienced a more intensified anxiety reaction to events that she would otherwise see as “non- threatening”. She had expected more action by Cota and reiterated her concern that the matter had not been discussed at team meetings and her perception regarding the absence of an appropriate protocol. Also, the Grievor had received a copy of the initial pages of the Occurrence Report, but was not shown the report as it was completed by Ms. Krueger for submission to Cota’s board of directors and was not told of any reaction by the directors. 26. On cross-examination, Ms. Kostadinova acknowledged that she had numerous opportunities to ask Ms. Krueger about a protocol; however, she asserted that she “felt uncomfortable” to raise the issue again – having raised the matter once on April 2nd, she never brought it up again and said that she “felt embarrassed to push the issue further”. The Grievor also admitted that she had learned of Client A’s return to Cota and involvement a “couple of months later”; however, she asked no one about that development, did not take it up with RG or Ms. Krueger, and did not raise the issue in any team meetings. 27. There was no evidence of Client A’s having had any contact with Ms. Kostadinova or of her having received or been the subject or target of any threats or inappropriate comments by him after the events of early April 2015. There was evidence of his having made inappropriate comments about at least one other client, of his discharge from the program, and of his subsequent incarceration for a period of time, but none of those circumstances involved the Grievor. The Physical Assault 28. The second incident raised by the grievance involved an individual Cota and the Grievor took on as a new client in June 2015. Client B was then at Seaton House. With the Grievor’s assistance, he was able to move to his own residence in January 2016. Ms. Kostadinova testified that he was psychotic, “preoccupied with his delusions” of being an alien, beaming people into space, tearing hands off a human, and eating people. The Grievor summed up his state as being “so delusional I wasn’t able to provide any services”. 29. The record presented in evidence documented the Grievor’s having had approximately 40 interactions with Client B – some by telephone, but a significant majority in person – over the period June 2, 2015 to February 2, 2016, the day on which he assaulted the Grievor. The notes also recorded a number of occasions on which Client B was not present for scheduled meetings. 30. The notes made by Ms. Kostadinova are descriptive and instructive regarding the challenges posed by Client B. The following are excerpted from the case notes she placed on his file leading up to and including her account of the assault that took 9 place when she visited Client B for the fourth time in the housing unit she had secured for him: • 6/25/2015: [at Seaton House]: Client presented with disorganised and tangential though [sic] (the usual predominant themes of aliens and the dangers of homosexuality). • 9/2/2015: [at Seaton House]: Client presented with extremely disorganized and tangential thoughts. Client was leaning over writer and shouting about aliens. Writer redirected client to respect her personal space as his behaviour could be interpreted as aggressive. Client endorsed some visual hallucinations and asked writer whether she can see “the small people on his hand”. . . Client was difficult to engage as he could not stay on topic due to his delusional believes [sic] and disorganized thought. • 9/14/2015: [at Seaton House]: Client presented with rapid speech and he needed to be redirected numerous times to stay on topic. Writer had to direct client on a couple of occasions to respect her personal space as he kept tapping her on the knee. • 9/14/2015: [at Seaton House]: Client presented with rapid speech and delusional thought. Client made reference to a psychiatrist and writer asked client if he had taken medication in the past. Client became extremely agitated, leaned over the writer and starter [sic] pointing and yelling that “he does not need medication, the gays are mentally ill and he is not going to be dragged into it”. Writer deescalated client and advised that we would have to reschedule if his behaviour continued to be threatening. Client sat back down and refrained from approaching writer for the rest of the meeting. Client’s delusions were focused on being an angel, creating radioactivity and aliens. • 9/28/2015: [at Seaton House]: Client presented with delusional thoughts and his body language was threatening. Client “spoke about angels eating humans” and made a sudden strangling gesture towards writer. Client was preoccupied with “gay people’s choices being wrong and deserving AIDS”. Client made a reference to being on probation some time ago and writer inquired about the charges. Client stated that he was on probation for sexual assault (stated that he had “grabbed a woman because she told him she is the devil”). • 11/4/2015: [at Tim Horton’s at Dundas & Jarvis]: Client appeared extremely agitated and presented with disorganised and delusional thought. Client screaming about “aliens eating humans, gays, and AIDS, women dumping their kids and doing crack”. Client was leaning over writer in an aggressive manner and she had to push him back away from her. Writer advised client that she cannot work with him if he does not respect her personal space. Writer advised that his 10 behaviour is threatening and we’ll have to reschedule. Client stepped back and was able to lower his tone but continued wit [sic] tangential thought. • 11/9/2015: [at Seaton House]: Client presented with delusional thought and his behaviour appeared aggressive. Client was advancing towards the writer on a couple of occasions screaming about aliens, homosexuals and radiation. Writer informed client that his behaviour is threatening and she could not work with him if he does not respect her personal space. • 11/16/2015: [at Seaton House]: Writer redirected client a few times when his behaviour got too erratic and he was invading with [sic] writer’s personal space. • 1/11/2016: [at Client B’s residence]: Client presented with delusional and tangential thoughts and showed writer a “picture of an angel on his wall” (a picture of a blurry spot). • 1/19/2016: [at Client B’s residence]: Client presented with extremely delusional thoughts and was showing writer pictures of “angels in his unit”. Client believed he is an angel and “the true son of god and nature” as well as friends with Lucifer. Client presented wit [sic] rapid and tangential speech and was [sic] difficult to redirect him or engage him on a goal related topic. • 1/26/2016: [at Client B’s residence]: Client presented with delusional and tangential thoughts and was [sic] difficult to redirect him (client’s delusions had a religious association). • 2/2/2016: [at Client B’s residence]: Client presented with delusional and tangential thoughts and needed to be redirected numerous times. Towards the end of the visit, client was sitting in a chair and appeared preoccupied in a delusion about the royal family when he suddenly got up and charged towards the writer and pushed her in the chest (writer was standing up at the time close to the exit). Client applied enough force for writer to lose her balance and fall back leaning on client’s bed. Writer proceeded to leave client’s unit and on the way out informed client that this behaviour is unacceptable and writer cannot provide services if she is not safe. Client stated t [sic] “OK, OK” and continued to talk about his delusional beliefs. • 2/3/2016: Writer discussed the incident with her manager Jeannette Kruger. [sic] We agreed to apply for a Form 2 [that allows the police to bring a person to a hospital for a psychiatric assessment] with the Justice of the Peace as client has been psychotic and presenting with persistent delusional beliefs. Client’s behaviour has been escalating and presents a danger to others. 