Re: Chantha Sar
ORB File No: 5273
Hearing held on: Thursday, September 25, 2025
Place of hearing: St. Joseph’s Healthcare Hamilton via Zoom
Before:
Alternate Chairperson: Mr. P. Capelle
Members: Dr. G. Nexhipi
Mr. R. Rainboth
Ms. K. Weisbaum
Dr. R. Wood Hill
Parties Appearing:
Accused: Chantha Sar
Counsel: Mr. T.R. McIver
Hospital: Counsel: Mr. S. O’Brien
Attorney General of Ontario: Counsel: Ms. A. Lepchuk
REASONS FOR DECISION
(Dated November 4, 2025)
I. Decision
On October 7, 2009, the accused, Mr. Chantha Sar, was found not criminally responsible on account of mental disorder on a charge of forcible entry, contrary to the Criminal Code. He is currently subject to a Disposition of the Ontario Review Board (“ORB” or the “Board”) dated February 3, 2025, detaining him at the Forensic Psychiatry Program of St. Joseph’s Healthcare Hamilton (“SJHH”, or the “hospital”), subject to a number of terms, conditions and privileges, including the privilege of living in the community in accommodation approved by the Person-in-Charge of the hospital.
A panel of the Ontario Review Board (the “Board”) met on September 25, 2025 via Zoom to review the restriction on Mr. Chantha Sar’s liberties because of his admission to hospital on August 13, 2025 and continuing as of the day of the hearing. The Board’s task was to determine if the Restriction of Liberty (“ROL”) imposed on Mr. Sar was necessary and appropriate, as well as the least restrictive and least onerous intervention in the circumstances, both at the time it was imposed and throughout its duration.
For the reasons set out below, the Board concluded that the restriction on Mr. Sar’s liberties when he was admitted to hospital was necessary and appropriate, as well as the least restrictive and least onerous intervention in the circumstances, both at the time it was imposed and throughout its duration. The panel decided it was necessary and appropriate for Mr. Sar to be admitted to hospital because his behaviour clearly indicated that he was not at his baseline mental state and that his medication regimen was not optimized accordingly. The ongoing detention was and continues to be necessary to return Mr. Sar to baseline so that he may return to living in the community with his risk appropriately managed.
Overview
Mr. Sar was admitted to SJHH on August 13, 2025. As described in the ROL Report to the Board dated September 17, 2025, in the weeks prior to his admission, Mr. Sar displayed a gradual decline in community function and cooperation. His attendance at Assertive Community Treatment (“ACT”) activities declined and then ceased. The Forensic Outpatient Program noted “more open grandiose and religious talk and less receptiveness to redirection.” The ACT team psychiatrist, being Mr. Sar’s prescriber, wanted to change Mr. Sar’s injection cycle of his antipsychotic medication from 12 to 10 weeks to avoid “end-of-cycle drift”, however, Mr. Chanthea Sar, who is Mr. Sar’s brother and substitute decision-maker (“SDM”) did not agree and declined to consent. When he was assessed at the hospital on the day of admission, Mr. Sar was not at his baseline. Given his apparent decline and the worsening of his symptoms/psychosis in the community, he was admitted. His admission continued as of the day of the hearing.
By letter dated August 25, 2025, the Person-in-Charge of the hospital provided notice pursuant to s. 672.56 (2) of the Criminal Code that the duration of the increased restriction on Mr. Sar’s liberties had exceeded 7 days.
On September 25, 2025, a panel of the ORB convened a hearing via Zoom videoconference to conduct a review of restrictions on Mr. Sar’s liberties pursuant to s. 672.81(2.1) of the Criminal Code. Mr. Sar attended the hearing and was represented by his counsel, Mr. Thomas McIver.
Mr. O’Brien appeared on behalf of the hospital and Ms. Lepchuk appeared on behalf of the Attorney General of Ontario.
Without Prejudice Positions of the Parties
At the commencement of the hearing, all parties were canvassed as to their initial recommendations to the Board.
