Ontario Review Board
Re: Cornelius B. VanWoerden ORB File No: 6512 Hearing held on: Wednesday, November 5, 2025 Place of hearing: St. Joseph's Healthcare Hamilton West 5th Campus, 100 West 5th Street Pursuant to: Section 672.81(2) of the Criminal Code
Before: Alternate Chairperson: Ms. L. Banks Members: Dr. W. Johnston Dr. G. Nexhipi Ms. B. Little
Parties Appearing: Accused: Cornelius B. VanWoerden Counsel: Mr. F. Bernhardt (by Zoom video-conference) The person in charge of hospital: Counsel: Ms. L. Barney Attorney General of Ontario: Counsel: Mr. B. Adsett
REASONS FOR DISPOSITION
(Dated November 13, 2025)
Introduction:
[1]. On April 9, 2014, Mr. Cornelius B. VanWoerden was found not criminally responsible on account of mental disorder (“NCR”) on a charge of aggravated assault, contrary to the Criminal Code of Canada (the “Criminal Code”). Since that time Mr. VanWoerden has been subject to Dispositions of the Ontario Review Board (“ORB” or the “Board”) most recently a Disposition dated April 3, 2025, pursuant to which he was discharged subject to a variety of terms and conditions including that he reside at a specified address in Hamilton and that he report to the person in charge of St. Joseph’s Healthcare Hamilton (“St. Joseph’s” or the “hospital”) as required.
[2]. By letter dated October 14, 2025, the hospital advised the ORB that Mr. VanWoerden had eloped from the hospital and that the hospital was of the opinion that his risk could no longer be managed under a Conditional Discharge Disposition. Accordingly, the hospital requested that the Board convene an early hearing to review Mr. VanWoerden’s Disposition.
[3]. On November 5, 2025, Board convened an early hearing to conduct a review of Mr. VanWoerden’s Disposition pursuant to s. 672.81(2) of the Criminal Code. Mr. VanWoerden was not present at the hearing but was represented by counsel, Mr. F. Bernhardt, who appeared by video-conference and requested that his client be excused from attendance at the hearing. Accordingly, the Board issued an order under s. 672.5 (10)(a) of the Criminal Code excusing Mr. VanWoerden from attending the hearing.
[4]. The issues to be decided at this hearing are whether Mr. VanWoerden meets the test of posing a significant risk to the safety of the public and, if so, a decision as to the necessary and appropriate Disposition to be made in the circumstances, including conditions to be attached to that Disposition, bearing in mind the four factors set out in s. 672.54 of the Criminal Code.
[5]. For the Reasons that follow, the Board found that the threshold for significant threat is met and the Board ordered that the necessary and appropriate Disposition is a Detention Order Disposition, on the terms set forth at the conclusion of these Reasons.
Position of the Parties:
[6]. At the outset of the hearing, all parties were canvassed as to their initial recommendations to the Board. Counsel for the Hospital recommended that Mr. VanWoerden continued to represent a significant threat to the safety of the public and that the necessary and appropriate Disposition was a Detention Order.
[7]. Counsel for the Crown supported the hospital’s recommendation.
[8]. Mr. Bernhardt indicated his client’s position was in support of the hospital’s recommendations in all respects and conceded the issue of significant threat.
[9]. All parties maintained their initial joint recommendation in closing submissions.
Index Offence:
[10]. The circumstances giving rise to the index offence are extracted from the Hospital Report to the Ontario Review Board dated November 3, 2025 (“the Hospital Report”), as follows:
“On Thursday, December 26, 2013, the accused Cornelius VanWoerden, 1980-09-23, approached the victim’s [male victim’s name] age 63, pick-up truck as it exited the drive through at Tim Horton’s located at 773080 Oxford Highway 59 in Norwich. [The male victim’s name] rolled down his window as he thought the accused was looking for directions as he did not have any shoes on. The accused opened the door of the victim’s pick-up truck, pulled the victim out of the truck and beat him unconscious and left him in a pool of blood. The accused then went into Tim Horton’s where he was refused service as a result of the assault and told to return to his room at the Glide Inn Motel, next door to the Tim Horton's.
While police were on scene investigating, the accused returned to the parking lot wearing only a pair of jeans. Police observed that the accused's hands were covered in blood and rested the accused for Assault Causing Bodily Harm.
The accused and the victim do not know each other; there was no prior altercation or words exchanged. This was a completely unprovoked random and violent assault. The accused showed no remorse for his actions.
