Re: Gavin Byron Bowles
ORB File No: 6477
Hearing Held On: Tuesday, September 23, 2025
Place of Hearing: Waypoint Centre for Mental Health
Pursuant To: Section 672.81(1) of the Criminal Code
Before: Alternate Chairperson: Ms. T. Mann Members: Dr. K. Hand Dr. G. Kerry Ms. A. La Viola Ms. R. Chopra
Parties Appearing: Accused: Gavin Byron Bowles Counsel: Ms. L. Landry Person in charge of Hospital: Representative/Counsel: Ms. J. Lefebvre Attorney-General of Ontario: Counsel: Ms. S. Curry
REASONS FOR DISPOSITION
(Dated November 25, 2025)
OVERVIEW
- Gavin Byron Bowles was found not criminally responsible on account of mental disorder on January 29, 2014, on a charge of assault with a weapon, contrary to the Criminal Code. He is currently subject to a disposition of the Ontario Review Board dated September 6, 2024, detaining him at the Waypoint Centre for Mental Health Care – High Secure Provincial Forensic Programs, Penetanguishene, Ontario. The terms of his Detention Order include hospital grounds privileges, beyond the secure perimeter, escorted by staff.
ISSUES
On September 23, 2025, the Board convened at Waypoint for a hearing further to s. 672.81(1) of the Criminal Code to review the disposition. The Board was asked to determine whether Mr. Bowles represented a significant threat to the safety of the public at the time of the hearing, and further, what the necessary and appropriate disposition is in the circumstances according to the factors set out in s. 672.54 of the Criminal Code.
At the outset of the hearing, the Representative for the Hospital, Counsel for the Attorney General, and Counsel for Mr. Bowles were invited to state their initial positions.
The Hospital and Counsel for the Attorney General both submitted that in their respective views – Mr. Bowles continues to represent a significant threat to the safety of the public and also agreeing that the necessary and appropriate disposition is that he continue under the terms of his current detention order, with no change at this time.
This position was reiterated in both the Hospital and Counsel for the Attorney General’s final submissions. Relying on the Hospital Report and Dr. Hudson’s testimony, they emphasized several concerning behaviours exhibited by Mr. Bowles, citing the report regarding threats to staff. They also referenced details of an incident on June 5, 2025, involving a broken spoon discovered in a damaged portion of drywall, and, three weeks later, an episode where Mr. Bowles was found with a towel around his neck, and again a broken spoon with a sharpened end. They remarked on Mr. Bowles’ improvements, such as utilizing off-unit privileges, stating that while there is still room for him to progress, (potentially reaching C5 level privileges – four hours of independent access to off-unit areas), he is not yet ready to leave Waypoint.
Counsel for Mr. Bowles’ position and submissions, on the other hand, strongly contested, that the threshold for a finding of ‘significant threat’ had not been met in this case – indicating that Mr. Bowles is entitled to be discharged absolutely, or, in the alternative, that he should be transferred to a less secure, less structured hospital setting, while acknowledging that a Rule 13 Notice1 had not been provided to the parties. After the evidence was heard, Counsel sought an Absolute Discharge for Mr. Bowles, highlighting improvements this year, including the absence of physical assaults, his kindness to animals, his pro-social behaviour through charitable donations, his renewed family relations, and his good rapport with fellow patients. Counsel emphasized that despite evidence about the anticipation of a point-of-care blood monitoring system, there has been very little progress over many years.
FINDINGS
After reviewing the evidence and submissions presented at the time of the hearing, the Board concluded that Mr. Bowles represents a significant threat to public safety. A Detention Order is required for the Hospital to be able to manage that risk to the public. The high secure setting at Waypoint remains necessary and appropriate. The Board ordered that the current disposition remain in place, with additional terms.
