Re: B. (R.D.)
ORB File 6904
Hearing held on: Wednesday, January 15, 2025
Place of hearing: North Bay Regional Health Centre – North Bay Site
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Mr. P. Capelle
Members: Dr. J. Watts
Dr. P. Wright
Ms. L. Banks
Mr. J. Cyr
Parties Appearing:
Accused: B. (R.D.)
Counsel: Mr. U. Agostino
The person in charge of hospital: Counsel: Mr. P. Trenker
Attorney General of Ontario: Counsel: Mr. P. Lambert-Belanger
REASONS FOR DISPOSITION
(Dated March 18, 2025)
Introduction:
On February 10, 2016, B. (R.D.) was found not criminally responsible on account of mental disorder (“NCR”) on a charge of utter threat to cause death or bodily harm, contrary to the Criminal Code of Canada (the “Criminal Code”).
Mr. B. (R.D.) is currently subject to a Disposition of the Ontario Review Board (“ORB” or the “Board”) dated January 24, 2024 pursuant to which he is ordered detained at the Forensic Programs of the North Bay Regional Health Centre (“North Bay RHC” or the “hospital”) subject to a variety of terms and conditions, including privileges up to living in the catchment area of the North Bay RNC, in accommodation approved by the person in charge.
On January 15, 2025, a panel of the ORB convened a hearing at the hospital to conduct an annual review of Mr. B. (R.D.)’s Disposition pursuant to s. 672.81(1) of the Criminal Code. Mr. B. (R.D.) was present at the hearing and was represented by his counsel, Mr. Agostino.
The Board had to decide whether Mr. B. (R.D.) continued to pose a significant threat to the safety of the public, and if so, the necessary and appropriate Disposition having regard to the criteria set out in s. 672.54 of the Criminal Code.
For the reasons set out below, this Board finds the test for significant threat continues to be met and that the necessary and appropriate Disposition under the circumstances is that Mr. B. (R.D.) continue to be subject to the terms of his existing Detention Order on the same terms and conditions as are set forth in his existing Disposition.
Index Offence:
- The details of the index offence are set out in last year’s Reasons for Disposition, as follows:
“The index offence took place on August 12, 2015 when Mr. B. (R.D.) threatened his sister, Abalina, in the presence of their parents. In her statement, Abalina said that she went to get a glass of water and B. (R.D.) threatened her with a knife, saying that he was going to stab her. Mr. B. (R.D.) was on an undertaking at the time, following a charge of mischief that was pending from July 2015.”
Positions of the Parties:
At the commencement of the hearing, all parties were canvassed as to their positions regarding Disposition recommendations. The hospital’s counsel submitted that Mr. B. (R.D.) continued to represent a significant threat to the safety of the public and that the necessary and appropriate Disposition was a continuation of his existing Detention Order.
Counsel on behalf of the Attorney General of Ontario supported the hospital’s Disposition recommendations.
Mr. Agostino indicated that he conceded the issue of significant threat and stated that he wished to hear the evidence before making a Disposition recommendation. In closing submissions, Mr. Agostino asked the Board to consider the appropriateness of a Conditional Discharge for his client at this juncture. He highlighted the doctor’s evidence that this has been Mr. B. (R.D.)’s “best year” while under the ORB’s jurisdiction. His client has been medication compliant, has remained primarily abstinent from substances of abuse, and has not engaged in any episodes of physical violence or elopement behaviours. Mr. Agostino acknowledged that if the Board does not agree with a Conditional Discharge, then, in the alternative, he was supportive of a continuation of his client’s existing Detention Order, without amendment.
Both counsel for the hospital and the Crown reiterated their recommendation to the Board for a continuance of Mr. B. (R.D.)’s existing Disposition in closing submissions.
Personal Background:
The Hospital Report dated December 20, 2024 (the “Hospital Report”) sets out in great detail information about Mr. B. (R.D.)’s personal history and course in the hospital subsequent to the index offence and need not be repeated here as the Hospital Report was made an exhibit at the hearing. Briefly stated, Mr. B. (R.D.) is a 25-year-old man who was born in Sioux Lookout and raised in Fort Severn, a remote First Nation territory northwest of Thunder Bay. He grew up with heavy use of alcohol in the household. He was subjected to physical and emotional abuse and possibly sexual abuse.
