Ontario Review Board
Re: Tenzin Norbu
ORB File No: 8573
Hearing held on: Tuesday, September 23, 2025
Place of hearing: Centre for Addiction and Mental Health 1001 Queen Street West, Toronto
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Mr. M.D. Segal Members: Dr. B. Sheppard Dr. G. Eayrs Ms. M. Labrosse Mr. W. Apted
Parties Appearing:
Accused: Tenzin Norbu Counsel: Mr. I.L. Dallas
The person in charge of hospital: Counsel: Mr. J. McIntyre
Attorney General of Ontario: Counsel: Mr. C. Coughlan
REASONS FOR DISPOSITION
(Dated October 28, 2025)
Introduction
Tenzin Norbu, age 42, was found not criminally responsible account of mental disorder on a charge of murder, contrary to the Criminal Code, on June 4, 2024.
Mr. Norbu, is on a Detention Order with privilege up to and including entering the community of the Greater Toronto Area, accompanied by staff or a person approved by the person in charge.
On September 23, 2025, Mr. Norbu appeared before the Ontario Review Board (the “Board”) for his annual hearing at the Centre for Addiction and Mental Health (the “hospital). The Board had before it as Exhibit 1, the Hospital Report dated September 18, 2025. A series of Victim Impact Statements comprised Exhibit 2. The Board also had before it the most recent Reasons for Disposition and the most recent Disposition.
At the outset of the hearing, the Board was advised that Mr. Norbu’s facility with English was well developed. A Tibetan interpreter arrived about 10 minutes late and accompanied Mr. Norbu who did not need to clarify any matters with the interpreter during the hearing.
In preliminary positions, the hospital advanced that significant threat remained, a Detention Order should continue but that the patient should receive the privilege of community living in a 24-hour supervised accommodation. The patient’s counsel agreed. Crown counsel opposed the addition of community living. At the conclusion of the hearing, the Board was of the view that the community living privilege should not be granted but that indirectly supervised privileges should be permitted with the caveat that Mr. Norbu may only access the TTC if accompanied by staff or an approved person.
Diagnoses
- Cannabis Use Disorder (severe, in sustained remission, in a controlled environment)
Schizophrenia
Index Offence
- The Board accepts the description and characterization in last year’s Reasons:
The circumstances of the index offence are horrific in the extreme. The victim was attacked shortly after she boarded a public transit bus in Toronto as she was on her way to work at midday. A brief outline of the incident itself, taken from the Agreed Statement of Facts contained within the court file, is found in the Hospital Report. That synopsis is reproduced as follows:
“On June 17, 2022, Mr. Norbu boarded a TTC bus at Kipling station approximately 20 seconds after the victim was seated on the bus. He stood in front of a seat across from the victim, and they engaged in a verbal interaction which was not in English. Approximately 1 minute later, Mr. Norbu approached the victim and poured a mason jar filled with lighter fluid onto the front of her shirt. He then ignited her with a lighter. He removed his shirt immediately after lighting the victim on fire. The victim ran from the bus, and Mr. Norbu walked off the bus after other passengers. The victim told bystanders that she did not know Mr. Norbu, and that Mr. Norbu had asked her if she was Tibetan, and she said ‘yes’. After exiting the bus, Mr. Norbu was heard to yell ‘Free Tibet’ in Tibetan. He then fled the station along the subway tracks and was arrested a short distance away. The victim suffered burns to 60% of her body and inhalation injury. She died after 18 days in hospital receiving intensive treatment, and the cause of death was determined to be complications of burns.
The Agreed Statement of Facts itself contains important additional details, including the following:
The victim, Nyima Dolma, was 28 years old.
On the afternoon of June 17, 2022, Ms. Dolma left for work from her home on Jameson Ave. Toronto. Like many Torontonians, Ms. Dolma traveled to her workplace via the Toronto Transit Commission (TTC). As she did each day, Ms. Dolma took the westbound subway train to Kipling station at 950 Kipling Ave. She arrived just after 12:15 pm. She left the train platform and took the stairs up to meet the 8062 bus for route 112.
