ONTARIO COURT OF JUSTICE
BETWEEN:
HIS MAJESTY THE KING
— AND —
IVAN ADEMOVIC
Before Justice M. Sean Gaudet
Heard on October 6, 8, December 2 and 3, 2025 and January 13, 2026
Reasons for Judgment released on February 26, 2026
Scott Arnold and Satomi Aki counsel for the Crown
Leo Adler counsel for the accused Ivan Ademovic
A. Overview
1In October 2024 Euplio Cusano was an inmate at the Toronto South Detention Centre (TDSC). He was 69 years old and was described by witnesses as an old, frail and forgetful man with dementia.
2In September 2024, Mr. Cusano was moved to a cell at the TDSC that was already occupied by two other inmates. One of these inmates was the defendant, Ivan Ademovic. The cell was not designed to accommodate three inmates; there was no bunk for Mr. Cusano to sleep on. As a result, Mr. Cusano had to sleep on a mattress on the floor.
3On the night of October 3, 2024, Mr. Cusano and the defendant, Ivan Ademovic, became embroiled in a physical altercation after Mr. Cusano spilled water on the defendant. The defendant inflicted significant physical injuries upon Mr. Cusano, from which he succumbed in hospital hours later. As a result of this incident, the defendant is charged with one count of manslaughter, contrary to section 236 of the Criminal Code.
4The Crown’s theory was that the defendant committed unlawful act manslaughter; specifically that Mr. Ademovic intentionally assaulted Mr. Cusano, causing him to suffer blunt force head trauma that precipitated catastrophic brain injury and death. The Crown argues that the assault was a significant contributing cause of the victim’s death and was not justified by self‑defence.
5The Defence accepts that a physical altercation occurred between the defendant and Mr. Cusano but contends that self‑defence applies and that, in any event, intervening medical decisions and pre‑existing conditions sever causation, or raise a reasonable doubt that the assault significantly contributed to Mr. Cusano’s death.
6For the reasons that follow, I am satisfied beyond a reasonable doubt that the Crown has proven the offence, including the requisite degree of causation, and has disproven self‑defence.
B. Evidence
1) The incident and immediate response
5Shortly after midnight on October 3, 2024, Correctional Officer Bueshan Arulnesan responded to a cell‑call from B4D Cell 1, occupied by Mr. Ademovic, Mr. Cusano, and a third inmate, Mr. Peter Deafy. The cell had two bunks. Mr. Ademovic occupied the lower bunk and Mr. Deafy the top bunk. Mr. Cusano slept on a mattress on the floor.
7From the doorway, CO Arulnesan heard Mr. Ademovic demand that Mr. Cusano be removed and say words to the effect of “If you don’t get him out of the cell I will beat him up some more.” Upon seeing visible facial injuries to Mr. Cusano, the officer initiated a Code Blue, which alerted medical staff to attend the unit immediately. When officers opened the door Mr. Cusano was able to walk out of the cell under his own power. He was immediately escorted to an assessment room where nursing staff attended.
8The institutional video that was introduced at trial depicts the sequence of response and movement of inmates as described by CO Arulnesan.
9CO Arulnesan provided an inmate statement form to Mr. Ademovic, who completed it and returned it to him at approximately 00:30 on October 4, 2024. In handwriting Mr. Ademovic noted that it had “just been problem after problem” with Mr. Cusano: he touched other cellmates’ belongings, took their juice and milk, and was flushing the toilet at night after 11:00 p.m. That evening he had spilled water while Mr. Ademovic was sleeping and started a “disturbing” (sic), so they ended up fighting.
10Staff Sergeant Jay Francis of the Toronto South Detention Centre attended the interview room and photographed Mr. Cusano’s facial injuries. The photos taken by him that were admitted at trial show extensive blood about Mr. Cusano’s face, with no noted injuries to the back of the head or body.
