A fatality inquiry report found that a lack of communication and safety standards contributed to the tragic death of Calgarian Deborah Onwu in 2019. Onwu worked at Wood’s Homes, a mental-health centre providing services for children, youth, adults and families in southwest Calgary. On Oct. 25, 2019, she was stabbed to death by her 18-year-old client, Brandon Newman A fatality inquiry into Onwu’s death, released this month, highlighted several concerns that might have contributed. The report mentioned a number of factors it said have already been addressed by Wood’s Homes but also made another four recommendations. Those included communication between partner agencies, sharing information with employees and frontline workers, changes to guardianship for minors at the threshold of adulthood and identifying sector-specific health hazards. Elk Island incident The inquiry said Newman had been violent before, but the full extent of his involvement in the “violent incident” was not shared with Wood’s Homes. In February 2017, Newman attacked a staff member at a youth residential facility in Elk Island, leaving that employee with “permanent injuries.” He was incarcerated for 16 months and once he was released, he was recommended for Wood’s Homes in order to be closer to his mother. The report said staff at Wood’s Homes was not properly briefed on Newman’s history. “A transparent disclosure of violence-related hazards posed by a client is not only critical to a receiving agency’s decision whether or not it is willing and/or able to accept such a client, but would greatly assist the receiving agency in properly assessing the risk posed by such a client, and in developing appropriate risk mitigation strategies and training programs,” the report said. The report added that “it is clear” Newman posed a risk to caregivers, given the breadth of evidence, but it’s not clear how much of that history Onwu was aware of. It recommended that Alberta’s Occupational Health and Safety legislation be amended to make it obligatory for employers in such cases to make their employees aware of client histories related to violence and/or harassment. Following Onwu’s death, Newman pleaded guilty to second-degree murder and was sentenced to 14 years in prison. The victim’s family, friends and co-workers have spoken out, demanding improvements to work safety standards. Being a CUPE member, the union requested the inquiry following Onwu’s death. “Even the most skilled are at risk without safe workplace legislation and protected policies,” Onwu’s CUPE rep Wael Elrafih said. “Tragedies do happen.” CUPE health and safety head Troy Winters said implementing the recommendations should be top of mind. “During the inquiry, the inspector said himself that the employer was found to be in compliance with Alberta legislation,” Winters said. “So what does that say about the legislation?” When reached by email, the spokesperson for Alberta’s Ministry of Children and Family Services told CTV News the province takes public fatality inquiry findings very seriously. “The report has been received, and the departments from involved ministries will review any recommendations to determine whether changes to our current policies or practices are needed to help prevent similar deaths,” a statement from Daniel Verrier read. Lou Arab, communications representative for CUPE calls the response non-committal. “We know the workers know the job best,” he said. “They understand the hazards best and they understand the ways that controls can be put in place to make the work safer.”