Ms. Dolma entered the bus immediately behind Ms. Angela Campbell just prior to 12:20 pm. Like Ms. Dolma, Ms. Campbell also relied on the TTC for transportation. Ms. Campbell did not know Ms. Dolma or Mr. Norbu. However, when interviewed by police, Ms. Campbell did recall seeing Mr. Norbu at the Kipling station in the days leading up to June 17th. She told the police she thought Mr. Norbu was acting “crazy”, by pacing up and down the platform in an unusual way.
Once they boarded the bus, Ms. Dolma and Ms. Campbell sat on the first upper seats at the back. Ms. Dolma took the window seat on the right; Ms. Campbell took the aisle seat directly across from Ms. Dolma.
Approximately 20 seconds after the two women were seated, Mr. Norbu entered the bus wearing a black T-shirt and carrying a backpack. He initially went to the aisle seat behind Ms. Campbell but remained standing. Approximately 10 seconds later, he engaged in a verbal interaction with Ms. Dolma. He remained standing throughout the interaction.
This verbal exchange was not in English but was heard by Ms. Campbell. Mr. Norbu then began to rummage through his bag. Approximately one minute later, Mr. Norbu approached Ms. Dolma. He poured a mason jar filled with lighter fluid onto the front of her shirt. After two attempts with a lighter, it ignited, setting Ms. Dolma ablaze in a flame of fire that almost reached Ms. Campbell.
Almost immediately, Mr. Norbu removed his shirt to become topless.
Miss Dolma, still aflame, ran from the bus. Mr. Norbu casually followed the other panicked passengers off the bus. While more than 50 people were present on the platform when Ms. Dolma exited the bus on fire, pleading for help, only a few came to the rescue. TTC supervisors, Cameron Jackson and Renee Joseph, along with two bystanders, each displayed heroic efforts to save and comfort the severely injured victim.
Ms. Dolma told bystanders that she did not know the man (later identified as Mr. Norbu). Ms. Dolma also said that Mr. Norbu asked if she was Tibetan and she said “yes”.
While others comforted Ms. Dolma, Mr. Norbu momentarily returned to the door of the bus. Approximately 20 feet away from where miss Dolma had escaped, he began to yell in Tibetan “Free Tibet”.
Mr. Norbu then fled the station along the exterior subway tracks. He was arrested a short distance away. At the time of his arrest, he was wearing a grey long-sleeved sweater. He was found with a lighter, pepper spray and a driver's license. The backpack he was carrying on the bus was empty. The bus was secured by Cameron Jackson and later examined by members of the Toronto Police Service. The mason jar and lid were retrieved and later tested by the Centre of Forensic Sciences, confirming that Mr. Norbu had been carrying a jar of lighter fluid in his backpack.
Victim Impact Statements prepared by two sisters and a niece of the victim describe Ms. Dolma as a dedicated individual who was educated in India and worked there as a nurse for two years before immigrating to Canada, intending to continue her nursing career. At the time of her death, she was working as a caregiver to elderly individuals and was just three months away from her nursing licensing examination.
The Victim Impact Statements vividly describe the great pain and suffering experienced by the victim during her days in hospital prior to succumbing to her injuries. She could not talk or see properly and struggled even to breathe. The Statements also speak to the emotional and psychological impact upon her mother, niece and sisters, one of whom was scheduled to take her own nursing exam just days after the attack. The victim’s older sister, also a TTC user, eloquently described the ongoing effect of the offence upon her in these terms:
“As someone who relies on TTC transit to go about my daily life, the idea of stepping onto a bus or subway car fills me with a paralyzing sense of dread. Every unfamiliar face becomes a potential threat, every unexpected noise a trigger for panic. The once-familiar rhythms of my daily commute are now marred by a pervasive sense of vulnerability and fear. But it's not just the physical act of taking transit that fills me with dread; it's also the psychological toll it takes on me. The trauma of Nyima's tragic death has left me feeling emotionally raw and fragile, unable to shake the constant sense of unease that hangs over me like a dark cloud. I find myself questioning everything – my surroundings, the people around me, even my own thoughts and feelings. It's a relentless cycle of fear and paranoia that threatens to consume me entirely.
