Ontario Review Board
Re: Sindiso Nyoni
ORB File No: 7966
Hearing held on: Tuesday, September 2, 2025
Place of Hearing: Brockville Mental Health Centre
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Mr. P. Capelle
Members: Dr. R. Kunjukrishnan
Dr. W. Loza
Ms. M. den Haan
Ms. R. MacIntyre
Parties Appearing:
Accused: Sindiso Nyoni
Counsel: Mr. A. Sheivari
Person in charge of the hospital: Counsel: Ms. P. Miltenburg
Representative Dr. E. Carefoot
Attorney-General of Ontario: Counsel: Mr. A. Findlay
REASONS FOR DISPOSITION
(Dated October 29, 2025)
Introduction
On November 5, 2021, the accused, Sindiso Nyoni, was found not criminally responsible on account of mental disorder on a charge of aggravated assault contrary to the Criminal Code of Canada (“Criminal Code”). Mr. Nyoni is currently subject to a Disposition of the Ontario Review Board dated September 14, 2024 which detains him in the secure forensic unit of the Brockville Mental Health Centre, (the “Hospital”) with privileges up to and including to live in the community in accommodation approved by the person in charge.
On September 2, 2025, the Ontario Review Board convened a hearing at the Brockville Mental Health Centre, (the “Hospital”) to conduct Mr. Nyoni’s annual review hearing. Mr. Nyoni attended the hearing and was represented by counsel, Mr. Ariya Sheivari.
A Hospital Report dated August 19, 2025 was entered as Exhibit No. 1.
The issue at this hearing is whether Mr. Nyoni continues to represent a significant threat to the safety of the public as defined in s. 672.5401 of the Criminal Code. If so, the necessary and appropriate Disposition in the circumstances must be determined, bearing in mind the factors enunciated in s. 672.54 of the Criminal Code.
Position of the Parties
At the outset of the hearing, the parties were canvassed for their initial recommendations to the Board. On behalf of the Hospital, Ms. Miltenburg submitted that Mr. Nyoni remains a significant threat to the safety of the public and that a continuation of the Detention Order remains the necessary and appropriate Disposition. The Hospital recommended a change to paragraph 2(f) of the Disposition from approved accommodation to supervised accommodation.
Counsel for the Attorney General supported the position of the Hospital but submitted that only 24-hour supervised accommodation should be permitted.
Counsel for Mr. Nyoni conceded the issue of significant threat for the purpose of the hearing and supported the Hospital’s recommendation for a continuation of the Detention Order Disposition with the change to supervised accommodation.
For the reasons below and based on the expert evidence and opinions before us, the Board concluded that Mr. Nyoni continues to represent a significant threat to the safety of the public. The Board further ordered that a continuation of the existing Detention Order is the necessary and appropriate Disposition in the circumstances with the change to increase the catchment area to Eastern Ontario. The Board also concluded that the risk presented by Mr Nyoni to the public can only be effectively managed by 24-hour supervised accommodation.
Index Offence
- The circumstances giving rise to the Index Offence are set out in last year’s Reasons for Disposition as follows:
“On September 3, 2021, Sindiso Nyoni approached the victim Christian Jerome who was panhandling. He walked up to the victim while his back was turned and quickly stabbed him in the head and then walked away. The victim was taken to the Civic hospital and released with stitches to the right side of his face.”
- Mr. Nyoni stated that the victim of the Index Offence was “against me” and that “something else was against me, wanting to put me down.” Mr. Nyoni explained that the unknown force or organization “killed my Dad, made my Mom hate me, made (the victim) attack me and made me get arrested.”
Diagnoses
Schizophrenia
Post-Traumatic Stress Disorder
Amphetamine type substance use disorder
Cannabis use disorder
Antisocial Personality traits
Background History
Mr. Nyoni’s background history is set out in detail in the Hospital Report (Exhibit 1) and need not be repeated here. Briefly summarized, Mr. Nyoni is a 33-year-old man who was born in Zimbabwe. He moved to Canada at the age of ten with his mother and sister and settled in Ottawa. He dropped out of high school when he began to experience symptoms of his mental illness but completed his diploma as an adult. He was diagnosed with schizophrenia at the age of 18.
He was hospitalized several times prior to the Index Offence, mostly at the Ottawa Hospital, but at the Royal Ottawa Mental Health Centre for longer admissions. He was followed by psychiatrists for several years until late 2021, then he stopped attending appointments. Drug use, in particular amphetamines, was noted to cause a deterioration in his mental stability.
After his diagnosis, Mr. Nyoni resided at the YMCA, a series of group homes, and with his mother for a period of time. Mr. Nyoni has not pursued post-secondary education or vocational training. Mr. Nyoni worked briefly at some fast-food restaurants in his late teens but has not worked since he became ill in about 2009. He is financially supported by ODSP.
