A 2009 report obtained by CBC News warned that a developmentally disabled Alberta man who was later accused of killing his mental health worker could be so aggressive that he posed a threat to anyone who cared for him.
"The consequences could be extensive and irreversible — including death or permanent disability to the staff or support workers involved," states the risk assessment report on Terrence Wade Saddleback.
Saddleback, 26, was charged with manslaughter in the Feb. 12, 2011, strangulation of Valerie Wolski, 41, a worker with the Canadian Mental Health Association in Camrose, Alta.
Saddleback was found mentally unfit to stand trial in March and will remain indefinitely at Alberta Hospital, a psychiatric facility in Edmonton.
On a scale of one to five, Saddleback's aggressive outbursts were rated in the report as ranging from "Major, Level 4 to Catastrophic, Level 5."
"The likelihood that he will continue this behaviour is rated as Level 5, and is almost certain and expected to occur again," the report states.
Female staff are at a greater risk, the report adds, "because they are his preferred targets."
A psychiatric report that helped the judge determine Saddleback was unfit to stand trial was sealed by the court. A judge in Camrose released some of its contents last week after CBC applied to have the document unsealed.
CBC News learned at the hearing that Saddleback's court-appointed guardian, Graham Jones, wanted to speak to reporters about the case.
CBC News contacted Jones and he sat down for an interview. He also provided reporters with a copy of the risk assessment report.
"I'd say I'm very, very sorry what happened. Because I am," Jones said when asked what he would say to Wolski's husband if he had the chance.
"But I want you to know that Terrence wasn't completely to blame. Both he and Val were set up for failure … and that is criminal."
Guardian warned association
The 2009 risk assessment report was prepared after Saddleback attacked a female staff member in Wetaskiwin, Alta., in July 2009.
It took five RCMP officers and a male staff member to subdue him using handcuffs and pepper spray. The report states Saddleback was taken to Alberta Hospital Ponoka. He was heavily sedated but an RCMP officer carried a Taser stun gun just in case.
The author of the risk assessment recommended the best place for Saddleback would be a facility where staff could get to a locked area if he attacked.
The non-profit society that ran the Wetaskiwin group home decided in November 2009 that it was too dangerous to let Saddleback return.
He stayed at Alberta Hospital Ponoka for more than a year until the Canadian Mental Health Association decided to place him in one of their homes and provide care around the clock.
Jones said he warned the association that they needed to be careful.
"What I said mainly was, 'Are you aware of what you're dealing with?' And it was like they didn't hear me," Jones said.
"Terrence is capable of getting out of control, [that] sort of thing. Are you aware of that? And it was just snuffed off … I said something like I hope it's not females that are looking after Terrence. He relates better to men and he respects them more."
The head of the Canadian Mental Health Association in Camrose would not comment on the case until an investigation is completed by Alberta Occupational Health and Safety.
Wolski's husband, Craig, also declined to comment until the investigation is completed.
The psychiatric report given to the judge indicates that Saddleback was unable to understand the charge he faced or comprehend why he was at Alberta Hospital. The report notes that Saddleback was "calm and settled" after he was transferred back to the facility.
Jones raised his concerns about the case in an April 2011 letter to Mary Anne Jablonski, Alberta's minister of seniors and community supports.
In the letter, Jones alleges that "gross errors in judgment" were made when the province placed Saddleback with the Canadian Mental Health Association.
He asks if the province intends to carry out more investigations in addition to the Occupational Health and Safety probe now underway.
So far the province has sent him a form letter in response.