In the aftermath of Nyima's death, I have become a shell of my former self – anxious, withdrawn, and utterly pathetic. The once vibrant and outgoing person I used to be has been replaced by someone who struggles to find joy or meaning in anything. Every day feels like a battle just to make it through, a constant struggle against the overwhelming tide of grief and despair.”
Mr. Jackson, the TTC station supervisor who first attended to the victim, provided a Victim Impact Statement. He was the first TTC staff member to assist the victim after she got off the bus, engulfed in flames. He was severely impacted by the offence, having been diagnosed with post-traumatic stress disorder, anxiety, and depression. He has sought the help of a psychologist and relies on the support of an occupational therapist during public outings. Persistent nightmares and psychological distress from the event have left him unable to carry out the demands of his professional role. The impact of the event fundamentally altered his relationships, worldview, and sense of self, resulting in him becoming reclusive and withdrawn from the world.”
Background
- The Board adopts the description in last year’s Reasons:
“Mr. Norbu is 41 (43) years old in chronological terms (35 years old according to his legal birthdate). He is single, with no dependents. He had been living with his mother, sister and sister’s husband at the time of the index offence. He was last employed in construction in 2012 and was financially supported by ODSP since 2016 or 2017. His diagnoses in the Hospital Report are “probable” schizophrenia (a matter further discussed in the evidence) and cannabis use disorder (severe), in remission in a controlled environment.
Mr. Norbu was born in Nepal. His parents were originally from Tibet but had moved to India with their respective families as children. They met in India and moved to Nepal, where they lived together until 2000. Mr. Norbu immigrated to Canada in 2008 or 2009 with his mother and sister. His eldest brother had immigrated to Canada earlier. They were sponsored by his father, who had become a Tibetan Buddhist in Nepal and came first to the United States and then to Canada.
Mr. Norbu’s childhood development, education, limited work experience, relationship history, substance use history, course since immigrating to Canada, and prior psychiatric history are summarized in the Hospital Report and chronicled in detail in the two criminal responsibility reports. As these documents are in evidence, it is not necessary to summarize this information in these Reasons. Several details are, however, helpful for the purpose of understanding features of his personality and their relationship to his mental health issues.
After attending school in Nepal for approximately three years, Mr. Norbu and his brother, Sherab, reportedly were sent to a boarding school in India, to learn the Tibetan language and culture. This was reportedly a common practice.
Mr. Norbu reported that at the age of 12, he was sent to live in a “boy hostel” where 60 boys lived together. He stated that it was accepted that there would be “sexual things between boys”, a tradition which, in Mr. Norbu’s account, was “passed on by elders in monasteries...older monks have sex with younger monks...it’s allowed because they don’t want to lose the monks”. Mr. Norbu stated that if the teachers found out about such sexual activities, they would ignore it. He further indicated that after partaking in several such sexual contacts, “Everything was kind of normal to me...I learned it.”
While in Grade 4 at the boarding school, he was reportedly sexually assaulted by a boy six or seven years older than him and was again sexually assaulted by a 19-year-old boy when Mr. Norbu was 13. By age 15, he was engaging in sexual activity with other boys and on one occasion, engaged in forced sexual activity upon another boy. He returned to Nepal at age 16 after realizing that he had “done something wrong” (engaging in the previously mentioned sexual activity). He did not complete further education in Nepal.
Mr. Norbu’s brother, Sherab, reportedly died by self-immolation in Nepal in 2008. Mr. Norbu and his sister, Tsering Yangzom, provided inconsistent accounts as to the circumstances leading to their brother’s suicide, but in any event, Mr. Norbu had great difficulty coping with his brother’s death as he had been very close with him. Ms. Yangzom opined that their brother’s passing changed Mr. Norbu. He had behavioural difficulties afterward that she was unaware of beforehand.