Mr. B. (R.D.) dropped out of school in grade seven and began drinking alcohol and doing drugs. His substance use escalated in his teenage years and included sniffing gasoline, and using cocaine, pills, and cannabis. His employment was sporadic.
Mr. B. (R.D.) was involved in a high-speed accident resulting in serious injuries.
According to the Hospital Report, Mr. B. (R.D.) has “... a history of significant substance abuse, traumatic experiences, relationship problems, antisocial behavior other than violence, and treatment or supervision response problems, including numerous elopements from forensic psychiatric wards. He also has a history of significant problems with major mental disorder that dates back to his early-to-mid-adolescence and has a recent diagnosis of Posttraumatic Stress Disorder. His records also mention narcissistic and antisocial tendencies.”
Legal and Mental Health History:
- He has no criminal record prior to the index offence; however, by the age of 16, he was being treated for mental disorders. Since his behaviour was erratic and violent, he had two encounters with police. In his later teenage years, he reported an increasingly distant and sometimes hostile and angry relationship with his parents and siblings. He was admitted to the Thunder Bay Regional Health Center in November 2015 where he exhibited a fairly prominent thought disorder with multiple bizarre references. He appeared to be responding to internal stimuli and believed he was receiving messages from the television. Several assaults occurred while he was in hospital and as a result, he was placed in seclusion.
Current Diagnoses:
- Mr. B. (R.D.)’s current diagnoses are:
Schizophrenia;
Post-Traumatic Stress Disorder (“PTSD”);
Opioid Use Disorder, Moderate;
Cannabis Use Disorder, Mild; and
Stimulant Use Disorder, Moderate.
Evidence at the Hearing:
Dr. G. Munro, who has been Mr. B. (R.D.)’s attending psychiatrist for the past several years since his admission to the hospital, testified at the hearing to supplement the contents of the Hospital Report.
Dr. Munro commenced her testimony by stating that this has been an “outstanding” year in review for Mr. B. (R.D.). He has made significant improvements in many areas as will be described below.
Over the year in review, Mr. B. (R.D.) has remained detained in the hospital on the Owl Lodge.
Mr. B. (R.D.) continues to be assessed as capable to consent to psychiatric treatment. He is treated with a long-acting intramuscular injection (“LAI”) of antipsychotic medication, Paliperidone Palmitate (Trinza), which he receives every 3 months. His treatment is augmented with Quetiapine, a mood stabilizer, and Bupropion, an antidepressant medication. The doctor acknowledged (in response to a question from a panel member) that this medication is at a rather high dose and she advised that it will likely be decreased over the next few months.
The doctor indicated that despite the risks associated with this medication, Mr. B. (R.D.) also received Vyvanse daily to address his Attention Deficit Hyperactivity Disorder (“ADHD”). The doctor advised that he has responded extremely well to this ADHD medication and he has been closely monitored for abuse of this substance.
Dr. Munro advised that the treatment team considers that Mr. B. (R.D.)’s medications are currently optimized. Dr. Munro advised that Mr. B. (R.D.)’s ongoing medication compliance together with his abstinence from substances of abuse are the most important factors in maintaining his ongoing psychiatric stability.
Mr. B. (R.D.) has been cooperative and adherent to his medication regime. He has engaged openly with Dr. Munro in discussions regarding medications and has acquired good insight into the role medications have in his mental health. He has tolerated his medications well and has not evidenced symptoms of psychosis. He has denied experiencing any perceptual disturbances, delusional beliefs, suicidal, self-harm, violent or homicidal ideation. His insight into his illness and treatment has significantly increased over the year in review.
Mr. B. (R.D.) has a significant history of polysubstance abuse, including cannabis, alcohol, cocaine, opioids, and methamphetamines. Over the past reporting period, urine drug screens (“UDS”) conducted between January and April 2024, showed no evidence of illicit substance use. However, on May 28, 2024, Mr. B. (R.D.)’s UDS tested positive for cannabis. He was forthcoming and admitted consuming "weed gummies" with peers on his unit. He stated that he had never previously consumed edible cannabis products and was curious to try same. He did not present in a decompensated state following his use.
Dr. Munro confirmed that all subsequent UDS results from June to the hearing date have all been negative for illicit substances. Dr. Munro stated that overall, Mr. B. (R.D.)’s insight into the importance of abstinence from substance use has also improved over the course of the year in review. His active engagement with the hospital’s concurrent disorders specialist has yielded significant improvements.