Counsel for the hospital, Mr. O’Brien, stated the position that the Restriction of Liberty (“ROL”) imposed on Mr. Sar from August 13, 2025, to the date of the hearing was necessary and appropriate and in the circumstances of the case, represented the least onerous and least restrictive decision available.
On behalf of the Attorney General, Ms. Lepchuk stated agreement with the position of the Hospital.
Counsel for Mr. Sar, Mr. McIver, stated that he wished to reserve his position until after the evidence was reviewed. He stated he was not sure that bringing Mr. Sar back to the hospital was the least restrictive option but wanted to reserve until he had heard the evidence.
Issues
The Board’s task was to determine if the Restriction of Liberty (“ROL”) imposed on Mr. Sar was necessary and appropriate, as well as the least restrictive and least onerous intervention in the circumstances, both at the time it was imposed and throughout its duration. Pursuant to the decision of the Ontario Court of Appeal in Regina vs. M.L.C. (2010 ONCA 843), the Board must consider not only the reason for the restriction and the initial decision to impose a restriction but also the ongoing circumstances of the accused for the period of time that the restriction remains in place including up to the time of review. The initial restriction of liberty and ongoing restriction of liberty must be the least onerous and least restrictive necessary for public safety and for the accused.
In other words, regarding Mr. Sar’s hospitalization and continued stay at the hospital, the precise issues are:
i) Was the initial restriction of Mr. Sar’s liberty by virtue of his rehospitalization on August 13, 2025, necessary and appropriate, as well as the least restrictive and the least onerous intervention?
ii) If so, was the ongoing restriction on Mr. Sar’s liberty by virtue of maintaining him at the hospital from August 13, 2025 and continuing as of the day of the hearing necessary and appropriate, as well as the least restrictive and the least onerous intervention?
Index Offence
- The following are the facts related to the index offence, taken from the most recent Reasons for Disposition, dated March 25, 2025:
"On Monday, May 25th, 2009 at approximately 12:48 p.m. the accused Chantha SAR went into the backyard of 26-2 Weiden Street, in the City of St. Catharines. The accused cut the screen door in the rear of the townhouse, enabling him to unlock the door: The accused entered the townhouse and began to walk up the stairs of the townhouse. The accused was found by the occupants of the townhouse [K.D.] and (A.V.] walking up the stairs. The accused then walked down the stairs and exited the front door to the unit.
[K.D.] and [A.V.] contacted Police and observed the accused standing watching them from the backyard of 5 Louis Avenue. The immediate area was searched with negative results. Police spoke with the superintendent, Loraine JAMES of 5 Louis Avenue, who stated that a male matching that physical description resides in unit 105, which is the same unit that the girls had watched the accused enter. Police were let into unit 105 by the accused’s brother Chanthia SAR. Police located the accused within the unit and placed him under arrest for Break and Enter with Intent. While Police were placing the accused in the rear of a marked Police vehicle, a female identified as [A.K.] advised that the accused had followed her and her young child around the park just north of 5 Louis Avenue.
Police attempted to obtain a statement from [A.K.] at the time of this writing; however, they were not able to get in contact with her.
Police re-attended 26-2 Weiden Street and obtained a statement from [K.D.] and [A.V.]. It should be noted that the two females looked to be approximately 15-16 years old, much younger than their actual age.
Diagnosis
- Mr. Sar is diagnosed with schizophrenia and cannabis use disorder, in remission.
Evidence
The evidence at the hearing consisted of the hospital report provided to the Board for the January 29, 2025 annual hearing, the ROL report dated September 17, 2025, and the oral evidence of Dr. Shariati.
Dr. Shariati testified that he is Mr. Sar’s attending psychiatrist and has had that role for at least two years. He had read the hospital report from January 2025, provided to the Board for Mr. Sar’s annual hearing on January 29, 2025, and adopted its contents. He is also the author of the ROL report dated September 17, 2025, which was filed for the hearing, and adopted its contents.
