Re Brett Butterfield, 2025 CanLII 117188

Ontario Review Board

Re: Brett Butterfield

ORB File No: 7894

Hearing held on: Thursday, September 18, 2025

Place of hearing: Ontario Shores Centre for Mental Health Sciences 700 Gordon Street, Whitby

Pursuant to: Section 672.81(1) of the Criminal Code

Before:

Alternate Chairperson: Mr. M.D. Segal Members: Dr. S. Nagari (by Zoom) Dr. M. Choptiany Ms. J. Greenwood Ms. C. Plyley

Parties Appearing:

Accused: Brett Butterfield Counsel: Mr. S.F. Gehl

The person in charge of hospital: Counsel: Ms. A. Marshall

Attorney General of Ontario: Counsel: Ms. N. MacDonald

REASONS FOR DISPOSITION

(Dated November 13, 2025)

Introduction

1. On May 13, 2021, Brett Butterfield was found not criminally responsible on account of mental disorder on a charge of aggravated assault, contrary to the Criminal Code. Mr. Butterfield was conditionally discharged on September 26, 2024, for the first time.

2. On September 18, 2025, Mr. Butterfield appeared before the Ontario Review Board (the “Board”) for his annual hearing at the Ontario Shores Centre for Mental Health Sciences (the “hospital”). Mr. Butterfield's mother was in attendance.

3. The Board had before it as Exhibit 1, a Hospital Report dated September 3, 2025, and by way of background the most recent Disposition and most recent Reasons for Disposition.

4. In preliminary positions, the hospital advanced that the conditional discharge should remain in place. There is a pending referral to the Outpatient Psychosis Clinic of the hospital that was made a few weeks ago. Should the patient be accepted into the clinic, the hospital would be prepared to call an early Board hearing where it would probably support an absolute discharge. Crown counsel supported that approach. The patient’s counsel did not concede significant threat. If for any reason, the Board was of the view that a conditional discharge should continue to be in place, the patient would be requesting that the privilege of indirectly supervised travel passes within Canada and internationally with an approved itinerary for up to seven days be extended to 14 days. The hospital and Crown counsel had no issue with that alternative request. After hearing the evidence and submissions, the Board concluded that on the evidence, significant threat was not made out, and that the Board must award an absolute discharge.

Diagnoses

5. Schizophrenia

Cannabis Use Disorder, moderate, in sustained remission in a controlled environment

Obsessive-Compulsive Personality Disorder

Index Offences

6. The circumstances of the index offence are taken last year’s Reasons for Disposition, as follows:

“Agreed Statement of Facts

Mr. Butterfield began experiencing mental health problems during his first year of university and was assessed by a psychiatrist in the spring of 2018. His symptoms of psychosis worsened by the fall of 2018 and his mental health continued to deteriorate in the winter of 2019. He had increasingly frequent and intense paranoid delusions, believing that most of the women he talked to had been raped or murdered. He believed an evil syndicate was against him and he purchased a hunting knife for protection.

On March 23, 2019, Mr. Butterfield and his mother attended a gun store in Cambridge. He was agitated and wanted to buy a gun for protection, as he was convinced someone was going to break into their condo and shoot them. The owner of the store and victim, Mr. Carr, was present at the time. Mr. Butterfield presented his Possession and Acquisition License (PAL) and inquired about buying a high-capacity firearm and handgun, before pointing out two different shotguns he wanted to buy. When Mr. Carr pumped the gun to demonstrate its function, Mr. Butterfield felt threatened and feared for his mother’s safety. He came to believe that Mr. Carr had raped and murdered his female friends. He briefly left the store to retrieve a hunting knife he had been carrying for protection and re-entered the store, approaching Mr. Carr and slashing him on the head. He yelled at Mr. Carr, “You raped and killed my girlfriend!” Mr. Carr fled towards the back, but Mr. Butterfield pursued him and attempted to stab him. One of the witnesses observed the initial assault and jumped on Mr. Butterfield to try to stop him, but he continued to slash and stab at Mr. Carr’s head, striking him several times. The witness grabbed hold of his wrist and the knife and during the struggle, Mr. Butterfield yelled that “murderers need to be murdered”.

Police arrived on scene, but Mr. Butterfield managed to escape while they tried to place him under arrest, grabbing the knife in the process. He ran out of the business and was located by officers a short while later. He demanded that they shoot him, and he began slashing at his own throat, inflicting significant injuries to his neck. He was transported to Hamilton General Hospital and placed on a Form 1 under the Mental Health Act.

As a result of the attack, Mr. Carr suffered three significant lacerations to his head and neck. One severed several nerves, and he required staples and stitches for his wounds. He also suffered a severe concussion and injured his jaw. After his discharge, his wounds became infected, and he required multiple rounds of antibiotics.

Mr. Butterfield’s mother told police that he was experiencing psychosis at the time and had withdrawn from substances for approximately three days. He had previous psychotic episodes due to substance use and depression. She told them that “he was yelling that my husband was his dad and that he had killed his 17-year-old sister. He was saying that he had also killed innocent children”. He also asked her to “shoot him”.”