11 Writer and her manager saw a Justice of the Peace at Old City hall and provided an account of the incident. The Justice of the Peace issued Form 2 which the manager took to 14 Police Division. [emphasis added throughout] 31. Ms. Krueger had access to the case notes regarding Client B. In describing the process she follows for the supervision meetings, she stated in her evidence both that she reviews case notes in advance of the meetings and “I don’t have to read every note”. She did not testify to having read the Grievor’s case notes relating to Client B prior to the filing of the grievance. 32. The Grievor and Ms. Krueger had four supervision meetings during the period of Ms. Kostadinova’s involvement with Client B. The case managers choose the clients they would discuss in their supervisory meetings. Ms. Kostadinova referenced Client B in each of the four meetings, starting on June 9, 2015 and ending with a meeting on January 19, 2016, two weeks before the assault. 33. In addition, the Grievor raised her concerns about Client B at a number of the HOP team meetings. He was discussed at the team’s psychiatric consultation meeting on September 29, 2016, the day following the incident at Seaton House in which he had made a threatening gesture towards Ms. Kostadinova and had spoken of his having been charged with sexual assault. In the result, the specialist in attendance suggested that he and Ms. Kostadinova would conduct a joint visit with Client B at Seaton House. That took place on October 5, 2015. In her notes of that visit, the Grievor remarked: “Client was mild-mannered compared to the 2 previous visits”. She also recorded that she had sought information from him about his previous involvement with the criminal justice system and that he could not provide accurate information but stated that he had spent two months in jail for murder. 34. In addition to her statement of evidence, Cota submitted a compilation of notes made by Ms. Krueger regarding the history of the incidents involving Clients A and B and some subsequent interactions with the Grievor. Those notes were made an exhibit in the proceeding. The following appears in Ms. Krueger’s statement of evidence: The expectation is that staff send Case Load Status notes . . . to me electronically before each supervision meeting. . . . After we complete the supervision notes I email them to case manager and they can amend if necessary. Did you make other notes? Yes. If we had other interactions such as a phone conversation, impromptu meeting or text, I would make a note in my book. I often make notes during team meetings and consults. Tell about the notes you made about this matter. 12 I think it was the beginning of March when I pulled together notes from supervision and any anecdotal and memory reflections. I then put them in chronological notes and typed up a summary. I put all those notes in file folder and cannot locate that folder. 35. The upshot of the consultation meeting on September 29th was recorded as follows in those summary notes prepared by Ms. Krueger: Recommendations to meet with client only with someone around, and try to get release of information for past psych assessments. Also, Mark Cooper agreed to do joint visit, as there was an ABI [Acquired Brain Injury] query. Everyone agreed to support her if she needed someone to do joint visit. In the statement submitted as her evidence-in-chief, Ms. Krueger addressed the September 29th consultation twice. In the first reference, she asserted: On September 29 AK brought up Client B – she presented his delusional beliefs, psychotic symptoms. At no time during meeting did AK state she was personally threatened. At conclusion it was agreed that Client B should only be seen in a joint visit. It was agreed to do joint visit with Mark Cooper as matter of possible ABI was raised. AK agreed to this course of action. In the second, she responded to the question: “Did AK raise this client at any team meetings or consult meetings?” as follows: He was at the meeting on September 29. No risk was identified – her concern was ABI – he was encroaching on her space – she was told by the consulting psych not to meet him alone. 36. The Grievor acknowledged the recommendation from the September 29th team consultation that she should meet with Client B only with someone else present; however, she maintained that the advice was associated with his residing at Seaton House and the “context changed when he moved to his own residence in January 2016”. Her meeting with Client B accompanied by Mr. Cooper on October 5, 2015 was the only joint meeting she had with that client. 37. Ms. Kostadinova also agreed on cross-examination that she never asked Cota to assign someone to work with her as a team in dealing with Client B, but she maintained that she was “open about needing help”. 38. The Grievor testified on cross-examination that she developed serious concerns for her safety with Client B around October-November 2015. She said that she had been aware that the concept of work refusal was provided for in Cota’s policies and that it had been discussed at a town hall meeting; however, she added: 13 “We don’t feel we can refuse based on practices at work. We are directed to provide services”. She also acknowledged on cross-examination that her notes recorded that she had told Client B that she could not provide service if she was not safe and she explained: “I knew that I could withdraw services if assaulted”. Short of an assault, she said that the opportunity to terminate services was unclear to her based on many discussions: “It was never an option presented”. 39. In the record of Ms. Krueger’s supervision meeting with the Grievor on November 17, 2015 there was reference to Client B’s “very aggressive gesturing”, the Grievor’s having to push him back, his being paranoid, and his being barely able to have a conversation due to “pressured” and “very delusional speech”. Those observations were followed by: “Plan to meet only at Seaton House unless joint meeting in community”. On cross-examination, Ms. Kostadinova stated: “That was my plan at the time”. She was then asked: “So that’s what Ms. Krueger should have understood you to be doing?” and she answered: “Yes. I had been doing that until he was housed”. Again, Client B acquired his own living quarters early in January 2016. 40. Ms. Krueger’s evidence regarding the meeting on November 17th was that she was advised that Client B had been “exhibiting aggressive gesturing and he was paranoid”. She maintained that she had told the Grievor “she must be careful and she should meet him with someone else present”. She also testified about joint visits: Arranging a joint visit is always at staff initiative and is a common practice. I could arrange a joint visit if the staff person or I have a particular concern. A joint visit initiated by a staff person does not need my approval. 41. Ms. Kostadinova met with Client B alone in his residence four times including on the date of his assault on her. Her evidence was that circumstances changed when she started working on accommodation for Client B, that Ms. Krueger knew that she was working on housing for Client B, and that she believed that Ms. Krueger would know that she was meeting alone with Client B because Ms. Krueger knew that she was working on his housing. Ms. Kostadinova did testify that she told Ms. Krueger that she had visited Client B “at home”, but she did not state that she had told Ms. Krueger that she had been alone when she did so. 42. The Grievor was challenged on cross-examination that she had been in agreement with Cota that she would engage Client B only in joint meetings outside Seaton House and yet had engaged in “one-on-ones” with him even though the risk was escalating. She responded to that by saying that her manager had not facilitated joint visits and she did not feel that she had the flexibility or an option to do so. Ms. Kostadinova confirmed that she never approached her manager to request that someone be assigned to accompany her. Moreover, she admitted on cross- examination that she had not called on any of her co-workers to join her for a 14 meeting with Client B. She said that she had not done that “after he was housed” and that she “didn’t think it was an option”. 