Mr. Nyoni has convictions for assault and for robbery and assault with a weapon.
Following his NCR finding, Mr. Nyoni was admitted to the Hospital and was discharged to FITT House, 24-hour supervised housing on the Hospital grounds, on March 11, 2025. Due to concerns about an increase in Mr. Nyoni’s cravings for drugs and continued auditory hallucinations, a decision to transfer him to a less supervised residence was put on hold.
Increased urine drug screens were initiated and Dr. Carefoot requested that Mr. Nyoni meet with her at the Hospital on May 26, 2025. Mr. Nyoni was accompanied back to FITT House by members of the outpatient treatment team but ran ahead into the residence. He was intercepted coming out of his room and was found to have two knives in his pocket. He admitted on assessment that he had been feeling paranoid and unsafe for the past two weeks and had purchased the knives for protection. This incident triggered the restriction of liberty.
Evidence at the Hearing
The Hospital’s evidence was presented through the Hospital Report as well as through the oral testimony of Dr. Esther Carefoot, who has been Mr. Nyoni’s attending psychiatrist since July 2024.
Dr. Carefoot informed the Board that she met with Mr. Nyoni the morning of the hearing. She testified that Mr. Nyoni suffers from treatment-resistant schizophrenia, and hallucinations and delusions persist despite his two anti-psychotic medications. He also suffers from post-traumatic stress disorder and amphetamine and cannabis use disorders in forced remission. He has not used substances in approximately one year.
Mr. Nyoni shows traits of antisocial personality disorder, and there is evidence that he likely has antisocial personality disorder. In Dr. Carefoot’s opinion this is complicated by his early involvement in gangs and tumultuous upbringing in Zimbabwe. At the time of his Canadian charges, he exhibited some features of schizophrenia.
Mr. Nyoni continues to experience active auditory hallucinations, which he estimated to be three out of ten in intensity when she spoke with him before the hearing. Mr. Nyoni does not always understand the voices he hears, but they tell him that someone is going to kill him. He is not bothered now by the voices, they never identify a specific person, and he does not see a need to have weapons right now. In the past his symptoms have led him to violence, although currently this is not a concern.
Mr. Nyoni is compliant with taking his medications and takes his medication because the doctor tells him to. He has a superficial understanding of his diagnosis and needs continual re-education for the reasons for taking his medication as he does not appear to retain the information he is provided. Mr. Nyoni’s mental state decompensates quickly when he is not taking medication. He experiences symptoms even while adherent to his two anti-psychotic medications. Because he is taking clozapine, re-titration of the levels is required if Mr. Nyoni stops taking the medication.
In Mr. Nyoni’s mind, he had to act the way that he did when he committed the Index Offence. He does not have good insight into the Index Offence.
The last time that Mr. Nyoni testified positive for substance use was November of 2023, though he does indicate that he struggles with cravings for substances. He has poor insight into the impact of substance use on his mental health and has asked Dr. Carefoot if he could “use a small amount.” Dr. Carefoot is confident that Mr. Nyoni would use substances if he were not in the Hospital.
To Mr. Nyoni’s credit, the week prior to the hearing, he tried (unsuccessfully) to stop smoking. He was not previously interested in stopping. He will be meeting with staff to discuss smoking cessation aids. He struggles to remember why it is important to stop smoking with respect to the impact on his clozapine medication levels. A cognitive assessment indicated no direct evidence of developmental delay. Any cognitive impairments may be the result of substance use and his mental illness.
Mr. Nyoni has remained in the Hospital since his restriction of liberty May 27, 2025. There have been no incidents of aggression, and no weapons have been found on Mr. Nyoni although he is regularly searched with a wand for weapons. Mr. Nyoni follows the rules and there have been no verbal issues during the reporting period.
Mr. Nyoni exercises full grounds privileges from 9:00 a.m. to 9:00 p.m. He is required to check in hourly and to remain within the perimeter of the Hospital grounds. He adheres to these requirements.
Mr. Nyoni currently requires supervision, and his risk to public safety would increase in an unsupervised setting. He does well with the reassurance of supervision at the Hospital. There is concern about his feeling that the needs to purchase weapons for his protection. He requires improved insight into the Index Offence, violent attitudes, and substance use and its impact on his mental health.
Mr. Nyoni sees the addictions counsellor approximately every two weeks and sees a psychologist weekly. He attends N.A. meetings at the Hospital.
If Mr. Nyoni were to use substances, his mental state would decompensate very quickly. On page 56 of the Hospital Report, the risk assessment notes that in an unstructured setting, Mr. Nyoni’s risk to public safety is high. Without supervision, this risk becomes very high.
With respect to the change of paragraph 2(f) of the Disposition, there is a significant safety concern, even in 24-hour supervised accommodation such as FITT House, as demonstrated by the events leading up to the restriction of liberty.
