Re: Karoly Gonczi
ORB File No: 6308
Hearing held on: Wednesday, September 17, 2025
Place of hearing: Centre for Addiction and Mental Health Via Zoom Video Conference
Pursuant to: Section 672.81(2.1) of the Criminal Code
Before:
Alternate Chairperson: Mr. G. Beasley Members: Dr. D. Bourget Dr. W. Loza Mr. E. Siebenmorgen Mr. M. Hajek
Parties Appearing:
Accused: Karoly Gonczi Counsel: Mr. I.L. Dallas
The person in charge of hospital: Counsel: Ms. A. Marshall
Attorney General of Ontario: Counsel: Ms. V. Culp
REASONS FOR DECISION
(Dated October 22, 2025)
Introduction
On March 14, 2013, the accused Karoly Gonczi, was found not criminally responsible on account of mental disorder on charges of sexual assault (x2), indecent act (x2), and criminal harassment, all contrary to the Criminal Code of Canada. By reason of a Disposition of the Ontario Review Board (“ORB”) dated March 27, 2025, Mr. Gonczi was ordered to be detained at the Forensic Service of the Centre for Addiction and Mental Health, Toronto (“CAMH”). His Disposition included residing in the community of the Greater Toronto Area in accommodation approved by the person in charge.
On May 2, 2025, Sham Hishmeh, Manager of the Office of the Person in Charge of CAMH, advised the ORB that on April 24, 2025, Mr. Gonczi was transferred to the Secure Observation and Treatment Unit (SOTU) and continued to be detained on the SOTU at the time of the letter. The hospital considered this to be a Restriction of Liberty (ROL),and notice was sent pursuant to s. 672.56(2) of the Criminal Code.
On September 17, 2025, the ORB convened a hearing using Zoom technology for the purpose of the review of the ROL, pursuant to s. 675.81(2.1) of the Criminal Code. Mr. Gonczi was in attendance at the hearing and had the assistance of a Hungarian interpreter. Mr. Gonczi was represented by counsel, Mr. Dallas. Ms. Marshall appeared as counsel for CAMH and Ms. Culp as counsel for the Attorney General of Ontario.
Position of the Parties
- At the outset of the hearing, all counsel agreed that there would be no request to amend the existing Disposition. All counsel further agreed that the ROL at issue commenced on April 24, 2025, and ended on August 26, 2025.
Evidence
The evidence on behalf of the hospital was presented by Dr. Woodside. Dr. Woodside was Mr. Gonczi's attending psychiatrist prior to his transfer to SOTU on April 24, 2025. He stated that he had read and adopted the contents of the Hospital Report. Dr. Woodside stated that there were no updates to the report filed for the purposes of the hearing. He said that Mr. Gonczi had been transferred out of SOTU back to a Secure Unit on August 26, 2025. Prior to his transfer to SOTU, Mr. Gonczi was on a General Forensic Unit and had earned Level 7 privileges. This allowed him to have indirectly supervised community privileges for the purposes of rehabilitation along with indirectly supervised hospital and grounds privileges for recreation and socialization.
Dr. Woodside testified that Mr. Gonczi had assaulted a co-patient on the General Unit on April 11, 2025. As a result, he was placed in seclusion for a brief period of time. Mr. Gonczi stated that the reason for the assault was that he was “mad” at being in hospital. He did not demonstrate any psychosis and returned to baseline, resulting in his release from seclusion back to the General Unit on April 15, 2025. On April 20, 2025, Mr. Gonczi assaulted another, different co-patient. This assault took place after the co-patient had returned from ordering and picking up takeout Chinese food for Mr. Gonczi. Mr. Gonczi approached him and kicked him in the leg and hip, then threw the food in the garbage. Mr. Gonczi then went on his own to the seclusion room. When interviewed, Mr. Gonczi stated that he had been hearing a male voice, that of his brother, telling him to attack the co-patient during the day. Between April 20 and April 24, 2025, Mr. Gonczi remained in seclusion. He continued to report intermittent auditory hallucinations and threw his food trays around the seclusion room. On August 24, the decision was made that Mr. Gonczi could no longer safely be managed on the General Unit and he was transferred to the SOTU.
After his transfer to SOTU, Mr. Gonczi continued to report ongoing auditory hallucinations. As a result, his medications were adjusted with an increase in his clozapine level. On April 26, 2025, Mr. Gonczi was released from seclusion in SOTU but immediately assaulted another co-patient in the dining room. He attributed this assault to hearing voices and he was returned to seclusion. On April 30, 2025, Mr. Gonczi was taken out of seclusion in the SOTU on a trial basis. Once again, he assaulted a co-patient by punching him in the face. Again, he was returned back to seclusion in SOTU.
On May 1, 2025, Dr. Leblanc, who is Mr. Gonczi’s attending psychiatrist in the SOTU, recommended that a course of ECT be commenced. This was based on Mr. Gonczi's ongoing symptoms and unprovoked aggressive behaviour. Mr. Gonczi’s father, his SDM, consented to the ECT treatment. However, the treatment could not be initiated immediately due to potential complications from Mr. Gonczi's Ozempic prescription. After a three-week pause in Ozempic, Mr. Gonczi received his first ECT treatment on May 20, 2025.
Mr. Gonczi completed a full course of 12 ECT treatments by June 20, 2025, and was no longer in seclusion. In consultation with his SDM, it was agreed that Mr. Gonczi would receive a course of maintenance ECT (mECT) once weekly for four weeks. ECT was felt to be successful, with no further reports of psychotic symptoms and no further aggressive behaviour.