Specifically, any and all available information regarding the status of the implementation process for the PRONTO system2 (or its equivalent), must be provided to the Board by June 1, 2026, if it, or another point-of-care, finger-prick blood monitoring system has not been made available for Mr. Bowles’ use by that date. Further, should it remain the case that Mr. Bowles has not been offered it for use as of June 1, 2026, then a pre-hearing will be held to ensure all relevant evidence with respect to implementation issues will be made available to the panel at Mr. Bowles’ next annual review hearing.
PERSONAL BACKGROUND
The Hospital Report dated August 20, 2025, was entered as an exhibit at the hearing. Mr. Bowles also proffered a self-written report, which was also made an exhibit at the hearing (following the panel members confirming they had read the contents as per his request). The following background information, including the events surrounding the index offence has been taken from the Hospital Report, summarized here as follows.
On June 17, 2013, an employee at Waypoint Centre for Mental Health Care (then known as the Oak Ridge Division), contacted the Ontario Provincial Police to report an assault by patient Gavin Bowles. Mr. Bowles had grabbed a female nursing staff member from behind and attempted to stab her in the eye with a sharpened toothbrush – the toothbrush struck her eyeglass lens. Staff intervened, restrained Mr. Bowles, and placed him in seclusion. The staff member was upset, sustained no physical injuries, and was sent home early.
It should also be noted that Mr. Bowles was found not criminally responsible on two assault peace officer charges on August 9, 2007. He appealed that finding on January 3, 2008, and on May 7, 2010, the Ontario Court of Appeal allowed the appeal, set aside the NCR verdict and ordered a new trial due to procedural irregularities. He was not retried and both charges were withdrawn on January 27, 2011. The underlying incident (March 21, 2007) involved Mr. Bowles resisting handcuffing and transport from Central North Correctional Centre.
Mr. Bowles is now 48 years old. He was born in Barrie, Ontario, the eldest of three children. His birth was described as traumatic with a deformed skull and prolonged infant crying, and maternal bonding was difficult. His parents separated when he was 9 years old, and he lived with his father thereafter. He was described as shy and was teased by peers. He required family counseling at age 12 for frequent fights with his brother. From about age 17, he began to withdraw and drug use was suspected.
Academically he attended public schools in Barrie, performed well early but left school in Grade 11, and subsequent attempts to return were unsuccessful, with legal issues contributing to a final failed attempt in 1998. Employment history is minimal – two summers of part‑time pizza-making – since leaving school he has been described as unmotivated to work.
Mr. Bowles reports two significant relationships – a 1997-1998 relationship that produced a son who was given up for adoption, which ended with arguments and occasional physical violence, and a 2000–2001 relationship that ended after assaults led to hospital admission and police involvement.
In addition, substance use began around age 17 with daily cannabis and episodic use of MDMA (commonly known as ecstasy), cocaine, mushrooms, LSD, and alcohol. Prior to his psychiatric admissions, he lived with his father, was not working, he was socially withdrawn, and isolated.
A check of the Canadian Police Information Centre database shows that Mr. Bowles has a significant criminal offence history, beginning in 1999 to 2017. The record includes conflict with the law at an early age, involving assaultive and threatening behaviour. Some of his convictions and charges involved the use or possession of weapons and failure to abide by court orders, including terms of supervision.
PSYCHIATRIC BACKGROUND
Mr. Bowles’ current psychiatric diagnoses are Schizophrenia, Polysubstance Abuse (in sustained remission, in a controlled environment), and Antisocial Personality Disorder. He has been found incapable of making decisions about his medical treatment, but he is capable of managing his finances. His father is his substitute decision-maker. He is financially supported by the Ontario Disability Support Program.
Mr. Bowles is highly intelligent (IQ:131) but has longstanding emotional and interpersonal difficulties. From about 2000, he began experiencing recurrent psychiatric crises linked to substance use and episodes of psychosis. Early assessments noted marked introversion, marginal depression, and deficits in emotional intelligence. Over time his diagnoses evolved from drug‑induced psychosis and mixed personality traits to refractory paranoid schizophrenia with polysubstance abuse.