Dr. Shariati provided an encapsulated version of the ROL report as to why Mr. Sar’s ROL was necessary. Mr. Sar was living in the family home in St. Catherines with his mother and brother, Mr. Chanthea Sar, who is also Mr. Sar’s SDM. During the weeks prior to the admission, there was a clear decline in Mr. Sar’s functioning in the community. Mr. Sar had stopped attending the outpatient programs he had agreed to attend through ACT and Niagara programing. He was more openly grandiose and less redirectable. The ACT psychiatrist, Dr. Soren, who was the main prescriber for Mr. Sar in the community, had recommended shortening the cycle of Mr. Sar’s injectable antipsychotic, Paliperidone Palmitate, from 12 to 10 weeks to avoid the decrease in efficacy of the medication towards end of the 12-week cycle, which was resulting in increased symptoms of psychosis.
On August 13, 2025, Mr. Sar was assessed in clinic at the hospital and admitted. His mental state was markedly different from his baseline. He was flat and had an intense fixed stare. He was more explicit and bolder in terms of his long-standing beliefs about being God and having power over people, including over his psychiatrists. The ACT psychiatrist, Dr. Soren, had recommended to Mr. Sar’s brother and SDM a change from a 12-week to a 10-week cycle, but the SDM declined to give consent. Mr. Sar’s behaviours indicated his risk to the public was increased and he was admitted for further monitoring and management. Mr. Sar was cooperative with the admission.
Dr. Shariati testified that with respect to Mr. Sar’s shift away from baseline, the mainstay of the hospital intervention included increased monitoring, i.e., clinical checks by the clinical nurse every 15 minutes. During the first few days of the admission, Mr. Sar was hypoactive, displayed limited socialization and engagement, poverty of speech, and refused all medication (both psychiatric and medical). His ongoing refusal of medication was a concern, because his medication works slowly, which meant that his condition might initially become worse. The SDM came to understand the hospital’s concerns that resuming community living would be hampered if Mr. Sar declined further and did not receive the appropriate medication. The SDM then accepted the injection schedule change from 12 to 10 weeks. The SDM also agreed to oral medication for two weeks to speed up the effectiveness of Mr. Sar’s antipsychotic.
Dr. Shariati stated that upon his admission to hospital, Mr. Sar improved within the first two weeks, i.e., he became more engaged, smiled more and displayed improvements in insight. As of the day of the hearing, he continued to progress towards his baseline. Going forward, Mr. Sar will now receive his injectable antipsychotic every 10 weeks. Some of Mr. Sar’s initial response during the first two weeks of the admission was from the oral medication, however, Mr. Sar is responding and continues to improve.
In response to a question from Mr. O’Brien as to when the treatment team anticipated that Mr. Sar would become able to return to the community without endangering the safety of the public, Dr. Shariati stated that a meeting on September 24 with himself, Mr. Sar, Mr. Sar’s family, his social worker (Ms. Karen Derocher) and his case worker (Ms. Jodie Alderson) had gone very well. The SDM accepted the proposal for discharge for a six to eight week transition discharge plan, including predictable access to the home for ACT program team and the forensic outpatient program team (once a week for each), and a taxi for Mr. Sar to come to the hospital to check in once a week, attend one ACT program per week and receive his injections every 10 weeks. The necessity of decorum, i.e., respectful communication among all parties, was also emphasized and achieved at the meeting. Admission criteria were clearly outlined, including if there is loss of monitoring/visits by forensic program staff, a change of mental status/behaviour, unreasonable stopping of program attendance (e.g. if there is a pattern of absence), or non-adherence to medication.
Dr. Shariati testified that discharge transitioning for Mr. Sar is planned to begin on October 6, 2025. This is the most reasonable timing for a start date, given the process that is routinely followed. Mr. Sar and his family agree with the plan for discharge. While the details for Mr. Sar have yet to be finalized, typically transitioning begins with 24 hours overnight passes to home, increasing over the weeks to 48-hour and 72-hour passes, and then weekly check-ins with team members as part of home visits, or in hospital. A reasonable plan will be worked out with Mr. Sar and his family.