11Sergeant Francis also attended Cell 1 in Unit B4D, documenting blood on the cell floor and the bedding on the floor. He photographed Mr. Ademovic in the cell area, and his photographs revealed no visible injuries to Mr. Ademovic.
12Bryan Kafle is a registered nurse who was working at the TDSC the night of October 3-4, 2024. He assessed Mr. Cusano and his injuries in the interview room. He described Mr. Cusano as having blood round his face, nose, and mouth and having visible facial bruising, including under both eyes. This description was consistent with the photos of Mr. Cusano taken by Staff Sergeant Francis.
13In the course of examining Mr. Cusano the institutional nursing team evaluated his responses to various stimuli and recorded them on the Glasgow coma scale (GCS). The evidence from various witnesses was that the GCS is a tool used for measuring decreases in consciousness, including coma, by evaluating three parameters of responsiveness, best eye response, best verbal response, and best motor response. Mr. Cusano was given a score of 15 by the nursing staff, which is the maximum possible score.
14Mr. Cusano had a clear airway, normal respiration, stable vital signs, and facial trauma - specifically nose and mouth bleeding, and bilateral periorbital bruising.
15Based on the collective nursing assessment, the nursing team determined that Mr. Cusano was not stable, and needed to be sent to a hospital for medical treatment. At 12:20 a.m. on October 4th, the nursing team called 911 for Emergency Medical Services. The paramedics arrived at approximately 12:33 a.m., and transported Mr. Cusano to St. Joseph’s Health Centre.
2) Mr. Cusano is transferred first to St. Joseph’s Health Centre and then to St. Michael’s Hospital
16Toronto Paramedic Service records admitted at trial indicate that Mr. Cusano was assessed by the paramedics at 12:37 a.m. as suffering from no obvious facial fractures, swelling and bruising to both eyes, and complaining of left jaw pain. He was alert as to person, place and time.
17The paramedics brought Mr. Cusano to St. Joseph’s Health Centre soon after 1:00 a.m. Hospital records show that when he was triaged, he was assessed as having a GCS score of 15, and appeared to be calm, was communicating clearly, was in no acute distress, and was ambulatory.
18Mr. Cusano’s condition worsened considerably and suddenly about an hour later. At 2:20 a.m. Mr. Cusano started having a seizure. A CT scan was ordered and carried out around 3:20–3:30 a.m. It showed acute subdural and intracranial bleeding. This prompted a decision to transfer him immediately to St. Michael’s Hospital for an urgent neurosurgical consultation, as St. Joseph’s does not have neurosurgical capability.
19On arrival at St Michael’s, Mr. Cusano was assessed by Dr. Cusimano, a neurosurgeon. Dr Cusimano testified at trial. Prior to Mr. Cusano’s arrival he had taken the call from St. Joseph’s on the Criticall system. Upon arrival at St. Michael’s Mr. Cusano was assessed as exhibiting fixed and dilated pupils, and the absence of brainstem reflexes. It was determined that he was suffering from a severe brain injury consistent with catastrophic intracranial bleeding. Because of the extent of Mr. Cusano’s injuries, his prognosis was considered hopeless and neurosurgical intervention considered to not be medically appropriate. The degree of damage he had suffered was simply too advanced.
20Mr. Cusano died of his injuries soon after his arrival at St. Michael’s on October 4, 2024.
3) The post-mortem examination
21Dr. Maliha Khara was called by the Crown to testify as an expert qualified in forensic pathology. In her capacity as a forensic pathologist at the Provincial Forensic Pathology Unit in Toronto she conducted the postmortem examination of Mr. Cusano on October 6th 2024, and in doing so formed an opinion as to his cause of death.
22Dr. Khara observed significant injuries to Mr Cusano’s face, scalp, and mouth - namely bleeding in the left eye, bruising to both sides of his mouth and the inside of his lips, bruising around both eyes, a large bruise on the left side of the face, and a bruise on the bridge of his nose. She found extensive facial fractures in nine areas, including in the sinuses beneath both eyes where there was also bleeding present, the left and right eye sockets, both nasal bones, the right cheekbone, and the left jawbone. The facial muscles in the cheek were also damaged.