Mr. Norbu told Dr. Iosif that since his brother’s death, he had thoughts of “self-immolation for the country...videotaping it and showing it to the world because we don’t have a country, China took Tibet. I saw people set themselves on fire before, when I was at school in India...it was the way to take back our land, it was nonviolent. Dalai Lama said, ‘self immolation...set yourself on fire’. After that, 150 people set themselves on fire.” Dr. Iosif asked Mr. Norbu why he thought that China would care about Tibetan people setting themselves on fire. He replied that “the monks will know [the answer to the question]”. He agreed with Dr. Iosif’s suggestion that self-immolation was very important to him and that it appeared to always be the solution that came to his mind whenever he was angry or to make a political statement, even after he immigrated to Canada. Mr. Norbu stated, “Whenever when I thought of suicide, I thought of setting myself on fire...always”. However, he denied that setting other people on fire would be similarly glorious or heroic in his mind or for the community. Mr. Norbu denied any political involvement, either in Canada or while living in Nepal. He indicated that he never talked to those in the community about issues related to the Tibetan cause.
Despite living in the same home after immigrating to Canada, Mr. Norbu very rarely spoke to his sister. They stopped eating together as a family after they moved to Canada. Mr. Norbu would tell Ms. Yangzom not to eat certain things, and he seemed “very suspicious” about food. He ate alone in his bedroom. He either got leftovers out of the refrigerator, made himself simple meals, or sometimes skipped his meals.
Ms. Yangzom said that conversations with Mr. Norbu tended to end in arguments. If she did not agree with him, he got very upset. Whenever he was at home, Mr. Norbu was in his bedroom. Most of the time, he only went out at night. She did not know where he went. He sometimes missed appointments with his doctor. When people came to visit the family at their home, Mr. Norbu got upset and often left.
With respect to Mr. Norbu’s suspiciousness, Ms. Yangzom reported that when she spoke with a Tibetan friend on the phone, he would say things like, “Why did you call her? Now she’s going to talk about me.” He believed that all Tibetan people were “against him,” but she did not know why he thought this. She did not agree with his impression that Tibetan people from Nepal are not included by Tibetan people from India in the Tibetan community in Toronto, in that this was not something she had personally experienced or thought about. Ms. Yangzom also recalled Mr. Norbu saying he was once standing at a bus stop near their home and heard a Tibetan girl say, “The Jameson mental guy is here” (referring to the street where they lived at the time). She did not know if Mr. Norbu was hearing voices or talking to himself because he interacted with her so minimally and spent so much time in his bedroom.”
Substance Use
Mr. Norbu started using cannabis in school. In Nepal, he started using benzodiazepine in 2002. He attended a rehabilitation facility, but this ended abruptly when he left the institution without permission.
Mr. Norbu stated that he started smoking after being introduced to them by his older brother, whom he sought to emulate. He eventually attended a rehabilitation facility, but this ended abruptly when his brother committed suicide.
Mr. Norbu stated that in Canada, after he stopped attending school, he began drinking alcohol and started using cannabis again. He stopped seeing his friends and became socially isolated. His alcohol use fluctuated with his mood and with the use of antidepressant medication. He stopped taking this medication in 2011 and resumed alcohol consumption. From that point on, he went through cycles of starting antidepressant medication and reducing alcohol use, then stopping his medication, becoming more depressed, and using more alcohol. His heaviest period of alcohol use was reportedly in 2014.
Legal History
Mr. Norbu has no prior criminal convictions.
There is a prior history of assaultive behaviour recorded through police contacts: On April 14, 2010, Mr. Norbu assaulted two staff members at a DriveTest Centre after failing an examination; one person was knocked down during the altercation;
On May 13, 2010, during his arrest for being intoxicated in a public place, he lunged toward and grabbed at a police officer and kicked at an officer before being handcuffed.
On February 8, 2013, when police officers found Mr. Norbu sleeping in a stairwell and woke him, he became verbally abusive to the officers and spat at them, striking them both. Later, after being place into a police cruiser, he became violent again and kicked out the rear passenger side window; and
On July 11, 2020, Mr. Norbu assaulted the office manager at the Tibetan Cultural Centre and was apprehended by police under the Mental Health Act. A review of video footage showed Mr. Norbu repeatedly kicking him and then tackling him as the manager tried to flee.
Evidence at Hearing
Dr. Choptiany testified and noted that Dr. Benassi has now taken over the patient’s case following transfer to a general unit on July 15th. There have been no issues on the general unit. Mr. Norbu has achieved Level 6 privileges as of August 18, which permits indirectly supervised privileges on grounds for programs, recreation and fresh air. Mr. Norbu had exercised privileges on the secure unit at Levels 3 to 5 without incident.
