Report into Deborah Onwu's death contains four recommendations
A fatality inquiry into the 2019 workplace death of Calgary care worker Deborah Onwu has produced four recommendations aimed at improving safety in Alberta’s social services sector. The inquiry reveals major gaps in violence-related hazard communication and calls for legislative and regulatory reform.
Onwu, 47, was working an overnight shift at a Woods Homes Society (WHS) residence when she was stabbed 19 times by Brandon Newman, an 18-year-old client with a history of violence. That history, including a previous conviction for aggravated assault, was not disclosed to WHS when Newman was transferred to their care.
The Canadian Union of Public Employees (CUPE), which represents Onwu, requested the inquiry and is urging the Alberta government to act on the findings.
“Deborah Onwu didn’t need to die that night,” said Troy Winters, CUPE’s National Health and Safety Coordinator and a witness at the inquiry. “If she had the full history of the client’s behaviour, if she had a co-worker, if there were other precautions taken, she might still be here.”
Four recommendations
The report by Justice Karim Z. Jivraj outlines four key recommendations:
- Mandatory inter-agency hazard disclosure: Transfer files must include details of past violence to help receiving agencies assess and mitigate risks.
- Worker right-to-know enhancements: Employers must share clients’ violent histories and behavioural risks directly with front-line staff.
- Public guardianship for high-risk youth: The province should assign guardianship to cognitively impaired individuals aging out of care.
- Sector-specific OHS standards: Alberta should create occupational health and safety standards tailored to care settings where client behaviour poses risks.
Information gaps and privacy barriers
Winters said a lack of clear legal requirements for information sharing contributed directly to Onwu’s death.
“Privacy should never trump health and safety of a worker,” he said. “There are ways to maintain general confidentiality, but if you’re working with the client, then you need to know.”
The inquiry revealed WHS relied on a “white binder” system for staff communication. Winters said such informal systems are prone to failure and called for standardized procedures.
“If something doesn't get recorded, there’s no way for the information to be transferred,” he said. “We want to see systems that document how and when hazard information is presented to workers.”
Legal compliance not enough
Winters pointed out that WHS was in full compliance with Alberta’s Occupational Health and Safety Act at the time of the incident. He said that highlights significant regulatory gaps.
“Committees aren’t required to do inspections or participate in investigations,” he said. “There’s a lot missing from Alberta’s legislation that would support real prevention.”
Push for national standards
CUPE is also calling for the development of national safety standards for care work. Winters pointed to the CSA Group’s work in long-term care as a model.
“We suggested they borrow from the approach used in nursing homes to develop standards that include health and safety,” Winters said. “It doesn’t have to be CSA, but they’re one of several credible options.”
Culture of continuous improvement
Winters urged safety leaders to treat compliance as a starting point, not a final goal.
“Health and safety is never a one-and-done. It’s a journey. It’s continual improvement,” he said. “Just because changes are in place doesn’t mean everything is perfect.”
Alberta’s Ministry of Children and Family Services says it is reviewing the recommendations. CUPE, meanwhile, continues to advocate for reforms to ensure workers are properly informed, protected, and supported in high-risk care environments.
“We owe it to Deborah and other workers in the social work field to do everything we can to prevent this tragedy from happening again,” said Raj Uppal, CUPE Alberta President.