Between 2000 and 2007 he had multiple emergency admissions, forensic fitness and responsibility assessments, and short hospitalizations. Episodes included paranoid and disorganized behaviour, thought disturbance and auditory hallucinations. After the NCR in 2007 (set aside on appeal), he became increasingly entrenched in the forensic system.
Since 2003 he has been managed primarily in high‑security forensic units with many seclusions due to challenging behaviour despite trials of multiple antipsychotics and ECT (discontinued in 2014 due to extreme resistance). His course in hospital has included rigid delusional beliefs, self‑injurious acts (creating ligatures), weaponizing ordinary items, assaultive incidents, use of seclusions and physical restraints, and limited engagement with programming or off‑unit privileges.
EVIDENCE AT THE HEARING
Dr. Hudson gave evidence at the hearing. He highlighted that Mr. Bowles has a longstanding history of violence, which predates the onset of his psychotic symptoms. He noted that Mr. Bowles’ aggressive behaviours, including the attempted assault where he tried to stab a female nurse in the eye, were driven by auditory hallucinations and delusional beliefs related to his psychosis. Dr. Hudson emphasized that Mr. Bowles’ psychosis has largely gone untreated over the years, which has contributed to ongoing risks. It was also observed that Mr. Bowles fabricated a spoon into a sharp weapon earlier this year, signifying that he continues to contemplate violence.
Dr. Hudson described Mr. Bowles’ insight into his condition as limited but acknowledged his motivation to continue medication. Despite his resistance, Mr. Bowles expressed a willingness to consider treatment with clozapine, provided that he would not need to undergo blood draws, which he views as invasive and impactful to his ‘sense of life force’. He has been managed with high dosages of antipsychotics, notably zuclopenthixol, although his cooperation with blood tests has been inconsistent. Mr. Bowles’ delusions are somatic in nature, which complicates assessment of treatment adherence, but it is thought that that can be addressed through finger-prick testing.
Furthermore, Mr. Bowles has an intact, preserved level of intellectual functioning, with an IQ in the top 3%. He and his clinician discussed the potential of starting clozapine treatment, which he has been approved for, after screening. The plan involves regular blood monitoring, including weekly testing initially, to mitigate risks associated with this medication. Dr. Hudson believes that early intervention with clozapine could significantly improve Mr. Bowles’ mental state and facilitate his progress toward rehabilitation.
Dr. Hudson elaborated that currently, Mr. Bowles’ privileges are moderated by his level of security. He is managed in a less structured unit, which provides him with more freedom and opportunities for social interaction. He is able to participate in vocational and recreational activities, including socializing with peers in the canteen area for approximately one hour at a time.
Despite his increased privileges, there remain concerns related to safety – a sharpened spoon was found in his room, although Mr. Bowles’ denies any intent to use it and claims it was left there involuntarily. Dr. Hudson noted that although Mr. Bowles has greater freedoms in this environment, the risk of access to weapons and contraband persists (and would do so even in a less secure environment), especially given the history of self-injurious behaviours and episodes of hallucinations, such as wrapping a towel around his neck during a hallucination on June 25, 2025. Nonetheless, he continues to engage socially and has shown some progress in emotional regulation and social interaction.
After further inquiries – Dr. Hudson confirmed that Mr. Bowles has been somewhat stable over many years and the ongoing frustration with the pace of treatment, specifically related to the implementation of the PRONTO system (finger-prick blood monitoring), is an ongoing source of frustration for the treatment team as well. His family support remains somewhat inconsistent, with his father in Nova Scotia and recent contact reestablished with his sister.
Despite these challenges, Mr. Bowles has shown improvements in emotional regulation and social engagement, attempting to work towards greater independence. Dr. Hudson also stated that Mr. Bowles’ motivation to leave Waypoint is genuine, and that with appropriate treatment, including clozapine and continued family support, he has potential for substantial recovery.