Dr. Shariati testified that, going forward, the hospital’s expectation is that Mr. Sar should attend all appointments, work cooperatively with the forensic outpatient and ACT teams, take his medications on time (both his injectable and oral antipsychotic), adhere to urine drug screening, participate in ACT programs and abstain from the use of substances.
Dr Shariati stated that in his opinion, there was no alternative action that the hospital could have reasonably taken on August 13, 2025, given that Mr. Sar had experienced deterioration over several weeks, including symptoms that were previously associated with increased risk, i.e., grandiosity, psychosis and delusions, as well as the missed opportunity for optimizing his medication, and the questions around access. In all the circumstances, there was no alternative at admission or ongoing up to this point.
In response to questions from the Crown regarding the SDM’s reason for objecting to changing the schedule for Mr. Sar’s injectable antipsychotic from 12 to 10 weeks, Dr. Shariati testified that it is hard to say. Dr. Shariati stated that there may be a bit of baseline mistrust by the SDM regarding the hospital and psychiatric treatments. There is some mistrust of the hospital, but that fluctuates. The SDM acknowledges treatment is helpful to Mr. Sar but has worries about “medical experimentation” and admission without good reasons. Dr. Shariati stated that he had explained the reasoning behind the treatment schedule to the SDM at the meeting the day before the hearing, after which the SDM agreed there has been deterioration and that medication is helpful. It is not clear that the SDM would have consented to the plan for medication optimization without the ROL admission, and for Mr. Sar to be discharged, as the SDM had declined consent on two previous occasions. Nevertheless, the team is now confident that they can move ahead with the updated plan of treatment.
Dr. Shariati stated that he did not recall the ACT program in which Mr. Sar had participated. Dr. Shariati testified that he did not recall why Mr. Sar had not attended sessions for several weeks, nor did he recall if the ACT team had investigated why he did not attend. The SDM had indicated to Dr. Shariati that he had not noticed a decline in his brother but was not aware that Mr. Sar was not attending programs, although he seemed to realize that his brother’s absence from programming was a problem.
Dr. Shariati testified that as of September 25, 2025, the question of whether Mr. Sar has returned to his baseline will need to be tested in the community, but he believed that Mr. Sar is close to baseline. Mr. Sar was recently approved for privileges to attend programs and be on hospital grounds on his own. On October 6, 2025, Mr. Sar will begin a transition back to the community in a graduated fashion, beginning with overnight passes to his home, followed by 48 hours overnight, moving to seven days, and, if all goes well, he will eventually be returned to the community.
Dr. Shariati testified that Mr. Sar has been taking his injectable antipsychotic medication every 12 weeks, but SDM refused optimizing to 10 weeks, for better control of his illness; he also takes Seroquel, another oral antipsychotic, and had told the team that he had been taking it, however, the team was concerned that Mr. Sar was not taking this medication, which was subsequently confirmed in urine tests.
Dr. Shariati testified that at the time of writing the report for the hearing, the SDM would not consent to the change from a 12-week to a 10-week cycle of injections, leaving the situation at a standstill. However, in a productive meeting with the social worker and the family on September 24, an agreement was reached in relation to facilitating home meetings with the team and Mr. Sar’s treatment plan.
In response to questions from the panel, Dr. Shariati testified that Mr. Sar’s mother wants her son to be home. She may not have understood why Mr. Sar was admitted. She has stated to Dr. Shariati that given her son has had “god delusions” for a long time and asked why he was being admitted now. Dr. Shariati has explained to Mr. Sar’s mother that it is the intensity and how this is impacting his current behaviour. The team will continue to be vigilant in ensuring the family understands Mr. Sar’s condition and shares concern that in moments of crisis/disagreement, it’s important for them to understand if Mr. Sar is not doing well, maintain a good working relationship with the treatment teams, and maintain visits, urine screens and the medication schedule.