Mr. B. (R.D.) has remained highly engaged in a variety of therapeutic activities. He participates in 1:1 psychotherapy to address his history of trauma and he is learning stress management skills. As well, Mr. B. (R.D.) is involved in a wide variety of recreational activities, including volleyball, YMCA sessions, and community walks.
Mr. B. (R.D.) has regularly attended a “Seeking Safety” group to address his addiction issues. His involvement with Narcotics Anonymous over the reporting period has been intermittent. To his credit, Mr. B. (R.D.) also engages in an individualized program with his Concurrent Disorders Clinician. He expresses good insight into the effects of illicit substances on his mental health and has been successful in achieving near abstinence from substance use over the year in review. Additionally, Mr. B. (R.D.) celebrated one year of sobriety from crystal methamphetamine in October. Unfortunately, in November 2024, Mr. B. (R.D.) stated that his abstinence from substance use was externally driven by his ORB Disposition and he expressed an intention to resume substance use when no longer under the ORB’s jurisdiction.
The Hospital Report indicates that, “Mr. B. (R.D.) was presented with multiple emotional challenges throughout March and into April, which destabilized his progress. He identified that working through his trauma experiences with his new psychotherapist, the death of his aunt, a visit from his mother, a change in his treatment team and the emotional weight of his birthday contributed to increased stress and frustration, which manifested in behaviors such as signing out of his unit for an unauthorized privilege and displaying verbal aggression towards staff. His emotional responses led to a higher number of Aggression Incident Scale (AIS) scores in April, 2024, which are detailed below. He also began to express frustration with some of his peers and isolated himself from some group activities as a result. He was noted to manage the interpersonal frustrations in a prosocial manner by discussing them appropriately with staff. Dr. Munro met with Mr. B. (R.D.) and discussed the exacerbation of his symptoms of PTSD and his multiple significant psychosocial stressors. Dr. Munro added an order for clonazepam as needed to help Mr. B. (R.D.) address these challenges.”
The Hospital Report indicates that in April 2024, Mr. B. (R.D.) engaged in maladaptive behaviours such as calling hospital staff members derogatory names, yelling at staff, and using rude foul language during multiple interactions with staff.
In May 2024, Mr. B. (R.D.) learned that a cousin had passed away and this impacted his emotional stability. Additionally, changes in his treatment team were difficult for him to adapt to given the level of trust required for him to speak openly about his trauma history. Despite this, and to his credit, Mr. B. (R.D.) remained engaged in treatment.
Dr. Munro advised that in April/May 2024, the treatment team became aware that Mr. B. (R.D.) engaged in "cheeking" his Wellbutrin medication and sometimes giving it to a co-patient in exchange for money. The hospital’s response was to place him back on medication watch, provide health teaching, and impose a temporary hold on his privileges.
An ongoing area of concern continues to be Mr. B. (R.D.)’s online gambling. With prompting from the treatment team, Mr. B. (R.D.) has agreed to set daily limits on his gambling time and he has been successful in significantly decreased his gambling. However, members of the treatment team have concerns that if Mr. B. (R.D.)’s gambling yields substantial winnings, his risk of abscondment and a relapse would be likely to increase.
The Hospital Report indicates that, “Overall, while Mr. B. (R.D.)’s emotional regulation and interpersonal relationships have remained areas of challenge, his aggression and impulsivity appear to have decreased over the course of this treatment cycle, indicating positive progress in his ability to manage emotional distress and interpersonal conflict.”
To his credit, Mr. B. (R.D.) did not engage in physical violence over the year in review and his privileges have been gradually increased as his behavior has stabilized. Dr. Munro commented that there have been some discreet episodes of verbal aggression with staff. The doctor also commented that there have been no significant incidents of impulsivity but for his single use of cannabis gummies.
At the present time, Mr. B. (R.D.)’s privileges include staff supervised privileges on hospital and grounds and into the community, indirectly supervised hospital and grounds privileges for 30 minutes five times daily, and indirectly supervised privileges for the purpose of attending the Snack Shack (supervised by non-forensic staff), to attend the education centre to complete school work, and to attend cultural activities on hospital and grounds. The doctor confirmed that Mr. B. (R.D.) has utilized his privileges appropriately and has not engaged in any elopement-related behaviours.