In Dr. Carefoot’s opinion, it is possible that Mr. Nyoni could move into supervised accommodation during the treatment year, however, at the outset 24-hour supervision is required. He could move to less supervised accommodation when he shows that he is able to cope with less structure but would need to demonstrate substantial improvement in his insight and attitudes. FITT House is the highest level of supervision available but has only one staff member. In Dr. Carefoot’s opinion, housing with two staff members is preferable.
In response to questions from counsel for the Attorney General, Dr. Carefoot testified that Mr. Nyoni did not express remorse for the Index Offence. He explained that it was the result of prior history with the individual on the street. In Dr. Carefoot’s opinion some delusions and hallucinations likely played into the Index Offence. Mr. Nyoni has a violent criminal record. He has indicated that he is a member of the Crips gang and that he would return there.
Mr. Nyoni presents as superficially well, but he bought two knives which he explained were to protect himself. He still believes that he needs to arm himself for self-protection. He continues to hear voices and experiences negatively altered thoughts due to his post-traumatic stress disorder. In his mind the world is unsafe. When he began to experience increasing hallucinations, he did not disclose this to the treatment team. When asked what Mr. Nyoni perceives as a threat, he was unable to explain.
Mr. Nyoni’s antisocial personality traits are exacerbated by paranoia. He currently continues to endorse a criminal lifestyle despite the treatment team informing him that it is not in his best interests. His long-term idea is to return to drug use and human trafficking. In this lifestyle he will likely encounter situations that he perceives to be a threat.
Even with significant counselling, Mr. Nyoni’s insight is still suboptimal with respect to his illness. Despite the treatment team’s education that use of substances is an issue for someone with a mental health condition, Mr. Nyoni still endorses use of substances and indicates that he would like to use “some”.
Risk assessments indicate that Mr. Nyoni has some of the higher possible scores. His score on the VRAG-R assessment increased from the 2022 assessment, and placed him in bin 9 of 9, in the 92nd percentile. As noted at page 59 of the Hospital Report, others with these scores “reoffended at a rate of 76% within five years and 87% within 12 years.” Mr. Nyoni’s risk per violence according to the HCR-20 score is high without support, and moderate under his current level of supervision in Hospital. When assisted by a structured environment, Mr. Nyoni does well.
In response to questions from counsel for Mr. Nyoni, Dr. Carefoot testified that DD-TRHP housing is not available unless a patient has a developmental disorder, which Mr. Nyoni does not. The Murray Street housing is not an option for Mr. Nyoni as it is 8-hour supervised housing. The Social Worker is looking for other options, but none have yet been identified.
In terms of cognition concerns, the same conversations occur in therapy each week, and Mr. Nyoni presents as not knowing the information that is being repeated. As an example, the treatment team has spoken at length with Mr. Nyoni about smoking and its effect on his clozapine levels, but he does not appear to retain the information. He is currently taking medication to decrease his cravings. Smoking cessation aids are currently unavailable at the Hospital due to issues that the Hospital has had with diversion of these aids. Because clozapine levels are affected by the hydrocarbons in cigarette smoke, vaping, although unhealthy, is an acceptable alternative which Mr. Nyoni will be encouraged to consider.
Dr. Carefoot is unsure if a change to Mr. Nyoni’s Abilify medication would effect a change to the hallucinations he experiences. When Abilify was discontinued, Mr. Nyoni’s hallucinations decreased in intensity; however he had also been readmitted to the Hospital, where he felt safer. He was also not smoking at the time, and therefore his clozapine levels were increased.
Mr. Nyoni’s gang affiliations are all self-reported but have been fairly consistent. Mr. Nyoni’s mother reported that he was selling drugs but did not report that he had involvement with the sex trade or human trafficking.
Mr. Nyoni’s hallucinations appear to be related to the threat that he perceives, and they have improved since he has returned to hospital. When he was readmitted, he said his hallucinations had become worse which was why he obtained knives. He estimated the hallucinations were on a scale of 8 out of 10, but he now says they are much better, likely 3 out of 10. The content remains the same.
In order to progress to indirect community access, Mr. Nyoni’s insight into the Index Offence, violent attitudes, and the effect of substances on his illness would need to increase greatly. It is hoped that he will be able to achieve indirectly supervised access to the community within the treatment year. Originally, Mr. Nyoni was hiding symptoms of his illness, but he has become more open with the treatment team now with what he is experiencing. He currently does not understand that there is an alternative way to deal with the symptoms he is experiencing.
Dr. Carefoot will attempt to prioritize his placement on the waitlist for further psychological and risk assessment.
In response to questions from the panel, Dr. Carefoot testified that she is unsure if the immigration issue referenced in last year’s Reasons has been resolved, but Social Work will investigate to see if Mr. Nyoni is still required to check in with immigration.