23In terms of Mr. Cusano’s brain, there was evidence of bleeding within the layers between the skin and fat tissue of the scalp, in the muscle of the left temple, between the dura mater and the meninges, and in two ventricles of the brain. There was marked diffuse swelling of the brain, with herniation of the cerebellum and herniation of the uncal portion of the temporal lobe through the base of the skull. In other words, the brain had shifted out of its normal compartments into the spinal canal.
24Dr. Khara’s opinion was that the cause of death was blunt impact head trauma, which caused bleeding within the head, extensive brain swelling, and brain herniation, ultimately leading to Mr Cusano’s death. She did not deviate from this opinion as to the cause of Mr. Cusano’s death at any point during her cross-examination.
4) The evidence of the third cellmate, Peter Deafy
25Mr. Deafy was the third occupant of Cell 1 in range B4D. He slept on the top bunk. He testified that Mr. Cusano had been moved to their cell roughly three weeks before the incident. He described Mr. Cusano as being a frail old man with dementia. Mr. Cusano was forgetful, easily confused and who occasionally take his belongings thinking that they were his.
26Mr. Deafy testified that he was asleep on the night of the fight, and was awoken because of the sound of the commotion happening in the cell. He saw Mr. Ademovic punch Mr. Cusano in the head, Mr. Cusano punch back, and then heard Mr. Ademovic say “oh yeah” and saw him hit Mr. Cusano four or five times.
27Mr. Cusano fell to the ground, got up, and pushed the emergency button in the cell. In cross-examination, Mr. Deafy admitted that he was not sure whether it was Mr. Cusano or Mr. Ademovic who pressed the emergency button. By his estimate, the fight lasted about 15 seconds. After Mr. Cusano was removed from the cell, he overheard Mr Ademovic say that he thought he had taken it too far.
5) The Defendant’s Evidence
28Mr. Ademovic testified. He described that soon after Mr. Cusano was transferred to the cell he shared with Mr. Deafy, the victim was touching personal items that did not belong to him and was masturbating in the cell. Mr. Ademovic told him to stop doing this at least three times.
29The night of the incident Mr. Ademovic was awoken by Mr. Cusano touching his genitals, which triggered memories of abuse he had endured as a child by a man who he said looked like Mr. Cusano. He instinctively reacted by slapping Mr. Cusano. When he got up to apologize, Mr. Cusano punched him. Mr. Ademovic then punched him back, by his estimate 4 or 5 times, although he testified that the fight lasted about 5 minutes. He said he kept on punching Mr. Cusano because he kept trying to fight him. Once he saw blood coming from Mr. Cusano’s nose, he stopped and pressed the emergency button for Correctional staff to come to the cell. He claimed that he did not he did not intend to cause serious injury to Mr. Cusano and was “shocked” to learn that he had later died.
30In cross-examination Mr. Ademovic admitted that Mr. Cusano had been a very annoying cellmate. He described him as a “creepy, dirty, old man”. In addition to masturbating in the cell, Mr. Cusano would take Mr. Ademovic’s belongings, and would flush the toilet late at night in violation of the unwritten rule amongst inmates prohibiting toilet-flushing after lights out at 11:00 p.m.
31On the night in question, Mr Cusano spilled water on Mr. Ademovic while he was sleeping. In answer to questioning from Mr. Arnold, Mr Ademovic admitted that at this point he had “had it” with Mr Cusano, and “lost it”.
6) Factual Findings about the physical altercation
32I find that on the night of October 3, 2024 Mr. Ademovic had had enough of Mr. Cusano’s annoying and disruptive behaviour. Mr. Cusano was a difficult and annoying cellmate. He would take personal items that did not belong to him. He masturbated in the cell. He flushed the toilet late at night, disturbing his cellmates’ sleep. When he spilled water on Mr. Ademovic, Mr. Ademovic had had enough. As he put it in his written statement, “It was just one thing after another” with Mr Cusano.
