Ontario Review Board
Re: Robert Evans
ORB File No: 6491
Hearing held on: Thursday, September 25, 2025
Place of hearing: Centre for Addiction and Mental Health 1001 Queen Street West, Toronto
Pursuant to: Section 672.81(2.1) of the Criminal Code
Before:
Alternate Chairperson: Ms. M. Labrosse Members: Dr. B. Sheppard Dr. G. Eayrs Mr. M.D. Segal Mr. S. Doherty
Parties Appearing:
Accused: Robert Evans Counsel: Mr. A. Seymour-Butler
The person in charge of hospital: Counsel: Ms. A. Marshall
Attorney General of Ontario: Counsel: Mr. C. Coughlan
REASONS FOR DECISION
(Dated November 5, 2025)
Introduction
On March 3, 2014, Robert Evans was found not criminally responsible on account of mental disorder (“NCR”) on charges of assault with a weapon and aggravated assault, contrary to the Criminal Code of Canada.
Mr. Evans is currently subject to an Ontario Review Board disposition dated June 9, 2025, which detains him at the Forensic Service of the Centre for Addiction and Mental Health, Toronto (“CAMH” or the “hospital”), with privileges up to and including to live in the community in supervised accommodation approved by the person in charge.
By way of letter dated September 5, 2025, the hospital informed the Ontario Review Board that Mr. Evans had assaulted a co-patient on August 25, 2025, by striking him in the face with a 3-kilogram dumbbell, resulting in Mr. Evans being placed in locked seclusion on that same date. The letter also stated that Mr. Evans was brought out of seclusion two days later and claimed that he was being targeted by peers and that one had spat on him which is what he said in relation to the victim of the August 25 assault. Given that elevated risk, he was returned to seclusion. The hospital then provided notification to the Board under s. 672.56(2) of the Criminal Code that there had been a significant increase in the restriction of Mr. Evans’ liberty, as a result of the seclusion which was necessary to manage the elevated risk to co-patients and others.
On September 25, 2025, the Ontario Review Board (“ORB”) held a hearing at CAMH to review the restriction of liberty brought about by Mr. Evans’ seclusion.
The issues for this hearing are whether the hospital's decision to significantly increase the restriction of Mr. Evans’ liberty was necessary and appropriate and represented the least onerous and least restrictive decision available to the hospital to manage the risk. The Board was also tasked with reviewing the ongoing restriction on the same terms.
At the outset of the hearing, the parties were canvassed as to their preliminary positions and the hospital submitted that the decision to place Mr. Evans in seclusion was and remains necessary and appropriate. Counsel for the Attorney General, Mr. Coughlan, indicated that the Attorney General supports the position of the hospital. Counsel for Mr. Evans, Mr. Seymour-Butler, indicated that no position was being taken with respect to the restriction of liberty but that he wished to hear the evidence of the hospital before making final submissions.
For the reasons set out below, the Board finds that the hospital's decision to significantly increase the restriction of Mr. Evans’ liberty by placing him in locked seclusion was reasonable and warranted and represented the least onerous and least restrictive course of action available to the hospital to deal with the increased risk posed by Mr. Evans’ very violent and unprovoked assault on a co-patient, as well as Mr. Evans’ ongoing persecutory delusions involving other co-patients on the unit. The Board also finds that the ongoing restriction remains reasonable and warranted in so far as the hospital is maximizing its efforts to provide Mr. Evans with opportunities to come out of seclusion and enjoy privileges that more closely resemble the liberty norm that he was enjoying prior to being placed in seclusion, to the extent that is manageable.
As the only issue for this hearing is the restriction of liberty, there is no need to repeat the recitation of the index offences or the background information, all of which are contained in detail in the very recent Reasons for Disposition dated July 8, 2025, resulting from Mr. Evans’ annual review hearing which was heard on May 23, 2025.
Mr. Evans’ current diagnoses include schizophrenia and substance abuse, specifically marijuana, cocaine and alcohol, in remission in a controlled environment.
Evidence at the Hearing
The hospital's evidence was presented through its report dated September 15, 2025, and through the oral testimony of Dr. A. Arnold, a Psychiatry Resident under the supervision of Dr. R. Jones, who is Mr. Evans’ attending psychiatrist on Unit 3-2 on the Forensic Secure Unit of CAMH.
Dr. Arnold adopted the contents of the Hospital Report and advised that Mr. Evans' clinical status remains relatively unchanged. On September 22, 2025, a hearing was held before the Consent and Capacity Board which upheld the finding of incapacity of Mr. Evans. As a result, the treatment team started an augmentation medication, loxapine, in an oral formulation which was agreed to by Mr. Evans’ mother, who is his substitute decision maker. Mr. Evans also initially agreed to try this medication but refused to take it last night. Loxapine is also available in a short-acting injectable version, which means that it must be administered daily. Dr. Arnold stated that the treatment team will continue to encourage him to take it orally but that they may consider the injectable version should he continue to refuse to take it.