Dr. Shariati testified that Mr. Sar takes Quetiapine XR, 50mg nightly, reduced from 150mg due to sedation as a side effect and that this might be a contributing factor to Mr. Sar sleeping a lot, although he has been bored on the ward and many patients sleep more due to boredom. It was added at the same time as Mr. Sar began to receive Invega Sustenna (Paliperidone.) It may take a few 10-week cycles of the injectable medication for it to take effect, so more Quetiapine might be offered if symptoms come up or there are other concerns, if Mr. Sar’s symptoms increase and his SDM consents.
With respect to whether a four-week injection cycle might be revisited, Dr. Shariati testified that the team hopes that the current 10-week regimen will be effective, adding that it has worked well for other patients and the team wants to give this plan a chance. Timing of the involvement of the ACT psychiatrist still needs to be clarified; the team makes daily rounds and the team will likely see Mr. Sar weekly. However, Dr. Shariati stated that he will be taking back prescriber duties in consultation with the ACT team psychiatrist.
With respect to whether the position of the SDM in refusing optimization of medication might have been complicated by dealing with both Dr. Shariati and the ACT team psychiatrist, Dr. Shariati testified that he did not think that was the case. Rather, the family certainly want Mr. Sar to do well, however, Dr. Shariati stated he believes that refusal by the SDM happened because of the family’s initial position and concern is that hospital oversteps boundaries and that the psychiatrist was seen to overstep by overmedication, and in the absence of sufficient dialogue, “things can go sideways.” If there is the opportunity for discussion, the family is often aligned with the team.
Dr. Shariati testified that the SDM had expressed concerns about the team “doing experiments” on Mr. Sar. However, Mr. Sar’s main concern regarding his antipsychotic medication was sedation and there are no other acute health related concerns regarding Mr. Sar at this time. Dr. Shariati stated that currently, the SDM is agreeable to the team’s proposal about how to optimize Mr. Sar’s treatment, particularly because of the associated discharge plan.
Dr. Shariati testified that Mr. Sar came to Canada with his family in 1989 via Thailand from Vietnam. With respect to any relevant cultural issues from the family related to Mr. Sar’s mental health, in the meeting on September 24, when talking to the social worker, the family, and in particular Mr. Sar’s mother, opened up about their history and how challenging it was. This provided the team with greater understanding of the family context. Dr. Shariati testified that with respect to any culturally based preconceived notions about mental health and how it should be treated based on the family’s cultural background, going forward, including a cultural interpreter in discussions with the family might be a positive addition and the team could certainly consider the option going forward.
There were no further questions and no further evidence from the parties.
Mr. McIver reserved providing his position until after hearing the submissions of the other parties. He was not yet clear on the question of whether the ROL was warranted.
Closing submissions
For the hospital, Mr. O’Brien submitted that the treatment team has had a long relationship with Mr. Sar going back to 2009. Dr. Shariati has been Mr. Sar’s attending psychiatrist for two years. The hospital has significant experience with Mr. Sar and can recognize concerning behaviours when they develop. He had a “solid” situation as an outpatient, having the assistance of the outpatient program and Niagara ACT team. The team first noted a pattern of non-adherence, including Mr. Sar’s dropping attendance at ACT programs. The ACT psychiatrist noted a marked change in Mr. Sar’s behaviour and the corresponding need to move from a 12-week to 10-week injection cycle, which was also noted by the hospital team. There is no need to doubt the evidence of Dr. Shariati that Mr. Sar needed to be brought in given an obviously concerning shift in Mr. Sar’s behaviour. Following the admission, Mr. Sar began to gradually improve, not immediately, but also not terribly slowly. The team then obtained consent for reduction to a 10-week injection cycle, which produced a return to baseline. Based on that, and incorporating input from and to family, there is now a plan for Mr. Sar to return to the community that is both careful but also not overextended, that is scheduled to begin soon after the hearing. The current plan is to get Mr. Sar back into the community, based on changes observed to date and changes made to his care plan.