43. The Grievor said that after Client B moved from Seaton House to his own accommodation it was also not an option to meet in a public space as the expectation was that the case managers would conduct home visits. Nevertheless, she also agreed on cross-examination that she could have arranged to meet with Client B at Seaton House or at Cota’s office. She was asked whether the circumstances of her visits with Client B were “potentially unsafe” as contemplated by the Safety Protocols for the Cota HOP Team in directing that team members were not to enter a client home or dwelling if they feel any type of threat. Her answer was: “That’s the concern. Yes”. When challenged further that she had acted contrary to Cota’s policy and the Safety Protocols, in completing her last four visits with Client B, Ms. Kostadinova responded that she read the “guidelines to apply to visits in progress” and to direct that the case manager not complete the visit if the situation was unsafe. That sequence of questioning ended with Ms. Kostadinova’s statements that she believed that Client B had the potential to be a risk in any setting, but that she faced a higher risk meeting him alone. 44. Ms. Kostadinova expressly disputed the proposition that Ms. Krueger had told her on February 2, 2016 that she was to meet Client B with someone else present. 45. On re-examination, Ms. Kostadinova asserted that she thought that management would be involved if joint visits were to be arranged and that the manager would advise the other person of the need to be involved. Her evidence was contradicted by the Union’s second witness, her colleague and fellow case manager, MB. First, MB testified that she served as Ms. Kostadinova’s “buddy” in that they had arranged for phone calls so that MB could check up on the Grievor when she was scheduled to complete a visit with Client B after he was accommodated away from Seaton House. Moreover, MB testified that she was “on standby if needed” in connection with Ms. Kostadinova’s visits to Client B: “I was ready in case she would need someone if going to his place”. She also testified that if she herself did not feel comfortable with a situation she would ask someone to join her. MB’s evidence was that arranging joint visits was not always easy to do, but “we try to figure it out on our own; the manager is not involved”, and “others are available for phone calls or joint visits; we do arrange it when not feeling comfortable”. 46. The Grievor and Ms. Krueger spoke of Client B at a supervision meeting held on January 19, 2016. They recorded that he was housed and added: “Still very thought disordered and uncomfortably close and aggressive manner”. Ms. Kostadinova was scheduled to meet with Client B at 3:00 p.m. on January 19th. Nothing was written in the supervision notes of the scheduled meeting or of the Grievor’s plans to go alone or with a co-worker and the notes Ms. Krueger testified to having compiled in March 2016 did not refer to any events after November 17, 15 2015 and before February 2, 2016; however, in her evidence-in-chief Ms. Krueger concluded her reference to the January 19th supervision meeting as follows: “The conclusion was to continue to see him as previously discussed – joint visit”. 47. What proved to be Ms. Kostadinova’s last visit with Client B was scheduled for 3:30 p.m. on February 2, 2016. 48. There had been a psychiatric consultation team meeting that morning. Ms. Kostadinova brought up one of her other clients for discussion, but said nothing in the meeting about Client B. In her evidence-in-chief the Grievor had asserted that she had spoken about being afraid of Client B until she was “blue in the face” and that she had spoken to her manager about his being “very threatening” and having an “unpredictable manner”. She had testified that at first she was concerned that she would be punched by Client B and later that she would end up “in a pool of [her] own blood”. With reference to that evidence, she was cross-examined about her failing to say anything about Client B in the consultation notwithstanding her professed fears and the fact that she was to see him in his dwelling that afternoon. Her explanation was that she did not bring him up because she had spoken of him many times with the team and with her manager in the office. She also maintained that Ms. Krueger knew that she was always concerned about her safety and she said twice that she “believed” that she had mentioned to Ms. Krueger her fear of being in a pool of her own blood. 49. On cross-examination Ms. Kostadinova maintained that it would not have been appropriate for her to have recorded her fear of ending up in a pool of her own blood in the notes she entered for Client B. 50. Both the Grievor and Ms. Krueger testified about a private discussion they had on the morning of February 2nd after the consultation. 51. Ms. Krueger’s notes prepared in March 2016 dealt with the morning of February 2nd as follows: Met for team consult 9 am – Antoaneta attended and discussed a client but not [Client B]. After meeting she briefly came into my office stating [Client B] still invading her personal space and that she was seeing him only until his housing was stable. I agreed and reminded her to ensure she meets him with someone else. Her evidence-in-chief was more expansive: AK approached me immediately after consult. In consult AK did not raise Client B. At our impromptu meeting, AK advised she will be visiting Client B that afternoon. She said Client B was invading her personal space and she was only seeing him until he was housed stably. She did not express concern for her safety. She said he was 16 aggressively gesturing but not towards me. She said I am struggling because I cannot engage him. I asked her why she did not bring Client B up at consult. She said I wasn’t thinking about it then. I told her not to see him alone and I asked her if she wanted the new nurse to shadow her – she said fine and we will set up some dates. 52. Ms. Krueger’s evidence was that she believed that Ms. Kostadinova was going on joint visits or meeting Client B in public at Seaton House once Client B had moved into his own place. She admitted that she did not ask Ms. Kostadinova with whom she was doing joint visits, adding, with reference to the Grievor’s experience, that there was nothing “to lead me to believe she wouldn’t be doing joint visits”. She insisted on cross-examination that, on February 2nd, she had not been aware that Ms. Kostadinova was seeing Client B in his unit and that she had told her not to see him alone. 53. Ms. Kostadinova had previously testified that after the consultation Ms. Krueger called her in to discuss the addition of a male nurse to staff and to ask her whether she would like to have the nurse join her on a visit with Client B. It was in that context that Ms. Kostadinova said that she “believed” that she had mentioned to Ms. Krueger her fear of being in a pool of her own blood and she testified that Ms. Krueger had said “I have no words for you” and suggested that she bring the issue up in a team meeting where, perhaps, an answer would “percolate”. 54. The hiring of the male nurse was of no immediate significance to Ms. Kostadinova as she did not know when he would start work and the Grievor rejected the suggestion put to her on cross-examination that she could have postponed her meeting with Client B to await the arrival of the nurse. Ms. Kostadinova said that she was at her wits end regarding Client B by that time; she was considering withdrawing services as she had not been able to engage him over the course of six months. She testified that she was “constantly afraid” and he was so unpredictable that she was scared and could not assess her safety. 