33Whether in anger or frustration, or both, Mr. Ademovic slapped Mr. Cusano. He may have felt some immediate regret for doing this, but when Mr. Cusano struck back Mr. Ademovic unleashed a volley of blows on Mr. Cusano that left him with devastating injuries to his face and head from which Mr. Cusano would succumb hours later.
34Mr. Ademovic told Mr. Cusano to pack up his stuff and get out of the cell or he would beat him up some more.
35Mr. Ademovic admitted that with the benefit of hindsight, he went too far with Mr. Cusano.
36The impetus for the fight was Mr. Ademovic’s building frustration over Mr Cusano’s annoying and disruptive behaviour in the cell, which reached a boiling point when he spilled water on Mr Ademovic the night of October 3rd.
37I do not believe Mr. Ademovic’s evidence that he was sexually molested by Mr. Cusano, and that this triggered memories of childhood abuse by an abuser who happened to look like Mr. Cusano. This, in my view, was an invention intended to justify the defendant’s conduct after he learned that Mr. Cusano had died from his injuries.
38No mention of this sexual molestation appeared in Mr. Ademovic’s written statement provided immediately after the incident, when it would have been fresh in his memory. He did refer to the spilling of the water. He only set out this narrative of sexual molestation in a written statement after he learned of Mr. Cusano’s death.
39The Defence emphasized that Mr. Ademovic’s delayed disclosure of this incident of sexual touching should not undermine his credibility, as the Criminal law rejects myths about immediate reporting of sexual assault. That may be so, but if this was an accurate explanation for the assault on Mr. Cusano, I find he would have included it in his written statement.
40The fight lasted somewhere between 15 seconds (according to Mr. Deafy) and 5 minutes (according to Mr. Ademovic). The exact amount of time it lasted is not as important as the fact that it was Mr. Ademovic who was delivering the blows to Mr. Cusano, 4 or 5 punches according to Mr. Deafy.
41In contrast to Mr. Cusano, Mr. Ademovic had no visible injuries. Nor did he complain of any pain or injuries as a result of his fight with Mr. Cusano. He required no medical assistance after the altercation, although he admitted that his right hand was sore from punching Mr Cusano.
42He told the officer to get Mr Cusano out of the cell before he beat him up some more.
C. Issues and Analysis
43There are two issues in this trial:
whether the Crown has proven beyond a reasonable doubt that the accused committed an unlawful assault on Mr. Cusano that was a significant contributing cause of death, beyond a de minimis contribution; and
whether the Crown has disproved self-defence under section 34 beyond a reasonable doubt.
Issue 1: Was Mr Ademovic’s assault on Mr Cusano a significant contributing cause of his death?
44For unlawful act manslaughter, the Crown must prove that the accused’s unlawful act was a significant contributing cause of death. The defendant’s unlawful act must be more than trivial or insignificant, i.e. it must be beyond the “de minimis” range to constitute a legal cause of the victim’s death (see in R. v. Smithers, 1977 7 (SCC), [1978] 1 S.C.R. 506 at 519, R. v. Nette, 2001 SCC 78 at para 77, and R. v. Maybin, 2012 SCC 24, 2012 SCC24 at para 14). There may be a number of contributing causes of death. As long as the unlawful act contributed beyond de minimis to that death, it will meet this threshold.
45The defence argues that the failure to transport Mr. Cusano directly to a hospital where neurosurgical treatment could have been provided, and the failure to administer a CT scan earlier and diagnose the extent of his brain injuries were intervening factors that broke the chain of causation. The defence pointed to references in Mr. Cusano’s institutional health care records that indicated he had had previously suffered from seizures to buttress this argument. It argues that this information should have prompted medical professionals to have conducted a CT scan earlier, i.e. before he began suffering from seizures at St. Joseph’s less than an hour after his arrival there.