Mr. O’Brien submitted that based on the totality of observations of Mr. Sar prior to his admission, and in keeping with Dr. Shariati’s evidence, the hospital moved with alacrity in keeping with the terms of Mr. Sar’s Detention Order. Mr. Sar had veered significantly off his baseline, which was obviously concerning. As such, the ROL was necessary and appropriate, as well as the least onerous and least restrictive option at the time the ROL was implemented. The plan of care is working and Mr. Sar should be back in the community and family home in a reasonable amount of time. As such, the ongoing ROL is necessary and appropriate, as well as the least onerous and least restrictive option.
On behalf of the Attorney General, Ms. Lepchuk submitted that the Crown echoed the submissions of the hospital. She noted that in his 2022 risk assessment, Mr. Sar was found to be moderate risk with intensive case management, including participation in the ACT program. As such, when one of his supports falls away, based on his history, he is at risk of deteriorating quickly. In the circumstances, there was no other option but to admit Mr. Sar to return him to baseline given his risk to the public. As such, the ROL was necessary and appropriate, as well as the least onerous and least restrictive option.
On behalf of Mr. Sar, Mr. McIver submitted that with respect to Mr. Sar not attending programs, Dr. Shariati did not know the reason for Mr. Sar’s absences from programs. Related concerns should have been raised with Mr. Sar and not used as a basis for which Mr. Sar was admitted. The SDM did not consent to a shift in time frame for medication injections. Mr. McIver further submitted that given that Mr. Sar had been in the community for an extended period, being brought back to hospital was onerous and severe. Mr. Sar has “turned around relatively quickly.” Mr. Sar would only deteriorate quickly if there were other issues, i.e., if he was on no medications and/or using substances. However, even though there were recommendations for a change in his medication regimen, Mr. Sar was adherent to taking medications. More could have been done to keep Mr. Sar in the community while addressing the concerns of the team. Mr. McIver did not agree with the position of the hospital, noting it was not quite as “clear cut” as described by the hospital. The team took Mr. Sar’s non-attendance in programs as a red flag, but without investigating the reasons why. As such, in the circumstances, the ROL was not the least onerous option, nor was it appropriate in all the circumstances.
Analysis
In considering each issue, the Board reviewed the hospital record (January 2025, provided to the Board undated for the purposes of the January 29, 2025 annual hearing), the Reasons for Disposition (March 25, 2025), the ROL Report (September 17, 2025) as well as the viva voce evidence of Dr. Shariati.
The Board accepts the testimony of Dr. Shariati, the Hospital Report and the ROL Report and finds merit in the recommendation of Counsel for the hospital, Mr. O’Brien, and Counsel for the Attorney General, Ms. Lepchuk.
The initial restriction of Mr. Sar’s liberty by virtue of his hospitalization on August 13, 2025, was necessary and appropriate, as well as the least restrictive and the least onerous intervention.
During the weeks prior to the admission, there was a clear decline in Mr. Sar’s functioning in the community. He stopped attending outpatient programs and was more openly grandiose and less redirectable. He also had increased symptoms of psychosis related to end-of-cycle decompensation under his 12-week schedule of injectable antipsychotic medication. As Dr. Shariati testified, upon admission on August 13, 2025, Mr. Sar’s mental state was markedly off his baseline. Mr. Sar was more explicit and bolder in terms of his long-standing beliefs about being God and having power over people, including over his psychiatrists, which are historical symptoms of his psychosis and associated with his increased risk to the public. His ongoing refusal of medication was a concern, because his medication works slowly, which meant that his condition might initially become worse. In hospital, careful ongoing monitoring was possible. As the SDM came to understand, if Mr. Sar declined further and did not receive the appropriate medication, his return to the community would be hampered. As noted by Ms. Lepchuk in her closing submissions and in the Reasons for Disposition dated January 29, 2025, according to Mr. Sar’s 2022 psychological risk assessment, which was still considered valid and is included in the hospital report, “His risk for violent reoffending is considered moderate with intensive case management combined with external control. His risk for psychological harm is considered high.” The admission was essential for Mr. Sar’s return to baseline.