Dr. Choptiany indicated that in recommending community living the hospital had considered a risk analysis including violence, the illness in question, recovery and rehabilitative goals. The hospital was going to recommend community living in supervised accommodations but an incident in May of this year caused the hospital to add 24-hour supervision to its recommendation.
The May incident, detailed in the Hospital Report, involved a behavioural outburst that was unprovoked. The staff in question was not acting inappropriately or abrasively and is known to be a pleasant, empathetic individual. The nurse in question was trying to engage in a teaching in response to Mr. Norbu’s lateness for meals. Mr. Norbu viewed the nurse as being rude when there was no basis for that conclusion. The threats were serious. The outburst did not appear to be the product of psychosis but could be a sub-clinical symptom. Following that incident, Mr. Norbu’s medication was changed from oral to long-acting injection – Invega Sustenna monthly.
The recommendation for 24-hour supervised accommodation means a significantly longer waitlist than supervised housing. There are only two suitable residences that provide 24-hour supervision. A 24-hour supervised accommodation would not be locked and there will be freedom to go out into the community.
Having the community living condition in the Disposition will permit discharge planning and placement on waitlists. Generally, a residence will not place an individual on a waitlist until the Disposition contains a community living condition.
In recommending community living, the hospital has considered that apart from the anomalous May incident, there have been no other notable incidents. Mr. Norbu is now on a long-acting injection. He has not consumed substances and has no cravings for them. Mr. Norbu is well engaged with his treatment team. It will probably take at least three more months to progress to Level 9 privileges. That is the highest level of privilege and must be reached before discharge will be approved.
Mr. Norbu is interested in pursuing continuing education in the east end of Toronto.
Dr. Choptiany indicated that the diagnosis of schizophrenia has now been confirmed.
A conditional discharge would be premature in the doctor's view. The Mental Health Act is insufficient to managed Mr. Norbu’s illness, and treatment. The hospital would want to act swiftly if his symptoms emerged or substances were consumed. The risk scenario envisioned by the hospital is not consistent with the powers of the Mental Health Act. If Mr. Norbu decompensated his symptoms would not necessarily trigger the Mental Health Act powers.
Mr. Norbu is now at therapeutic doses of his injectable medication. While five injections would be the best measure of efficacy, Mr. Norbu has only had two or three injections to date. The antipsychotic medication appears to be working. There have been no side effects.
Crown counsel elicited that Mr. Norbu felt justified regarding the May outburst. That trait was like the position he took in relation to the index offence. Prior to the index offences there were incidents in which, fueled by paranoia, Mr. Norbu would lash out at authority figures. It could be that the May incident involved Mr. Norbu experiencing symptoms which staff had not picked up on. Dr. Choptiany noted that Mr. Norbu’s actions of May came out of left field. Suddenly, he lashed out.
To date, Mr. Norbu has only had accompanied passes into the community which have gone well.
Mr. Norbu participates in 1:1 weekly substance relapse prevention programming. His goal is to be abstinent. Mr. Norbu has been referred to concurrent disorders therapy and is on a waiting list which could take weeks or months.
Mr. Norbu’s substance history is long and concerning. Mr. Norbu has admitted that the nature of his behaviour is that if he consumes, he wants more substances.
Mr. Norbu is in the moderate range for psychopathy. He has never been assessed as having antisocial personality traits, but, there is a history of conduct disorder.
It will be prudent to continue climbing the privilege ladder so that Mr. Norbu can be tested on indirect passes. The ability to navigate indirectly supervised passes is a prerequisite to graduating to community living. It would be important to ensure that there is no return to substances. Dr. Choptiany said there is an aspect of reward in including a community living provision as it gives a patient something to work for.
Mr. Norbu has a history of depression and PTSD.
His cannabis consumption was very very high.
It is too early to know what impact Invega Sustenna will have on the patient’s mental health.
It is possible another major incident could emerge. There is significant likelihood of a second incident absent adequate monitoring and the capacity to quickly address any emerging concerns regarding acuity of risk.