55. Ms. Krueger’s evidence-in-chief included the following exchange: Have you read the notes AK made about the client [B]? YES Is there any indication to you in her notes that he was a threat to her? NO If he was a threat what should she have written? 17 She should do an assessment and write her observations and client status as to how client presents in visits. As an experienced person, AK should report “client is presenting with threatening behaviour that makes worker feel unsafe. Worker will suspend visits until discussion with Manager” If he was a threat what should she have done? She should immediately disengage and report to Manager or Manager on Call if unable to reach Manager. Safety Protocol . . . provides: • “When you have any concerns about the potential for violence against yourself or others, discuss the situation with your Manager and evaluate whether Cota should continue to provide service to the person”. 56. Ms. Krueger’s evidence-in-chief concluded as follows: Did AK express to you, before the assault, that she felt that the client was a risk to her? NO If she had done so what would you have done? If she had done so, I would direct her to suspend service. Did AK say she was afraid she would end up in pool of blood? NO What would you have done if you knew AK was thinking that? I would direct [sic] to suspend service. 57. Ms. Krueger and Ms. Kostadinova exchanged messages over the evening of February 2nd and met the following day. Ms. Krueger’s notes of that read, in part, as follows: Antoaneta and I met in my office at 1:30 – discussed incident, she demonstrated situation and I empathized and stated I didn’t think she should continue to work with him, let alone meet with him alone. On cross-examination, Ms. Krueger maintained that she had been shocked to learn that the Grievor had been visiting Client B alone and that she had understood that Ms. Kostadinova had been attending on joint visits. 18 58. Ms. Krueger’s summary notes from March 2016 also recorded a number of statements that were not brought out in her evidence-in-chief, including the following Feb 5th – met with Antoaneta – provided support and discussed her taking some time off. She felt weekend would be enough of a break but appeared angry that she had to meet the client. I emphasised that everyone has an option to decline, and certainly I had never intended for her to feel she could decline [sic] seeing him. I clarified that she was not to have contact with the client and that I would deal with his care. I then suggested we debrief the team on Feb 9th as its good learning for everyone. She agreed this would be helpful. I stressed that it was important everyone on the team know that they can decline a client if they feel unsafe. 59. The particulars Ms. Kostadinova submitted on March 21, 2016 in support of her grievance and which were included in the exhibits addressed that circumstance. She wrote the following and testified to the same effect: During a discussion with the manager on Feb 5, she stated that “she feels guilty and takes the blame for not directing me to not work with the client after I had expressed concerns that I am uncomfortable”. The manager stated that she thought it was understood that I can decline work with clients if there are concerns. This option was never presented (or implied) when I had discussed my safety concerns. In her testimony, Ms. Kostadinova stated that she objected to Ms. Krueger’s statement that she thought that the Grievor understood that she could decline to work with a client and that she told her manager that she did not agree that she had that understanding. 60. Ms. Krueger acknowledged that the case notes concerning Client B were available to her and that she probably should have reviewed them in connection with her supervision of Ms. Kostadinova; however, she did not do so. Nevertheless, she recognized on cross-examination that the November 17, 2015 supervision meeting in which she had recorded the Grievor’s advice that there had been physical contact – he had demonstrated “very aggressive gesturing” and “she had to push him back – established that Client B posed a physical risk to Ms. Kostadinova. Similarly, the supervision notes for January 19, 2016 in which she had recorded Client B’s being “uncomfortably close” and exhibiting an “aggressive manner” could be viewed as relating to a physical risk. Moreover, her evidence-in-chief regarding the consultation on September 29th established that the consulting psychiatrist had told Ms. Kostadinova that she should not meet Client B alone and Ms. Krueger agreed that in speaking to the client’s encroaching on her space, the Grievor was identifying a risk to her person. 19 61. Ms. Kostadinova testified to the effects of the assault and her perception that Cota had failed to respond to her concerns regarding Client B. Her evidence was that her sister noticed that she was more irritable and she said that she had difficulty sleeping, was drinking more than her usual glass of wine before bed in order to sleep, was disillusioned, distrustful and disengaged. 62. The Union submitted no medical evidence in support of the Grievor’s testimony regarding any of the consequences she attributed to the events involving Clients A and B. 63. The notes compiled by Ms. Krueger and submitted by Cota reflect Ms. Kostadinova’s absence from work, meetings Ms. Krueger had with her on April 19 and 21, 2016 to discuss her return to work, as well as communications between the two later in April 2016 -- the last of which referred to the then “upcoming arbitration”. Positions of the Parties 64. The Union submitted that Article 17 of the collective agreement incorporates the OHSA and, particularly, clause 25(2)(h) identifying an employer’s obligation to “take every precaution reasonable in the circumstances for the protection of a worker”. The burden of the grievance was that Cota had failed to meet that statutory standard in relation to what befell Ms. Kostadinova as a result of the misdeeds of Client A and Client B. 65. I was urged to assign little or no weight to Ms. Krueger’s notes and, consequently, her evidence-in-chief as that relied on those notes and was supplemented by recollections that had surfaced after those notes had been prepared. The Union cast doubt on the reliability of the notes given that they were prepared after the fact and after the filing of the grievance, were said to have been supported by original notes that had then been lost, and were indefinite as to whether the contents were based on those lost notes or Ms. Krueger’s “memory reflections”. 66. In the Union’s submission, the evidence established that Cota failed to respond to “significant workplace violence concerns”. It had done nothing with respect to the situation presented by Client A other than to instruct him to stay away from its drop-ins. The supervision notes relating to Client B established that he presented a risk and the Union argued that instructing Ms. Kostadinova to have joint visits was simply not enough. In any event, the Union disputed the proposition that Ms. Kostadinova had an understanding with Cota that she would restrict herself to joint meetings. 67. The Union submitted that the Grievor’s conduct was not in issue. Ms. Krueger, on the other hand, “should have been more meticulous in following up with 20 Ms. Kostadinova regarding Client A” and the Grievor had raised her concerns about Client B repeatedly, but Ms. Krueger failed to follow up regarding joint visits and did nothing to help in setting up a protocol for joint visits. 68. The Union asked me to note that Ms. Kostadinova had invoked a “buddy system” in connection with Client B and also to accept that the Grievor had told her manager on the morning of Client B’s assault that she could see herself on the floor in a pool of blood – both being factors in demonstrating the level of her concern. 