There has been no evidence of drug sales despite the reference at page 49 of the Hospital Report that Mr. Nyoni had a large amount of cash. Dr. Carefoot is aware that he received a lump sum ODSP payment before he moved to FITT house. He received back pay and was not using all of his money each month. In her opinion, if he was dealing drugs, he would use drugs, and he has not tested positive.
Mr. Nyoni has not started cognitive behavioural therapy, but it is the first on his list of groups and hopefully he will be able to attend sessions in the fall.
The hallucinations that Mr. Nyoni continues to experience are more than residual, and he tries to distract himself from them. He stated that he experiences them several hours per day and Dr. Carefoot hopes that there is room for improvement. It is possible that Mr. Nyoni will be returned to FITT House, but there would need to be substantial improvement in order for him to be discharged there. In her opinion, he should have gone to a higher security accommodation the last time that he was discharged from hospital.
Mr. Nyoni’s mental state has been superficially good in Hospital; however the treatment team needs to be very cautious. One staff member at FITT House is insufficient to manage Mr. Nyoni’s risk, and regular searches for weapons are not done at FITT House.
Dr. Carefoot supports an expansion of the radius under paragraph 2(f) of the Disposition to expand the availability of 24-hour supervised housing. She is unaware of facilities that may be available in Ottawa, but it would be easier to affect a transfer if the Disposition indicates the region of Eastern Ontario with accommodation approved.
The next treatment conference is scheduled for the end of September, at which time Mr. Nyoni’s privileges will be discussed. An increase in privileges may be discussed, including directly supervised privileges in the community.
No further evidence was presented.
Final Submissions of the Parties
In final submissions, Dr. Carefoot submitted that the Disposition should be changed to 24-hour supervised accommodation with the extension of the radius to Eastern Ontario in order to increase the number of potential residence placements available to Mr. Nyoni. Counsel for the Attorney General supported the recommendation.
Counsel for Mr. Nyoni maintained his initial position and asked the Board to consider not specifying 24-hour supervised accommodation in case Mr. Nyoni’s mental state improves sufficiently that he does not require that level of supervision later in the treatment year.
Analysis and Conclusion
Having heard and considered the entirety of the evidence, as well as the submissions from the parties, the Board has no difficulty in independently reaching the conclusion that Mr. Nyoni remains a significant threat to the safety of the public. In coming to our conclusion in this matter, the Board relies on the uncontroverted expert evidence of Dr. Carefoot, in addition to the documentary evidence before us.
In Winko, the Supreme Court outlined that, in coming to the conclusion on the issue of significant risk, the Board should closely examine a range of evidence, including: the circumstances of the original offence; the past and expected course of the accused’s treatment; the present state of the NCR accused’s medical condition; the NCR accused’s own plans for the future; the support existing for the NCR accused in the community; and most importantly, the recommendations provided by experts who examine the NCR accused.
Mr. Nyoni suffers from a major mental illness, schizophrenia, and continues to experience residual symptoms and auditory hallucinations despite adherence to two anti-psychotic medications, including clozapine. Although Mr. Nyoni made significant progress early in the treatment year, he was re-admitted to Hospital from 24-hour supervised accommodation due to increased cravings for substances and was found to have purchased weapons. He did not pro-actively disclose to the treatment team that he had been experiencing increasing paranoia and feelings that he was unsafe, thus requiring him to arm himself.
Mr. Nyoni’s ongoing violent attitudes are concerning, and his insight into the Index Offence and particularly into the need to abstain from substances is undeveloped.
In light of the Board’s finding of significant threat, it is charged with shaping a Disposition for the coming year. The panel accepts the expert opinion of Dr. Carefoot that 24-hour supervised accommodation is required to mitigate the risk posed by Mr. Nyoni. The uncontroverted evidence before us is that even with the support of 24-hour supervised housing with one staff member, Mr. Nyoni experienced a setback and an increase in symptoms which led him to feel the need to purchase two knives for self-protection.
Dr. Carefoot’s evidence was clear that Mr. Nyoni feels safe in a structured environment and his mental state has improved since his readmission to hospital. Suitable 24-hour supervised housing is not currently available. Due to the limited placement opportunities for 24-hour supervised housing in the Brockville area, the Board agrees that expanding the catchment area to Eastern Ontario will assist Mr. Nyoni to access the community when he is ready to do so.
In consideration of all the evidence, submissions of the parties, the criteria set forth in s. 672.54, the paramount consideration being the safety of the public, in addition to the mental condition of Mr. Nyoni, his reintegration into society and his other needs, the necessary and appropriate Disposition is the continuation of the existing Disposition with the changes noted in our formal Disposition.
DATED this 29th day of October, 2025, at the City of Toronto, in the Toronto Region.
Ms. M. den Haan Legal Member
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Office of the Registrar
Ontario Review Board