As a result of the attack, the victim suffered three facial fractures, which will require surgery to repair. The victim also suffered lens subluxation, which is trauma to the eye…”
Personal Background:
[11]. As the Hospital Report provides extensive details relating to Mr. VanWoerden’s personal, criminal and psychiatric history, there is no need to repeat that information in these Reasons. Briefly stated, Mr. VanWoerden is a 45-year-old man who is single with no dependents. He was born in the Netherlands and immigrated to Canada with his family when he was three years old.
[12]. Mr. VanWoerden is from a large family (originally of 16 siblings). When Mr. VanWoerden was 23 years old, his parents returned to the Netherlands, but continued to visit Canada annually. Mr. VanWoerden’s mother died on February 19, 2018. His father continues to reside in the Netherlands.
[13]. Mr. VanWoerden has a great deal of family support. His brother (Henk) is an Approved Person and serves as Mr. VanWoerden’s substitute decision maker (“SDM”).
[14]. Mr. VanWoerden did not complete high school. Mr. VanWoerden has a particular interest and skill working with horses. Since coming under the ORB, he has maintained that interest, painting pictures of horses and expressing a wish to volunteer on a farm or at a stable.
[15]. Mr. VanWoerden does not have a history of substance use. According to the Hospital Report, Mr. VanWoerden has consumed alcohol and has used a little marijuana but he denied any other illicit drug use.
Criminal History:
[16]. Prior to the index offence, Mr. VanWoerden had a criminal record for assault and causing a disturbance in 2009. Other incidents where police were called to deal with Mr. VanWoerden’s behaviours were addressed without criminal charges.
Psychiatric History:
[17]. Mr. VanWoerden’s first psychiatric admission occurred when he was eighteen years old and experienced a psychotic episode for the first time. The Hospital Report also indicates a family history of mental illness.
[18]. Between then and the commission of the index offence, Mr. VanWoerden was admitted to hospital multiple times due to a decline in his mental health. During his many admissions, he has presented as depressed, suicidal, and delusional. His delusions have included grandiose and religious content and he has experienced visual hallucinations and believed that he has heard God's voice. Mr. VanWoerden has a long-standing history of non-adherence to antipsychotic medications which has precipitated rapid declines in his mental health.
[19]. Mr. VanWoerden’s current diagnosis is Schizoaffective Disorder.
Evidence at the Hearing:
[20]. Dr. O. Kolawole testified at the hearing to supplement the documentary evidence available to the Board. Dr. Kolawole advised that he has been Mr. VanWoerden’s attending forensic psychiatrist since approximately 2023.
[21]. Dr. Kolawole reminded the panel that Mr. VanWoerden was discharged from the hospital on December 7, 2020 to reside at Indwell Residence in Hamilton, a 24-hour residential care facility. His oral medications were administered by housing staff. He was seen in the community by the Forensic Outpatient (“FOP”) team twice a week. He had been cooperative with the team and has attended appointments regularly.
[22]. The doctor reported that Mr. VanWoerden was on October 12 or 14, 2025, deemed incapable to consent to treatment and, under the authority of his SDM, he currently receives a long-acting injection of the antipsychotic medication, Abilify Maintena, every 28 days, together with daily oral doses of Paliperidone/Invega, Epival, Clonazepam and Lithium Carbonate. He receives evening medications of Seroquel and Imovane for sleep.
[23]. Mr. VanWoerden’s medications had been administered by the residence staff at Indwell but he is responsible for attending on time for the medication. He receives bi-weekly bloodwork to monitor his Lithium and Epival levels due to his fragility and historical fluctuations in his levels.
[24]. Dr. Kolawole testified that Mr. VanWoerden has continued to require support and prompts around personal hygiene and attending to the cleanliness of his room.
[25]. The Hospital Report notes that it continued to be difficult to engage Mr. VanWoerden in structured daily activities as he has difficulty following through with his stated intentions. He primarily spent his time in the community: sleeping, attending scheduled appointments with his team, smoking cigarettes, going for walks, or running errands for co-residents at Indwell.
[26]. Over the year in review, Mr. VanWoerden had two voluntary hospital readmissions. He was initially discharged from the hospital on August 5, 2025, after having had a 9-week admission (since May 14, 2025) for medication changes and stabilization. On August 12, 2025, Mr. VanWoerden was voluntarily readmitted to the hospital (Orchard 3 unit). When he presented to the Forensic Outpatient Clinic, he expressed that he wished to be readmitted to due to feeling anxious and distressed about the living conditions at Indwell. Although appearing tired and stressed, with circumstantial, tangential, and disorganized thought process, no delusional thought content was noted.