Mr. B. (R.D.) engages with Chaplaincy as well as Mînowacihewin Regional Services for Indigenous People (“MINO”) for spiritual support. He also engages with MINO services for cultural programming and attends the North Bay Indigenous Hub where he speaks with cultural practitioners.
Mr. B. (R.D.) is also pursuing his educational goals and is working toward completing his Grade 12 through the Employment Literacy group in the Education Centre at the hospital. He has also expressed an interest in pursuing vocational goals and he plans to enroll in a Heavy Equipment training program in the spring of 2025. He is also planning to apply for a recording engineering program offered by Canadore College in the fall of 2025.
Mr. B. (R.D.) currently works at the patient-operated Snack Shack and he is noted to be highly engaged with the program and has taken on a leadership role.
Mr. B. (R.D.) continues to receive support from his family. He is in regular contact with them via telephone and virtual visits. Dr. Munro stated that this is a very significant improvement from previous years. In March 2024, Mr. B. (R.D.)’s mother visited and he reported that the visit went well. It was the first visit with his mother since he has been detained at North Bay RHC.
The Hospital Report indicates that the treatment team is of the unanimous view that the Mr. B. (R.D.) continues to pose a significant threat to the safety of the public and the following factors were identified in coming to that conclusion:
“Mr. B. (R.D.) suffers from a serious mental illness, namely Schizophrenia. His illness has been characterized by auditory and visual hallucinations, paranoia, suicidal thoughts, anxiety, disorganized unpredictable and aggressive behaviour, emotional dysregulation and poor impulse control;
Mr. B. (R.D.) has lengthy history of substance abuse. He started to experiment with cannabis and alcohol around the age of 11. By age 12, he was regularly sniffing gasoline and glue. He reported using crack cocaine and opioids. He is slowly developing insight into the extent to which his use of intoxicants adversely affects his mental state and behaviour, and is in the early stages of recovery from his substance use disorders;
Mr. B. (R.D.) has a longstanding history of breaching the terms of his ORB Disposition Order by using a variety of substances while on unauthorized leaves of absence from both the Thunder Bay Regional Health Sciences Centre and the North Bay Regional Health Centre. However, he did not elope or attempt to elope during the current reporting period;
While an inpatient at Thunder Bay Regional Health Sciences Centre, Mr. B. (R.D.) attempted to smuggle drugs onto the unit;
Mr. B. (R.D.) has a history of absconding from secure hospital settings even while under supervision;
Mr. B. (R.D.) has stated that without the oversight of the ORB he would return to some degree of illicit substance use.”
Dr. Munro commented that Mr. B. (R.D.) is not yet an appropriate candidate for discharge to community living as he has not yet exercised the full envelope of privileges available to him under his current Disposition. The hospital has recently approved the grant of indirectly supervised community access but the paperwork for same has not yet been issued. It is anticipated that Mr. B. (R.D.) will be granted such privileges within the next week, on a graduated, cautious basis.
Dr. Munro testified that the team is not yet in the process of discharge planning; however, she stated that if he remains on the current positive trajectory, he is likely to be a candidate for community living potentially over the course of the current reporting year. Dr. Munro stated that she would anticipate that Mr. B. (R.D.) would be initially discharged to a supervised facility, likely, Maplewood Housing, which is staffed by forensic mental health staff from the hospital. The doctor commented that she believes that Mr. B. (R.D.) is likely incentivised by the inclusion of a community living condition in his Disposition.
Dr. Munro endorsed the view expressed in the Hospital Report indicating that absent a Disposition of the Board, Mr. B. (R.D.) would be highly likely to disengage from appropriate mental health supports and, over time, discontinue taking medication. In light of his longstanding history of substance abuse, it is anticipated that Mr. B. (R.D.) would relapse to substance use, resulting in a further decompensation of his mental state, further heightening his risk to public safety.
The Hospital Report further indicates that in the assessment of the treatment team, a Conditional Discharge would not be adequate to manage Mr. B. (R.D.)’s risk at the present time. Dr. Munro testified that the hospital continues to require the ability to have oversight of Mr. B. (R.D.)’s placement in the community when he is ready for discharge. Further, the hospital requires the ability to promptly readmit him at an early juncture to the hospital should he evidence signs of a mental health decompensation while living in the community. Further, the doctor noted that Mr. B. (R.D.) has a significant history of polysubstance use and elopement which remain significant risk factors. The doctor stated that Mr. B. (R.D.) continues to require close supervision within the structured environment of the hospital to further progress through the forensic system.