69. The Union contended that there should be a declaration of Cato’s breach of the collective agreement and failure to meet the requirements of the OHSA; that the Grievor’s evidence established that her reaction to the issues and her concerns – her difficulty in going to work, drinking and sleeplessness – warranted an award of general damages in the order of $20,000 referable to the period April 2, 2015 to February 2, 2016; and that Cota’s failure to take adequate safety measures constituted an independent actionable wrong that supported an award of punitive damages, also in the amount of $20,000. 70. Cota questioned how the situation respecting Client A was properly before me in that the Union had relied on that history as part of a pattern of events but made clear in its submissions that it sought compensatory damages from the discovery of the threatening text message. If Client A’s behaviour generated any compensable harm, the time for filing a grievance had long expired before the Grievor made any formal complaint. 71. To the extent that Cota was faulted for failing to have or introduce a protocol to address the situation created by Client A, I was asked to note that neither Ms. Kostadinova nor the Union had identified any appropriate change to be made to the policies and protocols that were in place at the time. Those set out various obligations accepted by management and, it was argued, there was no demonstration that any of those had not been met in the circumstances. 72. As for the second situation, Cota took the position that there had been no threat to the Grievor prior to the assault by Client B. She had had a period of months and many visits on which to base an assessment of any risk posed by the client. Her notes remarked on his being “in her space” and “gesturing aggressively” on an number of occasions. He was said to have been “unpredictable”. Cota noted that Ms. Kostadinova had an obligation, if she considered the client to present a threat, to make notes and ensure that her assessment would be clear to her co- workers who might refer to her notes in contemplation of dealing with Client B. However, it argued, there was nothing in the notes or in the supervision sessions to communicate the view of Client B’s being a physical threat to her or another case manager. 73. Cota’s submission assigned blame to Ms. Kostadinova for having failed to withdraw services and for having failed to conduct joint visits with Client B. As to 21 the latter, there was no evidence that the Grievor had attempted to arrange joint visits, notwithstanding that her co-worker’s evidence was that she was ready to provide that assistance. Cota maintained that, knowing that she was supposed to conduct joint visits, the Grievor’s case reduced to a complaint that Ms. Krueger had failed to make sure that she was complying with that requirement. 74. The Grievor’s recorded comments to Client B and to Ms. Krueger confirmed that she knew that she could withdraw services and if she did envision herself in a pool of blood she would not have visited Client B alone on four occasions. The reality, in Cota’s submission, was that her decision to continue as she did indicated that the situation was not at all as she attempted to make out after the assault. 75. Cota submitted that there was no evidence on which to base the Union’s claim for general damages. The Grievor had referred to her sister’s observation, but the sister did not testify. There were no medical reports, no counseling records, no notes of any events or suffering, or any supportive documentation. The claim was made for the full period from April 2, 2015 to February 2016, but there was no claim processed in 2015 regarding Client A and, Cota argued, her unassisted recollection in October 2016 was not a sufficient foundation for a claim associated with Client B’s behaviour. Analysis 76. The central core of the Union’s case is the proposition that Cota breached its collective agreement by failing to meet the obligation imposed by clause 25(2)(h) of the OHSA in relation to the threat attributed to Client A and the assault committed by Client B. 77. While so saying, the Union did not attempt to persuade me that Cota had any means to prevent a person such as Client A (or the unidentified and probably fictional friend who allegedly borrowed his device) from sending an offensive and grossly threatening text message to another individual. Cota has no opportunity to police the conduct of its clients away from its precincts and no opportunity to monitor and intercept their private communications so as to preclude a repetition of the conduct attributed to Client A. 78. Accordingly, there simply were no precautions reasonable in the circumstances that Cota might have taken to protect Ms. Kostadinova from the frightening impact of the crude text message that was brought to her notice on April 1, 2015. In that context, no one would sensibly suggest that the parsing of the exact words of the text message might have had any ameliorating effect. One would expect anyone to be dramatically and negatively affected on learning that another person had expressed either a desire or a threat to rape them. 79. In prosecuting this grievance, Ms. Kostadinova repeatedly voiced her concern and complaint that Cota had no protocol to deal with the situation created by Client 22 A’s text message. She maintained that the absence of the protocol contributed to or perhaps even caused her to experience angst that affected her life in the period after she learned of the text message. Having regard for all of the evidence, however, I am not satisfied that the Union established that the absence of a responsive protocol – rather than the threatening text message – occasioned any pain and suffering for which the Grievor sought general damages associated with the first incident. 80. In my view, the position advocated by the Union and the Grievor is defeated by their failure to identify any protocol that was necessary, available and effective in the circumstances and that was not implemented by Cota. Client A was taken to task and appropriately cautioned that his conduct exposed him to the possibility of criminal proceedings; he was brought before a community relations officer who reinforced that message; he was given instructions regarding his behaviour, including being told to have no contact with Ms. Kostadinova; and he was barred from attending the drop-ins at which case managers would normally be present. Neither the Union nor the Grievor identified any additional precautions that Cota might have taken to meet its obligations, and the repetition of the Grievor’s complaint for which no solution was proposed is of no assistance to me or, with respect, to the achievement of workplace health and safety improvements. 81. That is not to say, however, that Cota acquitted itself as it should in addressing its obligations to the Grievor and other case managers. Having identified the barring of Client A from the drop-ins as part of its response and its means of protecting potentially exposed workers, Cota failed to ensure that Client A heeded the injunction and stayed away until advised that he might return. The evidence established that he attended at the drop-ins on at least two occasions shortly after the exclusion was imposed. In the result, Cota failed to protect its workers by enforcing one of the precautions that it had deemed reasonable in the circumstances. 82. There was no evidence that Cota’s lapse regarding Client A’s attendance at drop-ins in 2015 occasioned any direct or indirect harm to the Grievor or any of her co-workers. There was no suggestion that he misconducted himself towards staff while in attendance contrary to the direction that had been given. There was no evidence that Ms. Kostadinova encountered Client A at the drop-ins or at any time after April 2015. She learned, after the fact, that he had been in attendance and stated, in connection with discovering that he had been present in February or March 2016 – possibly after the commencement of the Grievor’s absence following the February 2, 2016 assault – that she had been traumatized by his presence or as a result of learning that he had been present; however, I regard that as a late discovery following from the production of documents in this proceeding and give it no weight in assessing the Grievor’s claims or entitlement. 