[27]. By the end of September 2025, Mr. VanWoerden started to present with a significant deterioration in his mental health. He exhibited thought disorganization and paranoia and delusions regarding hospital staff allegedly talking about him and making fun of him. He also expressed grandiose delusions. In response to his symptoms of paranoia, he presented with agitation and aggressive behaviour towards hospital staff. Medication adjustments were made to better address his ongoing symptoms.
[28]. On October 10, 2025, Mr. VanWoerden did not return from his therapeutic pass on time and notice of his unauthorized leave of absence (“ULOA”) was sent to police. He was returned at 1 a.m. by police officers who found him in the London area.
[29]. On October 11, 2025, a Form 1 under the Mental Health Act (“MHA”) was issued to involuntarily detain Mr. VanWoerden in hospital. He had been refusing his scheduled medication since the evening on October 12, 2025 and, as a result of his medication non-compliance, his mental health deteriorated.
[30]. A Form 3 under the MHA was issued on October 14, 2025 to extend his admission.
[31]. Mr. VanWoerden was placed in seclusion on October 16, 2025, given that he was posing an imminent risk of violence towards others with heightened aggression and agitation. He was presenting with heightened symptoms of his psychotic illness.
[32]. On October 21, 2025, Mr. VanWoerden was successfully trialed out of seclusion despite presenting as chronically psychotic at that time. At the present time, he presents as more settled and regulated; however, he continues to exhibit residual psychotic symptoms, including, disorganized and tangential thoughts and paranoid ideation.
[33]. A pre-board meeting was conducted on October 23, 2025 and the decision was made to recommend that his Disposition be changed to a Detention Order at his upcoming ORB hearing given the heightening of his risk profile.
[34]. A Form 4 under the MHA was later issued on October 27, 2025 to further extend his involuntary detention in hospital.
[35]. Pages 81 to 86 of the Hospital Report includes details of many notable incidents of concern between August 13 to October 23, 2025. While the report contains much detail around these many incidents, we highlight the following:
- On October 7, 2025, a few days prior to his ULOA episode, Mr. VanWoerden got temporarily trapped in the sallyport area and when free, he presented with heightened agitation and paranoia regarding staff and punched the care desk glass at the nursing station and banged his fist on the counter. Security was phoned for support and he was given PRN medications for agitation and break-through psychosis.
- On October 10, 2025, the day of the ULOA, Mr. VanWoerden advised that he was not taking his evening medication and his tone was reported to be threatening in nature. Over the next few hours, he settled and requested and was granted a level 3 pass requiring that he return to the unit at 8;30 p.m. He did not.
- On October 14, 2025, Mr. VanWoerden presented as thought disorganized, agitated, and guarded when seen by his psychiatrist. He declined to discuss the circumstances surrounding his elopement and all attempts to obtain information were unsuccessful due to the degree of thought disorganization. His mental status had deteriorated significantly over the week, coinciding with his discontinuation of medication, despite an increase in his regimen two weeks prior. His mood was labile. He denied suicidal or homicidal ideation but remained unpredictable and on edge. He continued to refuse to take his prescribed psychiatric medications.
- On October 16, 2025, although he initially stated that he would accept his medications, he later refused. The Hospital Report indicates: “A silent code white was called. While the clinical team was planning on how to approach Mr. VanWoerden, he came out of his bedroom quite agitated and floridly psychotic. He ran in the hallway shouting “call the police”. He then approached the care desk and banged on the glass. At this time, the decision was made to seclude Mr. VanWoerden as a low stimuli environment was deemed to be the best management option to mitigate the risk of violence towards others. He was then approached by nursing staff and they were successfully able to de-escalate him, and he agreed to walk into seclusion. He was given his schedule dose of his long-acting antipsychotic – 400mng Abilify IM in addition to a chemical restraint - 5mg Haldol IM, 2mg Ativan IM”.
- On October 17, 2025, when assessed in seclusion by nursing staff and the attending psychiatrist, Mr. VanWoerden presented with pressured speech, thought disorder and bizarre delusional content.
[36]. According to the Hospital Report, “The following risk factors contribute to Mr. VanWoerden’s level of risk:
- History of mental disorder, namely Schizoaffective Disorder
- Mild decompensation in mental health at times during this period of review
The following are potential protective factors for Mr. Van Woerden:
- Positive Social Supports
- Positive Engagement with Treatment Team
[37]. Dr. Kolawole stated that the treatment team finds that Mr. VanWoerden continues to represent a significant threat to the safety of the public. Over the past reporting year, he has experienced periods of decompensation in his mental state and has been rehospitalized. To date, he remains in hospital as he Is not yet at his baseline presentation given that he abruptly stopped his medications for a significant amount of time. The doctor stated that the treatment team is in the process of titrating his medications to a therapeutic level. The doctor commented that when unwell, Mr. VanWoerden is prone to experiencing mood fluctuations and significant psychotic symptoms.
