Mental-health worker’s 2011 death was preventable: fatality report

(Canadian OH&S News) — A newly released fatality report has concluded that the death of Camrose, Alta. caregiver Valerie Wolski, who was strangled by a developmentally disabled client at his residence nearly six years ago, could have been prevented.

Wolski, 41, was an individual supports worker employed by the Canadian Mental Health Association’s (CMHA) Alberta East Central Region. On the afternoon of Feb. 12, 2011, Wolski paid a visit to the CMHA residence of Terrence Saddleback, and her husband unsuccessfully tried to reach her by text that evening. A co-worker found her dead on the floor of Saddleback’s living room the next morning, according to the report, which was dated Nov. 10, 2016, but not released to the public until Feb. 1.

Following a public inquiry on the case in Camrose last June, Judge B.D. Rosborough wrote in the report that Saddleback had a lengthy history of “antisocial and aggressive behaviour” that included violent attacks, hallucinations, pulling other people’s hair and inappropriately touching women. But Persons with Developmental Disabilities (PDD), a branch of Alberta Human Services that had previously dealt with Saddleback, never sufficiently briefed CMHA on how dangerous he was, the judge added.

“There has been no suggestion that CMHA withheld or consciously avoided disseminating this information,” wrote Judge Rosborough. “It seems probable that information relating to Saddleback’s aggressive tendencies was not emphasized or perhaps even relayed to all CMHA staff.”

Colleen Swanson, executive director for CMHA’s Alberta East Central Region, agreed that PDD had not adequately informed the organization about Saddleback. If it had, CMHA would not have taken him on in the first place, she told COHSN.

“Our program doesn’t serve high-risk individuals,” explained Swanson. “He wouldn’t have met our criteria to enter our program if we had all the information.” CMHA has a strict screening process to keep out aggressive potential clients, she added, but “communication has been an ongoing issue in all service over the area.”

Judge Rosborough made seven recommendations for preventing similar tragedies, including the following:

— PDD should collaborate with an outside agency to review how it generates, secures and disseminates information about developmentally disabled clients;
— Any organization caring for such clients should keep separate records of safety-related information;
— No caregiver should be assigned to a client that he or she cannot manage physically;
— Female caregivers should not look after clients who have a history of behaving aggressively towards women; and
— The provincial government should prepare status reports on the implementation of recommendations from all fatality inquiries, following the example of the Ontario Ministry of Community Safety and Correctional Services.

In a Feb. 1 press statement, Alberta Community and Social Services Minister Irfan Sabir said that the provincial government valued Judge Rosborough’s recommendations and would commit itself to them.

“A number of changes were made as a result of this devastating tragedy, including changes to risk assessment for complex-need individuals and information-sharing,” said Sabir. “However, we know we have more work to do… We owe it to Ms. Wolski, and indeed to all Albertans, to learn from this heartbreaking incident.

“Our thoughts are with those who loved Ms. Wolski and all those affected by this tragedy. No one should have to go to work in an environment where their life is at risk.”

Swanson noted that Judge Rosborough had “put a lot of thought and consideration into the report” and ended it with “good recommendations,” but she stressed that enforcement from the government would be necessary.

“We’ll have to have somebody ensuring that those changes are going to be made,” said Swanson. “That would have to happen through one of the administrative organizations.”

She added that “transparent communication” was a vital element that could have prevented Wolski’s death by Saddleback, who was later found unfit to stand trial for manslaughter.

“If that information had been available, he wouldn’t have been in our services. He might have still been in an institution.”

Judge Rosborough’s fatality report is accessible online at https://www.scribd.com/document/338140433/Fatality-Report-Wolski.