Supervision and Patient Safety

Posted: March 20, 2026

The Case

The College received a complaint from a patient who was seeing a physiotherapist for back pain.

During an appointment, the physiotherapist asked a physiotherapist assistant to set the patient up on a Transcutaneous Electrical Nerve Stimulation (TENS) machine.

The patient said the assistant struggled to attach the electrodes to their back because they didn’t appear to be sticking properly. Eventually, the assistant turned on the machine and asked the patient if they could feel anything. The patient said they could not, and the assistant kept turning up the machine.

Suddenly, the patient experienced what felt like a strong shock. They screamed out in pain and the assistant scrambled to turn off the machine. Hearing the noise, another member of clinic staff rushed in and removed the electrodes.

The patient was then left alone in the treatment room where they could hear staff talking about the incident outside.

Panicked, the patient called 911. When paramedics arrived, they found the patient’s heart was racing and their blood pressure was very high. They were taken to hospital for monitoring.

The Standards

As detailed in the Supervision Standard, physiotherapists are responsible and accountable for all care provided by people working under their supervision.

As a physiotherapist, you must ensure the physiotherapist assistants (PTAs) you work with have the knowledge, skills and judgement to deliver safe and competent care. That includes only assigning tasks and activities that the PTA is competent to provide.

Physiotherapists are also responsible for ensuring all equipment is clean, safe and properly maintained and calibrated. See the Risk Management and Safety Standard for more details.

This case raises questions about whether the physiotherapist assistant was adequately trained and whether the TENS machine was working properly.

It is also concerning that the patient was left alone in the treatment room when they were panicked and scared.

In their response, the physiotherapist said the patient called 911 before they had a chance to talk to them. The patient then asked for aspirin, so the physiotherapist went to find it and later went outside to help the ambulance locate the clinic.

While the physiotherapist may have been trying to help the patient, they still shouldn’t have left them unattended while they were in distress.

After the incident, the physiotherapist waited almost two weeks to follow up with the patient and ask how they were doing. The physiotherapist said they did this because they wanted to give the patient time to cool down because they had clearly been very upset.

However, wanting to avoid an uncomfortable conversation is not a reason to delay follow-up. Physiotherapists are expected to take all reasonable measures to ensure patients’ wellbeing.

The Communication Standard requires physiotherapists communicate with patients in a timely manner.