83. In the result, I am not satisfied that anything that Cota did or failed to do in responding to the offensive text message justified an award of damages. I am not persuaded that the anguish for which Ms. Kostadinova claimed damages flowed 23 from any act or omission of Cota rather than the impact on her of the text message. To the contrary, the fact that no contemporaneous grievance was filed to challenge Cota’s handling of Client A and the text message stands as a clear indication that the arguments made so long after those facts were not identified as concerns in 2015. 84. The evidence of both Ms. Kostadinova and Ms. Krueger in relation to the circumstances leading up to and following the assault by Client B was problematic in several respects. 85. As noted above, Ms. Krueger was responsible for a compilation of a set of notes that supplied the substance of much of her statement of evidence. The notes purportedly reflected both notes that she had made in the ordinary course of her duties (in connection with supervision sessions and other exchanges) and “memory reflections” that typically were not identified as such or distinguished from reporting based on notes. She said that she pulled those notes together at the beginning of March. She also referred to notes that she had made in her book. When she completed typing the summary or compilation of notes that was introduced in evidence, Ms. Krueger explained the failure to produce documents by attesting that she “put all those notes in file folder and cannot locate that folder”. She also acknowledged her familiarity with the grievance submitted February 26, 2016. That is to say, Ms. Krueger compiled and “typed up the summary” in connection with the grievance filed days earlier and, notwithstanding that she made notes in her book, then “put all those notes in file folder” that she could not locate for the hearing. 86. That is far from convincing evidence and does not suffice to explain Cota’s failure to substantiate the sources or the content of some of the statements recorded in Ms. Krueger’s summary notes and given in evidence. It is also of concern that Ms. Krueger stated that she pulled these notes together shortly after the grievance was filed – “beginning of March” – while the document includes entries for April 19, 21, 22, 26, and 27, 2016 and closes with a reference to the “upcoming arbitration” that commenced on May 3, 2016. When, in those circumstances, did the witness lose control of the file folder? 87. There was an internal inconsistency in Ms. Krueger’s statement of evidence in that she stated in one paragraph that she could not recall whether the Grievor attended a team meeting on April 10, 2015 at which, she said, the incident involving Client A was discussed. In the following paragraph, she described her “recollection” that the situation was discussed at the April 10th team meeting and added: “I believe AK was present”. Those variations do not inspire confidence in the validity of Ms. Krueger’s observations. 88. Furthermore, Ms. Krueger directly compromised her credibility with the astonishing statement in her evidence-in-chief that, having read the notes that the Grievor made about her interactions with Client B, it was her evidence that there was no indication to Ms. Krueger in the notes that Client B was a threat to Ms. 24 Kostadinova. Notwithstanding that she revised her position on cross-examination, in my view the statement was absurd and contributed to the identification of Ms. Krueger as an unreliable witness. 89. An objective and fair reading of the notes excerpted above from June 25, 2015 through February 2, 2016 would lead any reasonable person and competent supervisor to conclude that Client B posed a threat to the safety of any case manager with whom he came into contact. Those notes included references to Client B “leaning over writer”, “shouting about aliens”, invading her personal space “as he kept tapping her on the knee”, becoming “extremely agitated”, leaning over the Grievor, speaking about eating humans and making “a sudden strangling gesture towards [the Grievor]”, referring to having been on probation in connection with charges of sexual assault of a woman, “leaning over [the Grievor] in an aggressive manner and she had to push him back away from her”, being told by the Grievor that his behaviour was threatening and that he does not respect her personal space, “advancing towards [the Grievor] on a couple of occasions screaming about aliens, homosexuals and radiation, invading the Grievor’s personal space, and, finally, charging the Grievor, pushing her forcefully in the chest, and causing her to lose her balance. 90. Ms. Krueger’s bald dismissal of the foregoing as failing to indicate to her that Client B posed a threat to Ms. Kostadinova is to be assessed in the context of Cota’s Safety Protocols. There, case managers for HOP are advised that if they have “any concerns about the potential for violence” against themselves they are to discuss the situation and “evaluate whether Cota should continue to provide service to the person”, that they are not to enter a client dwelling ”if they feel any type of threat”, and that they are not to complete a home visit with a client “if circumstances appear to be potentially unsafe”. The Grievor’s notes demonstrate that there were threats, there was the potential for violence, and she was potentially unsafe during most of the last five months of her involvement with Client B. 91. Moreover, Ms. Krueger’s assessment of the threat disclosed by the Grievor’s case notes is in direct contrast to the evidence relied upon by Cota to defend its position. The consultation on September 29, 2015 resulted in the psychiatrist’s counseling that the Grievor was not to see Client B alone and Ms. Krueger, while maintaining that Ms. Kostadinova had not stated that she was personally threatened, confirmed that “it was agreed that Client B should only be seen in a joint visit”. Then the supervision session on November 17, 2015 produced what Cota relied upon as Ms. Kostadinova’s agreement “to meet [Client B] only at Seaton House unless joint meeting in community”. That is to say, Ms. Krueger, having been told, on her evidence, that Client B had been “exhibiting aggressive gesturing and he was paranoid” advised the Grievor that “she must be careful and she should only meet him with someone else present”. Finally, notwithstanding her evidence that the Grievor’s notes would not have indicated to her that Client B was a threat to his case worker, Ms. Krueger gave testimony that she had cautioned Ms. Kostadinova at the January 19, 2016 supervision meeting “to continue to see him as previously 25 discussed – joint visit” and, on the morning of February 2nd, she had “reminded [the Grievor] to ensure she meets him with someone else”. 92. Simply put, why would the psychiatrist and Ms. Krueger have cautioned Ms. Kostadinova as alleged if Ms. Krueger’s assessment was in any way valid or deserving of consideration? The statement in Ms. Krueger’s evidence-in-chief was so inordinately contrived that her evidence is necessarily suspect. Clearly, Cota was concerned for the Grievor’s well being and her safety in dealing with Client B. The advice to the Grievor plainly demonstrated that Cota recognized that Client B, as described by Ms. Kostadinova in her notes and to the team meetings, put her safety at risk. 93. Also on that score, as pointed out by counsel for the Union, the statement of Ms. Krueger’s evidence-in-chief added to the summary notes in at least one surprising and questionable detail. The summary notes included no reference to a period of several weeks and, in particular, made no mention of the supervision meeting on January 19th. Furthermore, the document produced from that session made no mention of any advice to Ms. Kostadinova or any conclusion regarding the need “to continue to see him as previously discussed – joint visit”. Ms. Krueger offered no explanation for her omission of that detail in preparing the notes “beginning of March” that were largely relied upon for the statement of evidence submitted in October 2016. Similarly, the statement of evidence regarding the discussion after the psychiatric consult on February 2nd was expanded by the addition of indications that the Grievor did not express concern for her safety and had said that while Client B was aggressively gesturing it was not towards her. It is noteworthy that the expansions on the notes compiled in March were uniformly negative to the Grievor’s position. 