Regarding the assault on August 25, 2025, Mr. Evans presented no indications that he was off his baseline, which includes some ongoing residual symptoms. The assault on a co-patient at the therapeutic neighbourhood gym of the hospital appeared to have been entirely unprovoked and Mr. Evans continues to believe that he was the victim of targeting by this individual and that this person spat at him. The assault was quite violent. The victim sustained serious facial injuries as a result of being hit with a 3-kilogram weight.
Two days after being placed in seclusion, Mr. Evans was let out of seclusion and soon after started exhibiting persecutory delusions with respect to two specific co-patients, whom he felt were targeting him. As a result of this, Mr. Evans was returned to seclusion where he refused to take his Abilify, an augmentation antipsychotic medication that he has been receiving since 2018. Due to being considered an ongoing imminent harm to other co-patients, Mr. Evans has been kept in seclusion.
Dr. Arnold confirmed that prior to entering seclusion, Mr. Evans was enjoying level 6 privileges which include indirectly supervised grounds access for programming and recreation as well as accompanied community passes.
Once Mr. Evans returned to seclusion after being trialed out in the unit briefly, the hospital put in place a Protective Devices Plan (PDP), which entails providing multiple opportunities to patients to come out of locked seclusion daily. This included bringing Mr. Evans out for his meals off hours to the dining room as well as Click Station access for computer access, which Mr. Evans has consistently declined, morning showers which Mr. Evans has often declined but has sometimes accessed, as well as late afternoon yard access and early evening access to the dining room where Mr. Evans has often enjoyed doing math homework. Mr. Evans was initially escorted by security but now always has two staff members with him, including his primary nurse and another staff member. Dr. Arnold also indicated that it is part of the PDP for the hallways to be cleared of other co-patients when Mr. Evans is brought out to ensure that there are no altercations. Dr. Arnold also confirmed that bringing Mr. Evans out of seclusion is dependent on assessment and observation of treatment team staff to ensure that he is well enough to be brought out.
The treatment plan of the hospital is firstly to optimize medication to treat Mr. Evans’ psychosis, including his persistent delusions involving other co-patients. Once his illness is better treated, Mr. Evans would then be gradually reintroduced to his unit. Dr. Arnold could not predict how long it might take to get Mr. Evans back to baseline if he is accepting of the loxapine.
Dr. Arnold also added that even at his baseline, Mr. Evans is a very guarded individual which makes it difficult to assess him. Dr. Arnold would hope that there might be some improvement noted within a few weeks if the treatment is consistent.
Mr. Evans completely lacks insight into the fact that he suffers from a mental illness. Mr. Evans’ schizophrenia is resistant to treatment in general; however, his symptoms are currently much worse than at his baseline. He maintains that he was justified in assaulting the co-patient and continues to feel that he is targeted and that the hospital staff is not protecting him.
Dr. Arnold confirmed that Mr. Evans is continuing to accept to take his clozapine treatment, though he cannot say why.
If Mr. Evans was not in seclusion, the risk to the public, and specifically to peers on the unit, could not be adequately managed. Mr. Evans has a long history of unprovoked assaults against peers when he is symptomatic, and the risk remains quite high.
In response to questions posed to him by counsel for the Attorney General, Mr. Coughlan, Dr. Arnold confirmed that Mr. Evans believes that he was justified to assault the co-patient at the therapeutic neighborhood gym as he felt that he was being targeted and needed to respond. Mr. Evans does not see a problem with the gravity of his response, namely a dumbbell to the face, versus his claims that that co-patient had spat at him.
Though Dr. Arnold believes that community living is an unrealistic goal in the next year, the hospital is not asking to remove it from the disposition. Dr. Arnold did confirm that Mr. Evans sees community living as a goal that he would like to achieve and that just prior to the assault Mr. Evans was on the verge of being transferred to a general unit.
In response to questions posed to her by counsel for Mr. Evans, Mr. Seymour-Butler, Dr. Arnold testified as follows:
a) Dr. Arnold confirmed that prior to his last ORB hearing in May, Mr. Evans was at level 5 privileges and progressed to level 6 privileges after his annual hearing. Mr. Evans is motivated to reintegrate into the community.
b) Dr. Arnold confirmed that that PDP aims to give as much privileges as possible to patients who are kept in seclusion due to ongoing risk to others.
c) Mr. Evans’ outings from seclusion can vary in time from approximately 15 to 30 minutes though Mr. Evans does, at times, request to return to his room prior to the end of those outings.
d) Mr. Evans’ socialization opportunities are currently limited to his interactions with staff.
e) In order to restore Mr. Evans’ previously enjoyed liberty norm, the hospital will first optimize medication before it can safely start reintegration to the unit. It is not known at this time how long this might take.