Overall, Dr. Hudson emphasized that Mr. Bowles’ insight into his condition remains limited, although he is motivated to continue treatment, and he has expressed a willingness to consider clozapine, provided that the blood monitoring requirements can be minimized. Mr. Bowles has previously been managed with high doses of antipsychotics (specifically zuclopenthixol), which required regular injections every ten days.
However, Mr. Bowles’ non-compliance with blood tests has posed significant challenges to ongoing assessment and treatment. Notably, Mr. Bowles has attempted to escape from the Hospital – being the only patient at Waypoint to have previously managed to do so – which highlights the ongoing difficulties with risk management.
Evidence by Mr. Bowles
Mr. Bowles, represented by Counsel, addressed the panel to share his perspective. He expressed his desire to reside in an apartment in Barrie, his hometown, to be closer to his family. Regarding his medication, specifically zuclopenthixol, he stated that it has been working adequately, albeit with side effects such as dark circles and visual disturbances. Despite these issues, he has grown accustomed to the drug, though he emphasized that it was initially forced upon him.
In response to the incident involving the sharpened spoon found in his room, Mr. Bowles denied sharpening it and asserted that he had no intention of using it. He described acquiring it as a fleeting thought stemming from anger towards some staff members, but not a deliberate attempt to cause harm. Addressing the June 25th incident, where he was found with a towel wrapped around his neck, Mr. Bowles explained that he was not trying to strangle himself but was experiencing a hallucination of a wolf biting his neck, which he attributed to Dr. Hudson. He also expressed concerns about a pacemaker in his heart, believing that he is in danger.
When questioned about his preference between the Beckwith unit and a less structured environment, Mr. Bowles indicated that he would prefer to remain in the security of the Beckwith unit due to his positive relationships with the staff there. Mr. Bowles also stated that he felt he was a good person, highlighting his efforts to save 252 flies, believing that this action had resulted in increased intelligence for himself and made the insects happy.
ANALYSIS AND CONCLUSION
(a) Significant Threat
The Board must first determine whether Mr. Bowles continues to pose a significant threat to the safety of the public as defined in Winko v. British Columbia (Forensic Psychiatric Institute), 1999 CanLII 694 (SCC), [1999] 2 S.C.R. 625. Based on the totality of the evidence, including the testimony of Dr. Hudson and the most recent clinical and risk assessment findings, the Board concludes that Mr. Bowles meets the legal threshold for a finding of ‘significant threat’.
Several factors support this conclusion. First, Mr. Bowles has a significant history of violence, as evidenced by his past assaults, weapons charges, and the index offence of attempted assault with a weapon. This history demonstrates a pattern of violent behaviour.
Second, despite some progress in treatment, Mr. Bowles continues to experience active symptoms of psychosis, including auditory hallucinations, delusional beliefs, and disorganized thinking. These symptoms can contribute to unpredictable behaviour and increase the risk of harm to others. The incident involving the sharpened spoon, while not resulting in actual harm, demonstrates that Mr. Bowles continues to contemplate violence and has the capacity to create weapons – similar to the index offence when he attempted to stab a nurse in the eye with a sharpened toothbrush.
Third, Mr. Bowles’ lack of insight into his mental illness and the need for treatment remains a significant concern. He continues to express the belief that he does not need medication and attributes his condition to external factors, such as Waypoint or the effects of his medication. This lack of insight makes it difficult to manage his risk and ensure his compliance with treatment.
The Board acknowledges that Mr. Bowles has shown some improvements in recent months, including increased engagement in therapeutic activities and a willingness to consider clozapine treatment. However, these improvements are not sufficient to outweigh the significant risk factors identified above. The Board notes that Mr. Bowles’ VRAG score places him at the 67th percentile, indicating a notable risk for violent recidivism. The HCR-20 assessment also identifies multiple historical and clinical risk factors that remain relevant.