46The Defence called no expert evidence to support of this assertion. The neurosurgeon at St. Michael’s, Dr. Cusimano, testified that even if a CT had been done earlier at St. Joseph’s, he could not say with certainty that the outcome would have changed. He emphasized that a prior history of head trauma would not, by itself, automatically justify giving a patient who had presented to the triage nurse at the ER with a GCS 15, priority to a CT scan. His evidence was that the decision to order a CT scan is based more on a patient’s condition than on his prior history.
47In any event, delayed or suboptimal medical treatment does not relieve an accused of responsibility, unless the treatment amounts to an intervening cause that is both independent and not reasonably foreseeable. That is certainly not the case here.
48I am satisfied beyond a reasonable doubt that the punches thrown by the accused contributed significantly to the death of Mr. Cusano.
Issue 2: Did the accused commit an unlawful act in assaulting Mr Cusano, or was he acting in self-defence?
49Section 34 of the Criminal Code requires the Crown to disprove at least one of the following elements:
(a) the accused believed on reasonable grounds that force was being used or threatened against him;
(b) he acted for a defensive purpose; and
(c) his act was reasonable in the circumstances having regard to the s. 34(2) factors.
50The defence argued that Mr. Ademovic is not guilty of manslaughter because the accused was acting in self-defence when he beat up Mr. Cusano in their cell. He alleges that Mr. Cusano initiated the incident by committing the unprovoked sexual assault upon the accused while he was asleep, which triggered past trauma on the part of the accused who reacted by slapping Mr Cusano. Mr. Cusano hit him back, adopted a boxing stance, and kept coming after being repeatedly struck by Mr. Ademovic. The defence described the interaction as a consensual fight, which the accused stopped and pressed the call button once he saw that Mr Cusano was bleeding.
51I have rejected Mr. Ademovic’s evidence that he was sexually molested by Mr. Cusano. I have found that the fight began after Mr. Cusano dropped water on the accused, which was the final straw for him given all of Mr. Cusano’s earlier behaviour in the cell. Accordingly, I find that the accused did not believe on reasonable grounds that force was being used against him when he started the fight.
52However, even if he was touched in a sexual manner by Mr. Cusano, the accused’s response was not reasonable in the circumstances, within the meaning of section 34(1)(c). His response was not proportional.
53Mr. Cusano was described by the accused as an old man, and by Mr. Deafy as a frail old man. He was roughly 15 years older than the accused. The accused was physically stronger than Mr Cusano.
54The nature of the injuries suffered by Mr. Cusano, the lack of injuries sustained by Mr. Ademovic, the evidence of Mr. Deafy that he saw Mr Ademovic deliver 4 or 5 blows to Mr. Cusano, the admission by Mr. Ademovic that he went too far and could have stopped sooner, that he lost control of his anger, all of these elements point to Mr. Ademovic’s conduct not being proportionate under the circumstances.
55The lack of proportionality in the accused’s response is overwhelmingly established by the evidence of the injuries suffered by Mr. Cusano. The beating inflicted by the accused upon him was brutal – at least five blows to the head, which resulted in catastrophic facial, intracranial and brain injuries. Mr. Cusano’s face was extensively fractured in nine places. He had bleeding in the layers of his scalp and within the brain itself. The swelling in his brain caused it to herniate into his spinal column.
56In contrast, the accused suffered no injuries, except for a sore right hand.
57The accused’s post-incident conduct is also a relevant factor, in particular his statement to CO that if he was not removed from the cell he would beat Mr. Cusano up some more.
58For these reasons, I find that the Crown has proven that Mr. Ademovic committed an unlawful assault on Mr. Cusano, that the assault was a significant contributing cause of Mr. Cusano’s death, and the Crown has disproven self‑defence, all beyond a reasonable doubt.
Released: February 26, 2026
Signed: Justice M. Sean Gaudet