Mr. Norbu accepts his diagnosis. The doctor believes that Mr. Norbu’s desire to progress is not just externally motivated.
In final submissions, Crown counsel continued to oppose the inclusion of community living, noting among other matters, the horrific nature of the index offence, the May incident that came out of the blue, the history of mental disorder, substances and violence. Patient’s counsel stressed that although there had been a serious incident in May, his client is largely prosocial and that a 24/7 supervised setting would be sufficient to manage the risk.
Analysis
The crux of the hearing concerned whether 24-hour supervised community living should be included in the Disposition. It was common ground that the requirement for 24-hour supervision stemmed from the incident in May. It seems clear that the reason for the recommendation for community living is to facilitate discharge planning and have Mr. Norbu placed on waitlists for the two residences that are designed for 24-hour supervised accommodation. It is also clear that the likelihood of placement in the community is not going to occur in the next reporting year. It is accepted that the ability to be placed on a waitlist is an appropriate consideration for the Board and there may be somewhat of a therapeutic benefit to having such a clause included.
On the other hand, the Board finds that the May incident was very troubling in several respects. In the Board’s view that incident, against the history of this patient, does not support the inclusion of such a condition at this time, even as modified to include 24-hour supervision. The incident, in the context of the patient’s history, gives the Board deep pause and points to non-inclusion for the next reporting year. The Board finds that the May incident was unprovoked and came out of the blue. The characterization is in keeping with many of the notable incidents of violence in Mr. Norbu's history. It is observed that Mr. Norbu believes his actions were justified. The index offence is characterized as coming out of the blue followed by Mr. Norbu seeking to justify his horrendous act. Other of Mr. Norbu’s violent incidents have the same characteristics, arising on the sudden, unprovoked and laden with misperceptions followed by justifications. The hospital is not at all certain why the May incident occurred. It was agreed that the May incident may have been preceded by some clinical signs of decompensation that went unnoticed. That needs to be further explored. The Board has also taken the following into account in rejecting a community living provision for the coming year:
Mr. Norbu’s diagnosis was only very recently settled upon.
He only recently commenced his long-acting injection and the impact on his mental health is still being assessed.
Mr. Norbu has only moved to a general unit a few weeks ago.
His 1:1 therapy to prevent substance relapse and improve coping strategies is still ongoing.
While Mr. Norbu has been progressing on the privilege ladder, he has not been tested on indirect privileges yet. The jump, in his case to community living, without a track record of performance on indirect passes is a bridge far away. Trialling and testing him has special importance given the horrific nature of the index offence, other acts of violence, the May incident and a long history of mental disorder with a regular and consistent pattern of consuming large quantities of cannabis which exacerbates his unwellness.
There is a high probability of another violent incident absent close supervision.
Relapses can occur quickly. There is a continued and concerning history of acting out all of the sudden based on misperception.
Finally, the Board, in weighing any potential benefits to include the community living clause notes that the index offence is not that far removed, that Mr. Norbu has only been NCR since June of last year, that the index offence was committed against an unsuspecting innocent defenseless victim on public transport, informs a cautious approach. In other words, in the circumstances of this patient and these facts, public safety concerns override the recognized benefits to inserting a clause about community living currently.
The Board observes that the inclusion of indirectly supervised access to the community needs to be explored, albeit carefully. Successfully navigating indirect passes is a prelude to possible community placement. The hospital will want to require the administration of indirect passes to be tested in its traditional, cautious manner.
A conditional sentence has no air of reality in this matter.
The Board observed that Mr. Norbu has an interest in pursuing educational opportunities, apparently in the east end of Toronto. At this juncture, given the history and concerns about the safety of the public, the Board is of the view that indirectly supervised passes cannot be used on the TTC. The TTC may not be accessed unless the patient is accompanied by hospital staff or with a person approved by the person in charge. In coming to these conclusions, the Board has considered the compelling Victim Impact Statements, including references to the impact on users of public transportation. We wish Mr. Norbu well in the upcoming year.
DATED this 28^th^ day of October 2025, at the City of Toronto, in the Region of Toronto.
Mr. M.D. Segal
Alternate Chairperson
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Office of the Registrar
Ontario Review Board