While the Board appreciates the importance of promoting Mr. Bowles’ rehabilitation and reintegration into society, public safety must be the paramount consideration. In light of Mr. Bowles’ history of violence, ongoing psychotic symptoms, lack of insight, and elevated risk assessment scores, the Board is not satisfied that the risk of serious harm to others has been sufficiently reduced. Therefore, the Board concludes that Mr. Bowles continues to represent a significant threat to the safety of the public.
(b) Necessary and Appropriate
Having determined that Mr. Bowles continues to pose a significant threat to the safety of the public, the Board must next determine the disposition that is the least onerous and least restrictive of Mr. Bowles’ liberty interests, which is consistent with public safety, his mental condition, and his reintegration into society, as required by s. 672.54 of the Criminal Code.
In light of the evidence presented, the Board finds that Mr. Bowles’ continued detention in a high secure forensic facility remains necessary and appropriate. The Hospital and Counsel for the Attorney General submitted that the necessary and appropriate disposition is continued detention in a high secure forensic hospital setting, with no changes to the current terms of his Detention Order. Counsel for Mr. Bowles’ argued for a less restrictive disposition, such as a transfer to a less secure facility or even an Absolute Discharge. The Board has carefully considered these submissions, in addition to the evidence presented regarding Mr. Bowles’ current mental condition and treatment needs.
The Board finds that continued detention in a high secure forensic facility remains the necessary and appropriate disposition for Mr. Bowles at this time. Given Mr. Bowles’ history of violence, ongoing psychotic symptoms, lack of insight, and elevated risk assessment scores, the Board is not satisfied that a less restrictive disposition would adequately address the risk of serious harm to others. In particular, an Absolute Discharge is not appropriate in this case because Mr. Bowles continues to require ongoing treatment and supervision to manage his mental illness and reduce his risk of future violence. Furthermore, a Conditional Discharge is not appropriate, as Mr. Bowles’ lack of insight and history of non-compliance with treatment make it unlikely that he would adhere to the conditions of a community-based order, thereby posing an unacceptable risk to public safety.
The Board acknowledges that Mr. Bowles has made some progress in recent months, including increased engagement in therapeutic activities and a willingness to consider clozapine treatment. However, these improvements are not sufficient to warrant a less restrictive disposition at this time. A less restrictive disposition, such as a transfer to a less secure facility, would not provide the level of structure, supervision, and security that Mr. Bowles requires to manage his risk. In a less secure setting, he would have greater access to weapons, contraband, and substances, which could exacerbate his symptoms and increase the risk of harm to others. He would also be less closely monitored, making it more difficult to detect and respond to early warning signs of relapse or risk of violent behaviour.
While the Board is hopeful that Mr. Bowles will continue to make progress in treatment and that a less restrictive disposition may be appropriate in the future, the Board concludes that continued detention in the high secure forensic facility at Waypoint remains the necessary and appropriate disposition at this time.
Inquiry Regarding the PRONTO System
The Board heard evidence regarding the potential benefits of a point-of-care, finger-prick blood monitoring such as the PRONTO system for Mr. Bowles, particularly in relation to his renewed willingness to consider clozapine treatment, if there is a less invasive method of blood testing.
The Board understands that Mr. Bowles’ somatic delusions regarding traditional methods have been a significant barrier to his acceptance of this potentially beneficial medication, and the Board acknowledges that a more accessible method of blood monitoring could significantly reduce his anxiety and increase the likelihood of improving treatment outcomes.
However, the Board is also mindful that the implementation of a point-of-care blood monitoring system at Waypoint has been subject to delays due to competing fiscal priorities. While the Board understands the challenges and complexities involved in implementing new treatment technologies, we are deeply concerned about the potential impact of these delays on Mr. Bowles’ treatment optimization, and overall well-being.