Background

7. Mr. Butterfield’s background is well summarized in last year’s Reasons at paragraphs 10 to 16:

“Mr. Butterfield’s personal background and psychiatric history are set out in the Hospital Report and need not be detailed in these Reasons.

Briefly, Mr. Butterfield was born in Markham, Ontario and is an only child. He was significantly bullied during elementary school and as a result attended four different schools. He was diagnosed with attention deficit hyperactivity disorder (ADHD) and was prescribed stimulants for several years.

Mr. Butterfield completed high school and subsequently attended Wilfred Laurier University in 2017. He did not pass either semester in the first year because he got distracted and “fell in with the wrong crowd”. His friend committed suicide and other friends disclosed sexual abuse, and he became preoccupied by a need to protect other people. He was employed as a summer camp counsellor, worked as a landscaper and part-time for FedEx. He has not worked since 2019. Mr. Butterfield began using cannabis at the end of Grade 11 which increased significantly in his first year at university. He has no criminal record.

In 2018, while on vacation with his parents, Mr. Butterfield developed delusional beliefs and Capgras delusions that his parents were imposters who had brought him to the Bahamas to kill him. He believed people were going to hurt him, and at home was verbally aggressive and physical towards his father. He acquired a gun license and talked about buying a gun for protection. He subsequently purchased a knife and pellet gun and kept them in his room at university.

In May 2018, Mr. Butterfield was admitted to hospital on a Form 1 under the MHA with a differential diagnosis of substance-induced psychosis versus schizophrenia. Initially he refused to take prescribed antipsychotic medication but once discharged, did so with his mother’s persuasion. Despite out-patient psychiatric care, his mental state worsened with medication non-adherence. He improved significantly with antipsychotic treatment.

In 2019, Mr. Butterfield’s parents separated, and he lived with his mother. His mother reported that her son began using more cannabis in early 2019, prior to the index offence, and was more depressed and paranoid during this time.

After the index offence, Mr. Butterfield remained under house arrest on certain bail conditions together with a Community Treatment Order (CTO) and was found NCR on May 13, 2021. On August 11, 2021, he was admitted to Markham Stouffville Hospital following an argument with his mother. Mr. Butterfield was subsequently admitted to the Forensic Assessment and Rehabilitation Unit (FARU) at Ontario Shores directly from the psychiatric inpatient service at Markham Stouffville Hospital.

Evidence at Hearing

8. Dr. N. Bhullar, the patient’s outpatient psychiatrist, testified. At the outset, Dr. Bhullar informed the Board that testing had concluded that Mr. Butterfield does not meet diagnostic indicators of OCD.

9. Dr. Bhullar informed the Board that Mr. Butterfield’s has been complying with his medications and that there have been no incidents of concern this past reporting year. The same was true of Mr. Butterfield’s entire time under the Board.

10. Dr. Bhullar confirmed the risk assessment that there was a low to moderate risk of future violence in the context of an absolute discharge.

11. Mr. Butterfield receives strong support from his mother who assists him with his appointments. Dr. Bhullar characterized Mr. Butterfield’s attendance at appointments as intermittent. Mr. Butterfield had full-time employment for some months before being laid off. Mr. Butterfield missed an appointment with Dr. Bhullar and a few with his case manager, Ms. Wheaton. Mr. Butterfield would put his phone on airplane mode. On one occasion, the forensic team reached out to Mr. Butterfield's mother but only heard back from the patient the next day. The forensic team has emphasized the importance of attendance.

12. Mr. Butterfield has suffered from sleep deprivation. Mr. Butterfield has declined recommendations to undergo CBT for insomnia, citing he was too busy. Initially, Mr. Butterfield supported a sleep study. He attended a few sessions but stopped attending.

13. To his credit, Mr. Butterfield did participate in a full assessment of his personality. The decline in engagement is not related to psychosis. It appears to be as simple as a lack of interest and a focus on employment. The concerns about engagement started prior to starting employment.

14. In Dr. Bhullar’s view, Mr. Butterfield’s way of coping with stress is avoidance. Minimization and impression management are also concerns.

15. Mr. Butterfield lives at home with his mother.

16. When Mr. Butterfield contracted pneumonia, he was, according to Dr. Bhullar, reluctant to see his doctor. In the doctor’s view, should psychotic symptoms return, there was a concern that Mr. Butterfield would not be able to recognize them or seek treatment. The doctor acknowledged that the team was going to recommend an absolute discharge but, once concerns about disengagement surfaced, decided that the proper course was to continue to recommend a conditional discharge. If accepted to the Psychosis Clinic, the hospital would call an early Board hearing. It was hoped that the clinic would respond the week after the Board hearing. The clinic is part of the civil side of the hospital but resourced like a Forensic Outpatient Team with a psychiatrist and a social worker available.

17. In recommending a continuation of a conditional discharge, the team considered Mr. Butterfield's history, a very serious index offence, and current coping strategies. If absolutely discharged, Mr. Butterfield would continue to require oversight. If absolutely discharged, Mr. Butterfield would not be a typical client supervised by the clinic.