94. Ms. Krueger’s summary notes included reference to an exchange she had with the Grievor on February 5, 2016. The note for that date and Ms. Kostadinova’s note regarding that discussion suggest strongly that, prior to the initiation of the grievance, Ms. Krueger had acknowledged a degree of responsibility for failing to ensure that her subordinate was aware of her opportunity to take protective steps to avoid harm at the hands of her client. 95 . Aspects of Ms. Kostadinova’s evidence with respect to her involvement with Client B were equally troubling and suspect. The Grievor is an educated person, she demonstrated intelligence, and she has had a significant amount of experience with Cato and in dealing with difficult clients. It was manifestly her position in this proceeding that Client B posed a real threat to her health and safety. I regard her contemporaneous case notes to be reliable as they, unlike the notes proffered by Ms. Krueger, were written in the ordinary course, without a litigious context, and, until February 2, 2016, without the knowledge that Client B would in fact commit an assault or other dangerous act. Even then, Ms. Kostadinova’s description of the event and her reaction was, in my estimation, measured and objective. 26 96. Nevertheless, I cannot accept the Grievor’s explanation for having attended at Client B’s unit alone – notwithstanding what I consider to be her entirely justified concerns for her safety and the direction that she had received and agreed to in September and November 2015, if not more recently as alleged by Ms. Krueger. Simply stated, Ms. Kostadinova’s contention that the plan and injunction to see Client B only at Seaton House unless in a joint meeting in the community and not to see him alone applied only while he was resident at Seaton House and ceased to have effect when he moved into his own private quarters was nonsensical. Ms. Kostadinova‘s insistence on maintaining that position put all of her evidence under a cloud of incredibility. 97. Secondly, I cannot accept that Ms. Kostadinova so subordinated her interests in her wellbeing that she proceeded as if Cota’s published policies and safety protocols for the HOP team, as well as her statutory right to refuse unsafe work, were in some fashion trumped and neutered by an imperative to furnish services to a troubled population. 98. The only evidence that underscored that concern more than the Grievor’s failure to ask her manager for assistance in meeting the requirement that she conduct joint visits with Client B, was her admission that she had failed to ask any of her colleagues to join her and her co-worker’s evidence that she was aware of the issue and prepared to respond positively to any request for assistance. 99. Ms. Kostadinova testified that it would be too difficult to secure assistance from co-workers as they had their own caseloads and quotas to meet. That position was simply untenable. The Grievor could not succeed in maintaining the impossibility of securing assistance as her co-worker testified that she would have supported her if she had been asked. That is significant as it points to the adequacy of Cato’s protocols even though case managers might have been left to make their own arrangements. The Grievor also asserted that it was Cato’s responsibility to schedule others to allow for her joint visits; however, she did not ask for that assistance and she did not tell Cato that she was not engaging in joint visits. 100. Ms. Kostadinova contended that Cato should have known that she was proceeding alone because Client B was no longer an inmate of Seaton House. That position was patently illogical. Only the Grievor interpreted (or purported to interpret) the requirement to see him at Seaton House or with a companion as no longer applying when Client B had private quarters in which she would be visiting him. 101. The Grievor’s position was puzzling. On the one hand she appeared to be genuinely and justifiably concerned about her safety with Client B and she was a person with experience and intelligence. She struck up a “buddy” arrangement with her co-worker MB. Yet she never asked anyone for assistance in scheduling joint visits when she had arranged to meet this frightening individual in his unit. Why would she not make any effort if she were truly concerned? 27 102. I cannot accept the Grievor’s evidence that she came to envision herself in a pool of her own blood at the hands of Client B. I note that she twice said that she believed that she had communicated that to Ms. Krueger; however, as concerning as her notes were, nothing in what she had written intimated that degree of fear. More significantly, there was nothing in what she was attempting to do with and for Client B or that she was obliged to do in fulfillment of her duty to Cota that could ever explain a rational person’s believing that she was required to provide service to a person she believed to be capable of harming her to such an extent, if not committing her murder. 103. The Grievor’s position ignored entirely the protocols established in the evidence and quoted from above. Ms. Kostadinova complained that the policies were too general and did not address specifics such as the tipping point for a case manager’s decision to withdraw from a session or to decline service. Having had the benefit of hearing of the challenges confronting the Cota case managers I can appreciate that any attempt to develop an encyclopedic catalogue of situations and correlated solutions would be doomed to failure – either because the project would never be completed or because the objective could not be achieved as situations that the drafters did not foresee and did not address would almost inevitably arise. The situation of Client A comes to mind as the Grievor acknowledged that it was a one- of-a-kind circumstance in her history with Cota. 104. In my view, and noting that the Union did not propose any different or additional provisions, the protocols put into evidence afforded the concerned case manager ample scope for self-protection. Dealing specifically with home visits and recognizing the over-arching protection of the worker’s right to refuse work she or he considered to be unsafe, Cota’s protocols stipulate that: staff safety supersedes the program expectation that home visits are an integral part of the program to ensure that homeless clients succeed in new housing; HOP team members are not to enter a client dwelling if they feel any type of threat; and the case managers are not expect to remain on the scene “if circumstances appear [to them][ to be potentially unsafe”. The general nature of those directives is clearly to the benefit of the worker. They afford the concerned individual a wide scope of discretion to the extent that Cota could not have challenged Ms. Kostadinova had she declined to attend on Client B on February 2, 2016 given the history she had documented in her case notes and discussed with her manager and colleagues. 