In his final submissions, Mr. McIver presented concerns that the hospital and teams could have made more in-depth enquiries as to the reasons why Mr. Sar had not attended programs. Mr. McIver submitted that this was part of the rationale for admitting Mr. Sar, but was not the least onerous option, i.e. the team could have made enquiries as to the reasons for Mr. Sar’s absences, which may have led to an approach that would have been less onerous for Mr. Sar.
The panel considered Mr. McIver’s concerns but found that the team was justified in admitting Mr. Sar, given that Mr. Sar was historically inclined to decompensate quickly, which was already happening in the weeks prior to the admission, as evidenced by his behaviours and symptoms. Of note and consistent with his most recent psychological risk assessment, Mr. Sar’s index offence of Forcible Entry in 2009 occurred during a period of acute psychosis. Accordingly, Mr. Sar’s increased symptoms corresponding to the team’s concerns about his risk to the public. The lack of adherence to his appropriate medication regimen, and his absence from programs—for whatever reasons—meant significant diminishment of tools for case management and external control key to managing Mr. Sar’s psychosis and corresponding risk for violent reoffending and psychological harm. Concurrently, there were limits on the team’s ability to treat Mr. Sar in the community, given the refusal of the SDM to change Mr. Sar’s medication cycle timeframe.
The ongoing restriction on Mr. Sar’s liberty by virtue of maintaining him at the hospital from August 13, 2025 continuing as of the day of the hearing on September 25, 2025, was necessary and appropriate, as well as the least restrictive and the least onerous intervention.
- The Board accepted the testimony of Dr. Shariati with respect to Mr. Sar’s ongoing stay in hospital, the duration of the stay and the plan for Mr. Sar’s reintegration back into the community. Mr. Sar was not considered safe to return to the community until his mental state returned to baseline, with his medication optimized according to a 10-week injection schedule and a plan in place for transitioning back to the community that included regular visits by the team and routine visits to the hospital. Two weeks of concomitant oral medication was also required. The approach included a six to eight week discharge plan, establishing predictable access to the home for ACT program team and the forensic outpatient program team and transportation for hospital check-ins and injections every 10 weeks. Admission criteria are clearly outlined. The renewed relationship between the team and Mr. Sar’s family will facilitate the success of the plan. It provides for a gradual transition for Mr. Sar back to his home and strikes a balance between ensuring he reaches a stable state while getting him back to the community as soon as possible.
Conclusion
Considering the foregoing, the panel finds that the restriction placed on Mr. Sar’s liberties occasioned by his admission to hospital on August 13, 2025, and continuing as of the day of the hearing on September 25, 2025, was necessary and appropriate, as well as the least onerous and least restrictive intervention available to the hospital in the circumstances, both at the time it was imposed and throughout its duration.
The Board wishes Mr. Sar well. The panel notes that through the efforts of the team, Mr. Sar’s SDM now better understands his brother’s condition and the hospital’s concerns and has agreed to the new treatment regimen for Mr. Sar. The panel hopes that this renewed rapport between the team and the family will facilitate Mr. Sar’s best interests going forward, particularly as the team continues to learn about and appreciate the cultural perspectives of Mr. Sar, his mother and brother, and explores the possibility of including a cultural interpreter in discussions with the family.
In making this decision, the panel has considered the need to protect the public from dangerous persons, Mr. Sar’s current mental state, his reintegration into society and his other needs.
DATED this 4th day of November 2025, at the City of Toronto, in the Toronto Region.
Ms. K. Weisbaum
Legal Member
Office of the Registrar
Ontario Review Board