The following paragraphs were contained in the 2024 Board’s findings, analysis and conclusions, supporting the anticipated trial of clozapine based on Mr. Bowles’ willingness to try, providing he has access to the finger-prick blood monitoring system:
There is no doubt that Mr. Bowles has had a good year overall, relative to past years under the jurisdiction of the Board. The Board nevertheless agrees that Mr. Bowles’ improvement is incomplete due to the treatment refractory nature of his psychotic illness which leaves him with long-standing symptoms of disorganized thought, hyper-religiosity, grandiose, somatic and persecutory delusions. The Board notes that Mr. Bowles’ Schizophrenia, compounded by his substance use and antisocial personality disorders, explains much of his previous aggressive behaviour as well as continued risk of aggression if he remains as symptomatic as he currently is. Mr. Bowles continues to lack insight into his illnesses and the reason he is in hospital. He lacks capacity to consent to his own treatment. The nature of his somatic delusions poses a formidable barrier to treatment. However, it is an extraordinarily positive development that he is now agreeable to a trial of clozapine, provided he has access to a blood testing system which will allow for finger prick testing
None of the above is meant to detract from the good progress that Mr. Bowles has made over the past year. The Board encourages Mr. Bowles to continue to work cooperatively with his treatment team so that he may continue the positive trajectory which has been evident to the Board over the review period. The Board shares Dr. Hudson’s hope for the future, now that a clear path to a trial of clozapine is available in the not too distant future, bringing with it the possibility of resolving Mr. Bowles’ long-standing symptoms, as well as deepening his engagement in therapeutic pursuits and recreational activities. It is hoped that clozapine treatment will prove to be of benefit to Mr. Bowles and will ease the pain and distress that is so clearly and eloquently expressed in his writings (para 40).
The Board strongly encourages the Hospital to exercise their due diligence in their duty to advocate for the implementation of the proposed blood-testing system so as to enhance positive outcomes and reduce any barriers to treatment for Mr. Bowles.
Understandably, the implementation of new technologies can be a complex and time-consuming process. Notwithstanding, the Board expects the Hospital to be prepared to answer questions regarding the progress of the implementation of a finger-prick blood testing system, by June 1, 2026. Information should include explanations about any issues with the evaluation and/or integration processes, status of engagement with diverse stakeholders, adequate IT support and staff training.
Further, if such a system has not been implemented for use by Mr. Bowles by June 1, 2026, the Board orders that the person in charge of Waypoint request the Ontario Review Board convene a pre-hearing conference. The purpose of the pre-hearing conference will be to ensure all relevant evidence with respect to the Hospital’s implementational processes for a point-of-care finger-prick, blood monitoring system will be available to the panel at Mr. Bowles’ next annual review hearing.
Additional reasons in support of the order are based on the Board’s understanding that the current standard of care, which relies on traditional methods for blood draws, presents a significant barrier for forensic patients who are fearful of invasive procedures – particularly individuals like Mr. Bowles, whose hesitation has directly impacted his access to and adherence with clozapine, a medication with proven efficacy for treatment-resistant schizophrenia. A less invasive blood monitoring system has the potential to eliminate this fear, improve compliance, and ensure that Mr. Bowles is not deprived of potentially life-changing treatment.
The Board also recognizes that such a system supports broader health care objectives, including community-based care, reduced hospitalization, and successful reintegration – goals shared by both the courts and provincial health authorities. Its implementation is essential to providing forensic patients with the best chance at recovery and rehabilitation, and we encourage the Hospital to consult with other forensic programs already using similar systems to facilitate adoption/implementation, and to inform the Board of its progress.
DATED this 25th day of November, at the City of Toronto, in the Toronto Region.
Ms. A. La Viola Legal Member
___________________ Office of the Registrar Ontario Review Board
Footnotes
- Ontario Review Board Rules of Procedures, Schedule A, Rule 13 – transfer requests from one hospital to another requires no less than four weeks’ notice prior to the annual hearing be given to all parties, including the prospective receiving hospital, if one is identified.
- PRONTO (also known as CSAN® Pronto™) is a finger-prick blood testing device designed for point-of-care testing (POCT), offering prompt results for blood indicators. It is used in clinical settings for monitoring conditions like schizophrenia (e.g., Clozaril therapy).