Mr. Gonczi began to earn privileges in SOTU and by July 23, 2025, Dr. Leblanc was of the opinion that he was suitable for transfer to a non-SOTU unit. The transfer to a Secure Forensic Unit took place on August 26, 2025. Dr. Woodside stated that Mr. Gonczi continued to earn privileges which would be commensurate with his level of risk. He stated that Mr. Gonczi would ultimately be transferred back to a General Unit with demonstrated ongoing stability in his mental status. He would not return to Dr. Woodside’s unit as the co-patient who was the victim of the earlier assault is still on that unit.
In response to questions from Ms. Culp, Dr. Woodside stated that prior to the transfer to SOTU, Mr. Gonczi had Level 7 privileges on his unit. Dr. Woodside stated that he was not familiar with the privilege levels on the Secure Unit where Mr. Gonczi was presently detained as he had never work there.
In response to questions from Mr. Dallas, Dr. Woodside stated that Mr. Gonczi’s clozapine levels had dropped approximately 25 percent within a month prior to the assaultive behaviour. Dr. Woodside could not offer an explanation as to why the levels had dropped but said that it was possibly due to Mr. Gonczi's smoking habits. With that level of decrease, Dr. Woodside stated it would have been expected that Mr. Gonczi would have demonstrated psychosis, but this was not seen. He said that this was a similar scenario to that which led to Mr. Gonczi’s decompensation in 2024. Dr. Woodside agreed that the ECT had certainly helped Mr. Gonczi stabilize. He also said that the increase in his clozapine dosage to 500 milligrams per day was an important factor. Dr. Woodside testified that Mr. Gonczi remained in seclusion in the SOTU while receiving the ECT treatments from May 1 to May 20. This was due to the assaultive behaviour he had demonstrated. He responded well to the ECT treatments and was out of seclusion for breakfast and lunch.
In response to questions from the panel, Dr. Woodside stated that Mr. Gonczi had not been moved from SOTU to the Secure Detention Unit earlier due to bed availability. Dr. Woodside confirmed that Mr. Gonczi had gone from seclusion on the General Unit to seclusion on the SOTU encompassing the entire period from April 20 to April 26. He further confirmed that in the opinion of Dr. Leblanc, Mr. Gonczi was suitable for transfer out of SOTU on July 23, 2025. At the conclusion of his evidence, Dr. Woodside stated that he had known Mr. Gonczi for many years and that he had been an easy patient to deal with who got along well with his co-patients. Dr. Woodside acknowledged that the past year and a half had been challenging for Mr. Gonczi.
Neither Ms. Culp nor Mr. Dallas called evidence at the hearing.
Submissions
Ms. Marshall submitted that the decision to restrict Mr. Gonczi’s privileges was necessary and appropriate and the least restrictive option available to the hospital at the time. Ms. Marshall submitted that the Restriction of Liberty commenced on April 24, 2025. Ms. Marshall submitted that Mr. Gonczi is gradually re-earning privileges which are granted commensurate with the risk he presents.
Ms. Culp agreed with the submissions of the hospital with respect to the commencement of the Restriction of Liberty. However, Ms. Culp submitted that in the opinion of the Attorney General, the restriction is ongoing given that Mr. Gonczi remains on a Secure Unit pending his transfer to a General Unit.
On Mr. Gonczi’s behalf, Mr. Dallas acknowledged that his client was doing much better now. He agreed that the initial decision to increase the restrictions on his client’s liberty was warranted and advised that he had no further submissions.
Analysis and Decision
The Board is unanimous in accepting the joint submission of the parties that the decision to restrict Mr. Gonczi’s liberties was necessary and appropriate and the least restrictive alternative available to the treatment team at the time. As amply demonstrated from the chronology set out by Dr. Woodside and found in the updated Hospital Report prepared for the ROL hearing, commencing April 11, 2025, Mr. Gonczi began to experience a decompensation in his mental status. This led to a number of unprovoked assaults on co-patients on the General Unit. Even when placed in seclusion on the General Unit, Mr. Gonczi continued to demonstrate disorganized and dysregulated behaviour. As a result of the concern for the safety of patients and staff on the General Unit, the decision was made to transfer Mr. Gonczi to the SOTU. It is noteworthy that even this decision was held in abeyance for a number of days while the treatment team determined whether or not Mr. Gonczi would settle in seclusion on the General Unit. Once Mr. Gonczi was transferred to the SOTU, the pattern of behaviour continued with further assaultive behaviour on two co-patients on SOTU. Only after the decision was made to increase Mr. Gonczi’s antipsychotic medication and to prescribe and complete a full series of ECT along with a follow-up series of mECT treatments, was Mr. Gonczi able to leave seclusion in SOTU. By July 23, 2025, he had settled to the extent that Dr. Leblanc recommended his transfer out of SOTU. Due to issues with bed availability, this was not completed until August 26, 2025, when Mr. Gonczi was transferred to a Secure Unit at CAMH.
In her submissions, Ms. Marshall stated that she would “leave it up to the Board” to decide when the ROL started and when it ended. In considering the evidence in its totality, the Board is unanimous in finding that the ROL commenced on April 20, 2025, when Mr. Gonczi was placed into seclusion on the General Unit. This seclusion continued unabated until April 26, 2025, after he had been transferred to the SOTU. With respect to the end of the ROL, the Board is unanimous that this occurred on August 26, 2025, when Mr. Gonczi was transferred out of SOTU back to a Secure Unit at CAMH.
The panel was further satisfied that the increased liberty restrictions were warranted and represented the least onerous and least restrictive options available to the Hospital for their duration, up to the time of the hearing. Given the increased risk to public safety occasioned by Mr. Gonczi’s dysregulated behaviour and his mental health instability, the Hospital had no realistic alternatives for dealing with the situation in a less restrictive manner.
DATED this 22nd day of October, 2025, at the City of Toronto, in the Region of Toronto.
Mr. G. Beasley Alternate Chairperson
Office of the Registrar Ontario Review Board