[38]. The doctor advised that Mr. VanWoerden’s success in the community is due, in large part, to the intense structure, monitoring, and supervision afforded by the forensic program as augmented by the high degree of supports available at the Indwell residence. According to the doctor, Indwell residence has agreed to hold his placement at their residence for him. If that were to change and he was no longer able to return to Indwell, then Dr. Kolawole stated that it would remain critical, from a risk management perspective for the hospital to retain authority to approve his placement in the community. The doctor commented that this speaks to the importance of a Detention Order Disposition at this juncture.
[39]. In response to questions posed, the doctor advised that the current Conditional Discharge is no longer appropriate to manage Mr. VanWoerden’s risk to public safety. Over the past reporting year, Mr. VanWoerden absconded from his community residence and went to London and was required to be returned to hospital by police. Although he has attended at hospital voluntarily for an extended admission in June 2025, and again agreed to a voluntary admission in August 2015, in October 2025, he required an involuntary detention in hospital under the MHA. At the present juncture, the treatment team is of the opinion that the hospital’s safe management of Mr. VanWoerden requires the authority of a Detention Order. Dr. Kolawole stated that it is unclear whether or not Mr. VanWoerden would meet criteria for certification under the MHA.
[40]. The Hospital Report states that “His most recent admission (August–November 2025) has been marked by psychotic decompensation, medication refusal, paranoid delusions, aggression toward staff, elopement from hospital grounds, and the need for seclusion due to imminent risk of violence.”
[41]. No further evidence was called.
Analysis and Conclusion:
[42]. Having heard and considered all of the evidence, and the submissions of all the parties, the Board finds much merit in the joint position of the parties that Mr. VanWoerden continues to pose a significant threat to the safety of the public. We make this finding based on the evidence of Dr. Kolawole together with the documentary evidence made available to the Board at this hearing. Mr. VanWoerden suffers from Schizoaffective Disorder. When Mr. VanWoerden is unwell, he has engaged in serious incidents of unprovoked violence. The Board is mindful of the fact that the index offence was an unprovoked assault on a stranger with significant consequences to the victim. In addition, he presents with underdeveloped insight across all relevant domains.
[43]. Mr. VanWoerden has a lengthy history of noncompliance with antipsychotic medication prior to the commission of the index offence and, absent the oversight of the forensic system, the evidence indicates that he would be at great risk of discontinuing his medication with the likely result of a return of symptoms of his psychosis.
[44]. We find merit in the hospital’s recommendation that Mr. VanWoerden can no longer be safely managed under a Conditional Discharge Disposition. At this juncture, a Detention Order Disposition is necessary and appropriate. We note that over the past year, Mr. VanWoerden has presented with significant instability of his mental state and an inability to safely function in the community despite intensive supports. Even within the structured environment of the hospital, Mr. VanWoerden refused his prescribed medications and experienced a resultant acute deterioration in his mental health. He exhibited persistent thought disorder, paranoia, mood lability, and intrusive thoughts. This decompensation in his mental state led to him presenting with verbal aggression, aggression to property, and threats of physical aggression, ultimately necessitating a period of seclusion during this admission. Additionally, he required an extended involuntary admission under the MHA.
[45]. Accordingly, the Board orders that Mr. VanWoerden be detained within the Forensic Psychiatry Program at the hospital subject to the following terms and conditions:
- to attend within or outside of the hospital for necessary medical, dental, legal or compassionate purposes;
- hospital and grounds privileges, escorted by staff accompanied by staff or a person approved by the person in charge, or indirectly supervised;
- to enter the community of Southern Ontario, escorted by staff, accompanied by staff or a person approved by the person in charge, or indirectly supervised;
- passes for up to 7 days to enter the community of Southern Ontario, indirectly supervised; and
- to live in the community in supervised accommodation approved by the person in charge;
Mr. VanWoerden shall be required to:
- refrain from contact or communication, direct or indirect, with Beverly Zehr or his immediate family; and
- while living in the community report to the person in charge not less than once per week.
DATED this 13th day of November 2025, at the City of Toronto, in the Toronto Region.
Ms. L. Banks Alternate Chairperson
Office of the Registrar Ontario Review Board