In response to a question posed by Mr. Agostino, Dr. Munro stated that in her opinion, Mr. B. (R.D.) would likely be an appropriate candidate for a Conditional Discharge when he had successfully resided in the community for a significant period of time with stability and without relapsing to substance use. She stated that she would also want to see him meaningfully engaged in structured programming or employment activity and be incident free.
The conclusion of the Risk Assessment included in the Hospital Report indicates that given all of the supports in place under Mr. B. (R.D.)’s existing Detention Order Disposition, his probability of reoffending violently is assessed as low. In contrast, should he be subject to a Conditional Discharge, the risk of future violence would be moderate.
No other evidence was called by the parties.
Analysis and Conclusions:
The Board has considered the Hospital Report, the evidence of Dr. Munro, and the submissions of the parties, and finds that Mr. B. (R.D.) continues to represent a significant threat to the safety of the public. We note that this issue was not in dispute at the hearing. Mr. B. (R.D.) suffers from Schizophrenia, PTSD, and Polysubstance Use Disorder. His use of substances has historically contributed to Mr. B. (R.D.)’s significant mental deteriorations over the years. Mr. B. (R.D.) has a documented history of unauthorized leaves of absence from both North Bay RHC and a previous forensic hospital, during which he has engaged in substance misuse. During this reporting period, notwithstanding the significant progress he has made, Mr. B. (R.D.) has left his designated unit without authorization, engaged in an incident of consumption of cannabis “gummies” and has expressed a continued intention to resume the use of illicit substances when he is no longer under the ORB’s jurisdiction.
The evidence before the Board also indicates that in the absence of an ORB Disposition, Mr. B. (R.D.) would be likely to fall away from adherence to his prescribed medications and, over time, relapse to illicit substance use. In that context, he would be likely to experience a significant decompensation (likely experiencing auditory and visual hallucinations, paranoia, suicidal thoughts, anxiety, disorganized unpredictable and aggressive behaviour, emotional dysregulation and poor impulse control) and become acutely psychotic. Once decompensated, it would be likely that Mr. B. (R.D.) would engage in aggressive behaviour posing a heightened risk to the safety of the public in a manner similar to that at the time of the index offence. For all of these reasons, the Board finds that Mr. B. (R.D.) continues to pose a significant threat to public safety.
In coming to the conclusion that the necessary and appropriate Disposition in the circumstances of this case is that Mr. B. (R.D.) continue to be subject to a Detention Order Disposition, the Board relies on the uncontroverted, expert medical opinion of Dr. Munro. Mr. B. (R.D.) continues to require an inpatient admission at this juncture. He has not yet been able to demonstrate his ability to appropriately manage the full envelope of privileges available under his existing Disposition and, accordingly, Mr. B. (R.D.) is not yet considered to be an appropriate candidate for transition to community living.
At this point, the Detention Order allows the hospital to oversee his choice of residence in the community when he is ready for discharge. This remains necessary for the appropriate management of his risk. In addition, the evidence presented indicates that the hospital requires the authority of a Detention Order to intervene at an early juncture to readmit Mr. B. (R.D.) to the hospital should he suffer a decompensation in his mental status when, ultimately, he transitions to community living. The documentary evidence indicates that Mr. B. (R.D.) would be unlikely to meet criteria for an involuntary admission under the Mental Health Act in the context of the early stages of a mental status deterioration. For all of these reasons, Mr. B. (R.D.)’s existing Disposition remains the necessary and appropriate one to safely manage his risk to the safety of the public.
The Board congratulates Mr. B. (R.D.) for his significant progress over the past year, particularly his medication compliance, his ongoing abstinence, and his overall stability. He has not engaged in any incidents of physical violence and has not engaged in any elopements from the hospital. Further, his relationship with his family members is improving. All of this bodes well for his continued progression towards full community reintegration.
In making this Disposition, the Board has reviewed the provisions of s.672.54 of the Criminal Code and has carefully considered the need to protect the public from dangerous persons, Mr. B. (R.D.)’s mental condition, his reintegration into society and his other needs.
DATED this 18^th^ day of March 2025, at the City of Toronto, in the Toronto Region
Ms. L. Banks
Legal Member
___________________________
Office of the Registrar
Ontario Review Board