- In response to questions posed her by members of the panel, Dr. Arnold testified as follows:
a) It is not clear why Mr. Evans has been refusing antipsychotic medication augmentation while continuing to accept clozapine. Mr. Evans is under the false belief that he has never been on Abilify, though he has been taking it since 2018. He thinks that the hospital is lying to him about this and has at times voiced that he believes that the medication makes him ill and unwell. He does not believe that he derives any benefit from taking clozapine.
b) Though Mr. Evans’ persecutory delusions and threat of violent behaviour are in relation to two specific co-patients, it is not clear if the risk applies to others. Retaliatory violence by Mr. Evans has typically always been towards peers. Dr. Arnold confirmed that Mr. Evans had had no prior interactions with respect to one of the co-patients about whom he has persecutory delusions as this person was new to the unit, and they had never encountered each other before. Mr. Evans generally tends to isolate himself from his peers.
c) The victim of the August 29 assault had no known violent background and Mr. Evans has been known in the past to falsely misidentify people such as an incident recently where he had seen someone and thought that this person had raped him at the age of 11.
d) Dr. Arnold confirmed that the treatment team considered whether it could possibly separate these individuals and put them on other units, although this has not been pursued at this time given that the hospital has opted to try to treat Mr. Evans’ symptoms prior to reintegrating him on the unit.
e) Dr. Arnold confirmed that there were no changes in Mr. Evans’ clozapine levels around the time of the August 29 assault and that he was still taking Abilify at that time. Mr. Evans’ mental state has worsened since stopping Abilify. He is more irritable, more paranoid and whereas he is usually attentive to his hygiene, he has neglected it and refused to take a shower for up to two weeks. As well, Dr. Arnold stated that Mr. Evans’ insight has worsened and that he currently denies that he suffers from schizophrenia and needs treatment.
f) Dr. Arnold confirmed that Mr. Evans has been reassessed by a physician at a minimum once per week, but that currently, Dr. Jones and Dr. Arnold have been seeing him multiple times a week. Prior to being on the PDP, Mr. Evans was being seen twice per day.
- No other evidence was presented.
Analysis and Conclusion
The hospital and the Attorney General maintained their positions as expressed at the outset of the hearing. Mr. Seymour-Butler, on behalf of Mr. Evans, stated that he was not making a submission on the initial restriction and with respect to the ongoing restriction, confirmed that his client would like more freedom and that he is notably communicating with staff about his concerns.
Regarding the law applicable to restriction of liberty hearings, the analytical framework established by Campbell (Re), 2018 ONCA 140, requires the Board to consider the liberty norm and the liberty status of an accused on a restriction. The liberty norm and liberty status for each restriction must be examined to determine the significance of the increase (if any) on the restriction of an accused’s liberty caused by the restriction. In determining the liberty norm of an accused at the outset of each period of restriction, the Board must “take a contextual approach – one that considers the individual’s pattern of liberty in the recent past.” ((Re) Campbell, para. 66). The liberty she/he was actually experiencing (rather than what she/he was entitled to) at the time of the increase is what the Board is to consider, and that “liberty must be of sufficient duration to have become, objectively speaking, the NCR accused’s norm” ((Re) Campbell, para 65).
Having considered all of the evidence tendered at the hearing, and the submissions of the parties, the Board finds that the hospital’s decision to significantly increase the restriction of Mr. Evans’ liberty by placing him in seclusion on the date of August 29, 2025 when he committed a violent assault on a co-patient by striking him in the face with a 3-kilogram dumbbell without known provocation or warning, was reasonable and warranted and represented the least onerous and least restrictive course of action available to the hospital to manage the heightened risk to others. The assault was considerably violent, and it is reported that the victim sustained serious facial injuries.
The evidence of the hospital, both its report and through the oral testimony of Dr. Arnold, persuades us that the hospital is very mindful of Mr. Evans’ previously enjoyed liberty norm and is making reasonable efforts to maximize his privileges. The PDP program, which is currently in place, has Mr. Evans at enjoying multiple outings from seclusion per day.
The fact that Mr. Evans is refusing augmentation medication, that he continues to voice persecutory delusions towards two co-patients, that he has completely lost insight into his illness and the need for medication, all contribute to a heightened risk to others which the hospital has a duty to mitigate. In addition, Mr. Evans is typically a hard person to read though he has been quite open to sharing his ongoing persecutory delusions.
Despite ongoing serious concerns about the risk of assaultive behaviour to other co-patients, the hospital appears to be doing its utmost to ensure that Mr. Evans is afforded reasonable and regular relief from seclusion.
We therefore find that the ongoing restriction is reasonable and warranted and continues to be the least onerous and least restrictive decision to manage the ongoing risk, to the extent that Mr. Evans continues to benefit from regular and frequent seclusion relief, and seclusion should be discontinued as soon as Mr. Evans’ risk can be adequately managed on his regular unit.
DATED this 5^th^ day of November, 2025, at the City of Toronto, in the Region of Toronto.
Ms. M. Labrosse Alternate Chairperson
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Office of the Registrar Ontario Review Board