105. Counsel for the Union contended that Cota was guilty of “victim blaming” in connection with these matters. No one blamed or could blame her for the text message from Client A or the assault by Client B. However, when the Union argues that Cota’s protocols are inadequate and that it failed in its statutory obligation, it is appropriate to consider the extent to which – if at all – those protocols failed the worker for reasons over which Cota had no control. Given that Ms. Kostadinova considered herself to have been at risk and regarded Client B as posing a threat, the protocols quoted above provided certain protection: she felt threatened by reason 28 of Client B’s behaviours and the Safety Protocol stated without equivocation that in that circumstance she was not to enter Client B’s unit. Had she followed that directive on February 2, 2016 Client B could not have assaulted her as and where he did. Similarly, but less certainly, if she had seen Client B at Seaton House or on a joint visit with a colleague, there might have been no assault; however, an assault could have occurred in those circumstances as was evident from Client B’s behaviour towards the Grievor when the two met at a Tim Horton’s coffee shop. 106. As it was, the Grievor’s course of action was comparable to that of a mechanic in an industrial setting who not only fails to lock out a piece of equipment that is to be repaired, but proceeds with the repair while the dangerous machine is operating. Just as the mechanic ignores protocols that would require the equipment to be shut down and locked out, Ms. Kostadinova ignored the direction to stay out of Client B’s dwelling based on her perception of a threat, and proceeded to meet with him in private without the benefit of a co-worker’s presence. 107. In the result, I conclude that Cato was made aware of the Grievor’s justifiable concerns that Client B posed a threat. Cato had protocols in place that afforded Ms. Kostadinova precautions reasonable in the circumstance for her protection and it added to that the advice and requirement that Ms. Kostadinova was to see Client B only at Seaton House or on joint visits. 108. In that context, however, Cato interacted with the Grievor through Ms. Krueger and that interaction, in my view, was quite inadequate. First, the subsistence of policies and published protocols is not dispositive in a situation such as this. Ms. Krueger did not invoke the protocol that would have directed Ms. Kostadinova to decline to meet Client B in his unit. Rather, and putting her evidence at its highest, she said nothing to suggest that the Grievor might or should decline to conduct visits, but reiterated advice given in September 2015 that the Grievor should not see Client B alone. 109. Ms. Krueger maintained that she did not know that Ms. Kostadinova was going to see Client B alone. Yet she testified that she addressed the issue on January 19 and again on February 2, 2016 – in both case simply reiterating the advice that the Grievor should not go alone. In my view, it beggars belief that Ms. Krueger had such conversations without once asking for assurance that the Grievor was complying or without asking where the meetings were to take place and which of the very limited number of case workers was accompanying Ms. Kostadinova. 110. The conversation that Ms. Krueger had with the grievor on February 2nd took place immediately after a team consult and only hours before the Grievor was to visit Client B. Common experience precludes my accepting that in such a situation Ms. Krueger, as a competent manager with appropriate concern for the wellbeing of a subordinate involved with a patently disturbing client, would not have asked Ms. Kostadinova about her arrangements for the afternoon visit. 29 111. In all of the circumstances, I conclude that Ms. Krueger did not ask and likely did not tell. She was content to assume that matters were proceeding as they should. 112. The publication of protocols without inquiring to determine that they are being used or followed is not sufficient to meet Cato’s obligations when it failed, through its manager, to make any inquiries regarding the application of the protocols or adherence to their dictates. Moreover, by relying on the advice that Client B was to be seen at Seaton House or on joint visits Cato varied its established framework for statutory compliance and it cannot be said to have been taking every precaution reasonable in the circumstances for the protection of Ms. Kostadinova in her dealings with Client B when it failed to make any inquiries as to her compliance with its direction. 113. Cato established an approach to the provision of services to Client B that very well might have been sufficient to protect Ms. Kostadinova. The Union did not convince me that the approach as identified to the Grievor was necessarily inadequate. Cato’s obligations, however, were not extinguished by the proclamation of the appropriate safeguards to be applied in dealing with Client B. Having regard for the workplace norm testified to by Ms. Krueger, the evidence of MB regarding her willingness to assist and the general success enjoyed by case workers in establishing consensual arrangements, and the failure of Ms. Kostadinova to make any effort to comply with the direction to conduct joint visits away from Seaton House, it is my conclusion that, again, Cato’s sole failing in relation to its obligations under the collective agreement and clause 25(2)(h) of the OHSA was in failing to ensure that its designated precaution was complied with by the Grievor. 114. Having so found, I am obliged to allow the grievance to the extent of declaring that Cato failed in both instances to meet its obligations under clause 25(2)(h) of the OHSA; first by failing to enforce the exclusion of Client A and secondly by failing to ensure that the Grievor was adhering to the direction given about her meetings with Client B. 115. I reject the Union’s claim for an award of general damages attributable to the breach associated with Client B. I am not satisfied that the Union established that the Grievor endured any pain and suffering that was attributable to Cato’s failure to police its direction to her more diligently. The evidence I did receive was anecdotal and lacked any independent support or documentation. 116. Furthermore, the Grievor’s explanation for her failure to follow the dictates of common sense, Cato’s formal protocols, and the direction that she was not see Client B alone outside Seaton House was unworthy of her intelligence and at best an impoverished after-thought. Unlike Ms. Kostadinova, the employees involved in the 30 cases cited to me by the Union1 had done nothing to create or contribute to the situations that led to their being awarded general damages in response to their employer’s violation of the Human Rights Code, R.S.O. 1990, c. H.19. The school board employer in those cases was solely responsible, though its supervisory or managerial employees, for the harm that was occasioned those grievors and that had been found to have offended the statute. The grievors, unlike Ms. Kostadinova, had no ability to avoid the wrongdoing of their employer and the consequential harm. Here, as between Cota and herself, the Grievor’s contribution to the outcome was truly overwhelming and negates any potential entitlement she might have had to general damages. 117. In support of the Grievor’s claim for an award of punitive damages, the Union submitted the headnote of the decision of the Supreme Court of Canada in Whiten v. Pilot Insurance Company, 2002 SCC18, 2002 SCC 18 (CanLII). The headnote records the Court’s directions that “punitive damages are very much the exception rather than the rule, imposed only if there has been high-handed, malicious, arbitrary or highly reprehensible conduct that departs to a marked degree from ordinary standards of decent behaviour”. The evidence in this matter does not admit any possibility of an award of punitive damages as Cato’s conduct conformed to none of those indicia. 118. The Union and the Grievor are entitled to the declaration referred to above and the grievance is allowed to that extent alone. Dated at Toronto, Ontario this 28th day of November 2016. _________________________________ Derek L. Rogers 1 CUPE, Local 4400 v. Toronto District School Board (Mossissey Grievances), 2016 CanLII 26730 (ONLA) and Ontario Secondary School Teachers’ Federation, District 12 v. Toronto District School Board (Lazar Grievance), [2015] O.L.A.A. No. 61, 252 L.A.C. (4th) 39.