18. Mr. Butterfield has good insight in all domains. He understands his illness, his symptoms and what triggers risk.

19. There is a concern that placing so much of the care burden on the patient’s mother is inappropriate. That concern is heightened given that Mr. Butterfield has a history of Capgras delusions involving his mother in 2015.

20. It was elicited that if the hearing was a month from now and assuming acceptance by the clinic, the hospital would have recommended an absolute discharge. Dr. Bhullar stressed the importance of putting the final piece in place otherwise recovery and the public safety could be in jeopardy.

21. Patient’s counsel received clarification that at present Dr. Bhullar supervises medication administration. Mr. Butterfield has been medication compliant, drug free and non-violent since September of 2021. Patient’s counsel demonstrated that Mr. Butterfield did see his family doctor when he had pneumonia. He underwent three rounds of antibiotics that did not take root before losing interest in seeing that doctor. Dr. Bhullar could not say Mr. Butterfield would stop his medications on an absolute discharge. The concern was that if stressors mounted, Mr. Butterfield could fall away from treatment.

22. The hospital spent some energy convincing Mr. Butterfield to take on some of the household chores and begin making financial contributions when working.

23. Dr. Bhullar confirmed the commitment of the patient's mother to her son’s wellness.

24. Questions from the Board explored that prior to the referral to the clinic there had been fruitful discussions with Mr. Butterfield's family doctor, Dr. E. Ademgam. The family physician was willing to administer antipsychotic medications. A meeting was held between the forensic team and the family doctor involving the patient and his mother. The family doctor was prepared to participate in further meetings regarding treatment, but disengagement concerns caused the hospital to make a referral to the clinic.

25. In Dr. Bhullar's view there are two principal supports - the forensic team and the patient’s mother. Remove one, and there needs to be another strong pillar.

26. Dr. Bhullar agreed that in the event of an absolute discharge the Mental Health Act was not a perfect vehicle to have Mr. Butterfield assessed, readmitted and stabilized in hospital. The Mental Health Act poses challenges for families in such circumstances.

27. Final submissions echoed preliminary positions. Patient’s counsel stressed that the evidence fell short of demonstrating a significant threat. While the hospital was well-intentioned, a conditional discharge could not be justified on the evidence.

Analysis

28. Mr. Butterfield committed a very serious index offence. He has only been on a conditional discharge for one year. Mr. Butterfield has been medication adherent, substance -free and non-violent since coming under the Board. He has a very committed and protective mother. Mr. Butterfield is motivated to work.

29. What is intriguing about this matter is that the hospital was gearing up to recommend an absolute discharge. Once signs of disengagement appeared, the hospital started to look for a solution that would be a surrogate for the Forensic Outpatient Team. If the Psychosis Clinic accepts Mr. Butterfield, the hospital was candid in acknowledging that it would call an early Board, and it all probability would recommend an absolute discharge. The hospital is certainly well meaning. It is admirable that the hospital wants a solid plan in place to ensure stability and promote safety.

30. There is a nagging concern that Mr. Butterfield’s mother has an outsized burden. The patient’s mother has been targeted when Mr. Butterfield has been unwell.

31. Mr. Butterfield acknowledged that should the Board impose an absolute discharge it will do its utmost to prevail on the clinic’s management to expedite a decision and take on Mr. Butterfield as a client.

32. The central issue for the Board is whether we were satisfied that significant threat continues to the present. Although not entirely free of doubt, the Board is not satisfied that significant threat continues to be present. In coming to that conclusion, the Board has considered that:

• Mr. Butterfield has been medication compliant, violence free and substance free since coming under the Board jurisdiction.

• In the main, Mr. Butterfield has been following treatment advice. Until signs of disengagement began to appear, Mr. Butterfield had been doing well with his forensic team.

• Mr. Butterfield’s mother is a great source of support.

• Mr. Butterfield has shown he is intent on working.

• The Board is also impressed in the willingness of the family doctor to take on oversight of antipsychotic medication and to work with the forensic team to ensure a successful transition.

• The combination of family support and the family physician’s oversight, absent current symptoms of psychosis, satisfied the Board that there is a low risk to the safety of the public and that a sensible plan is in place. Acceptance by the Psychosis Clinic can only add to the protective features that will solidify stability.

33. In all the circumstances, the Board concludes that Mr. Butterfield does not present a significant threat to the safety of the public and that an absolute discharge must issue. The Board observed that Mr. Butterfield, when unwell in past, has resorted to the use of weapons. As the Board finds that an absolute discharge must issue, the weapons prohibition attached to the Board’s Disposition falls away. Assuming no other prohibitions in place, it will fall to Crown counsel to consider whether a preventative weapons ban is available. We wish Mr. Butterfield well.

DATED this 13^th^ day of November 2025, at the City of Toronto, in the Region of Toronto.

Mr. M.D. Segal

Alternate Chairperson

Office of the Registrar

Ontario Review Board