Fatality report finds errors contributed to death of Alberta mental health worker

A fatality report has found there were failings that contributed to the death of Camrose mental health worker Valerie Wolski, who was killed in a client’s home in 2011.

Wolski, 41, was the lone person providing care to Terrence Wade Saddleback in February 2011 when she was strangled.

Saddleback was found mentally unfit to stand trial after being charged with manslaughter. He has severe developmental disabilities and operates at the level of a toddler.

READ MORE: No charges to be laid in strangulation of Alberta health worker in care home

The Honourable B.D. Rosborough provided seven recommendations in the fatality report to prevent similar deaths from happening.

The first recommendation is that Persons with Developmental Disabilities (PDD) work with an outside agency to review and assist with any changes to improve the way it generates, secures and disseminates information to caregivers regarding developmentally disabled clients.

Rosborough stated that he believes PDD didn’t fully provide information about the extent of Saddleback’s developmental disability to the organization Wolski was employed by.

“The full SIS report of April 30, 2010 and Risk Assessment Update Report prepared in August 2009 are but two examples of documents or information which would be critically important to a community based caregiver such as the Canadian Mental Health Association (CMHA),” Rosborough wrote.

CMHA staff testified that Saddleback would not have been taken on as a client had that information been made available to them.

“If government agents would have passed along information that was vital in this instance, my wife wouldn’t be dead,” Valerie’s husband, Craig Wolski, said.

Tweet This Click to share quote on Twitter: "If government agents would have passed along information that was vital in this instance, my wife wouldn't be dead," Valerie's husband, Craig Wolski, said.

Rosborough also re-recommends that at no time should a careworker be assigned to the care of a resident the worker can’t physically manage. The same recommendation was made in another fatality report a couple years before Wolski’s death. Saddleback is 6’5″ and 300 lbs.

Additionally, Rosborough suggests that at no time should a female careworker be assigned exclusive care of a client who has previously expressed or demonstrated aggression toward females.

“While, at times, Saddleback demonstrated aggression toward males, he had a proclivity to attack females,” Rosborough wrote. “In particular, he would grab them by the hair.”

Tweet This Click to share quote on Twitter: "While, at times, Saddleback demonstrated aggression toward males, he had a proclivity to attack females," Rosborough wrote. "In particular, he would grab them by the hair."

The report stated the recommendations were made to address the failings, rather than “findings of legal responsibility or what may amount to conclusions of law.”

Craig Wolski is not confident the recommendations will be acted upon.

“Recommendations of this kind have been made repeatedly and they fall on deaf ears,” he said.

READ MORE: Fatality inquiry into Alberta mental health worker’s death hears killer’s violent history

Marilyn Conner, executive director of a Wetaskiwin-area community organization, was one of the people who testified during the fatality inquiry in June 2016.

Conner described hundreds of incidents involving Saddleback during the 19 years caring for him. She said Saddleback was aggressive, violent and pulled hair.

“His actions sometimes did not seem to be provoked by anything. He could be fine one moment and then would lunge,” she explained. “We had hundreds of incident reports across the years. Volatile and explosive at times. We couldn’t predict.

“I can tell you seeing what I saw, hearing what I heard, decades of aggressive behaviour. It was really scary just walking in. For me, I felt there was something else going on with him that was beyond our capacity.”

By 2009, Conner said all but two staff members refused to work with Saddleback. That’s when a serious incident happened. She explained in court that a staff member was working with a client when Saddleback said hi to her. He then proceeded to pick her up by the hair and throw her into a table.

The organization told the province it could no longer care for Saddleback because he was too dangerous and staff were afraid of him.

The last incident resulted in five RCMP officers pepper spraying and handcuffing Saddleback to diffuse the situation, Conner stated in the inquiry report.

READ MORE: Alberta orders fatality inquiry into death of mental health worker at home

In the fatality report, it was written that on Feb. 13, 2011 a co-worker found Wolski on the floor of the living room, where “it was apparent that she had been dead for some time.”

Saddleback was reportedly asleep on a couch until he woke up when the co-worker screamed Wolski’s name. The co-worker grabbed Wolski’s cellphone and fled the home after Saddleback reportedly moved toward her.

The co-worker called police from her car. Police took Saddleback into custody after arriving at the scene.

Minister of Community and Social Services Irfan Sabir issued a statement on the fatality report:

“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. In the PDD program, safety has always been about promoting not only safe and inclusive lives for the Albertans we serve, but also, and of equal importance, ensuring the safety and wellbeing of front-line workers who devote their lives to protecting others.

“We recognize that 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 so that staff and Albertans are kept safe and individuals’ support needs are best met. However, we know we have more work to do.

“Our government values Judge Rosborough’s recommendations and we are committed to taking action on the recommendations as they relate to Community and Social Services, and working with our service delivery partners and accrediting bodies to review existing policies and practices with a view to outlining options for specialized services to adults with complex service needs. It is a priority of our government, partners and contracted service providers to ensure the safety of caregivers and Albertans, and we will work collaboratively to conduct a cross-jurisdictional analysis to explore best practices to improve safety for all involved.

“We owe it to Ms. Wolski, and indeed to all Albertans, to learn from this heartbreaking incident and do everything we can to prevent similar tragedies.”

Fatality Report Wolski by slavkornik on Scribd