Ontario Review Board
Re: Ashley Coulson
ORB File No: 7398
Hearing held on: Tuesday, February 11, 2025
Place of Hearing: Royal Ottawa Mental Health Centre
Pursuant to: Section 672.81 of the Criminal Code
Before:
Alternate Chairperson: Mr. P. Capelle
Members: Dr. G. Glancy Dr. G. Boulais Mr. P. Hageraats Mr. A. Bernardo
Parties Appearing:
Accused: Ashley Coulson Counsel: Ms. M. Munsterman
Person in charge of hospital: Representative: Dr. J. Hwang
Attorney-General of Ontario: Counsel: Ms. M. Dufort
REASONS FOR DISPOSITION
(Dated April 9, 2025)
Introduction
On July 31, 2018, Ashley Coulson appeared in court on charges of possession of a weapon for a dangerous purpose, mischief by damage to property under five thousand dollars, and mischief-interfering with lawful enjoyment of property, offences contrary to the Criminal Code of Canada.
On that date, the court received psychiatric evidence establishing that Mr. Coulson was suffering from a severe mental disorder at the time he committed the offence. Based on that evidence, the court determined that Mr. Coulson was not criminally responsible on account of mental disorder (NCR).
Currently, Mr. Coulson is subject to a disposition of the Ontario Review Board (ORB or “the Board”) dated February 21, 2024. He was ordered to be detained at the Secure Forensic Unit of the Royal Ottawa Mental Health Centre (ROMHC or “the hospital”). Mr. Coulson was awarded privileges, including to live in the community in accommodation approved by the person in charge of the hospital. He was also authorized to attend a residential treatment facility for substance use issues, within the Province of Ontario, at a facility to be approved by the person in charge of the hospital.
On February 11, 2025, the Board convened at the ROMHC to conduct an annual review. Mr. Coulson attended in person. He was represented by counsel, Ms. Marni Munsterman. Also present was Ms. Jaime Allin. Ms. Allin is a registered nurse associated with the hospital. She has been working with Mr. Coulson for some time.
The Board received direct testimony from the attending forensic psychiatrist, Dr. J. Hwang, along with documentary evidence. The Board had the following materials to consider:
Decision and Disposition, dated January 7, 2025
Reasons for Decision and Disposition, dated January 30, 2025
Dr. Hwang’s written report, dated January 20, 2025, filed as evidence.
- The issues to be considered by the Board are whether Mr. Coulson presents a significant threat to the safety of the public, and if so, to determine the necessary and appropriate disposition. The Board was also asked to consider having Mr. Coulson’s care and treatment transferred from the ROMHC to the Brockville Mental Health Centre (BMHC).
Positions of the Parties
Counsel for Mr. Coulson, Ms. Munsterman, advised that they took no issue on the question of significant threat. They also took no issue with the hospital recommendation that Mr. Coulson should remain bound by the same terms of the existing detention order.
Ms. Munsterman further advised that Mr. Coulson opposed the hospital recommendation that patient care be transferred to Brockville.
Counsel for the Attorney-General, Ms. Dufort advised that she was in support of the hospital recommendations, including the transfer of patient care.
For the reasons set out below, the Board accepted all three hospital recommendations. A modified detention order issued, along with an order transferring the patient to the care of the BMHC.
Current Psychiatric Diagnoses, Hospital Report, p. 96:
Main Diagnosis: Schizophrenia, multiple episodes
Contributory Diagnoses: Stimulant Use Disorder, severe
Personality Diagnoses: Nil
Psychosocial Contributors: Social Isolation
Index Offence
- The circumstances are described in the hospital report and in the Board’s most recent Reasons for Disposition dated January 30, 2025. We note the following:
Mr. Coulson is from Deep River, Ontario, where he had his own apartment. He was being followed by mental health services in Renfrew County including the Pembroke Regional Hospital. Over an extended period, before the index offence arose in March 2018, Mr. Coulson had had 39 previous police contacts with the Pembroke Police Service and 62 additional contacts with the Upper Valley Ontario Provincial Police.
In January 2018, the local Assertive Community Treatment (ACT) team recorded an incident whereby Mr. Coulson had jumped on and physically struck a vehicle belonging to a food bank volunteer. He threw items about in the food bank hallway and was heard to mutter something about “killing someone and ripping them apart”. Police were contacted. In February 2018, Mr. Coulson came to North Renfrew Family Services looking for food vouchers. He asked for transportation to go home. When he was denied this due to aggressive behaviour, he became more agitated and aggressive. The police were contacted.
In February 2018 it was further discovered that Mr. Coulson had demolished the inside of his apartment. He had violently smashed almost all personal belongings except for his television and Xbox game system. When the ACT team member went to the apartment to help with cleaning, Mr. Coulson took out an axe. He started to bounce it off his hands. He spoke of having a woman’s severed head under the sink. He reported needing the axe to protect himself against the police, stating, “I will kill them all if I have to”. Police were contacted.
On February 20, 2018, Mr. Coulson was brought to the Queensway-Carleton Hospital under a Form 2 of the Mental Health Act. He was admitted and released 72 hours later. ACT team members had observed Mr. Coulson’s ability to hide his symptoms of psychosis when in hospital.
On March 2, 2018, the date of the alleged offences, the ACT Team, police and Pembroke Regional Hospital staff met to discuss how they could best collaborate to better manage Mr. Coulson’s risk in the community. When psychotic, Mr. Coulson’s delusional themes involve his feeling that he is indestructible, has important powers and is “reborn”. It was noted that Mr. Coulson had typically been on a very low dose of antipsychotic medication due to complaints of tardive dyskinesia. Reportedly, he had stopped all medications in December 2017.
The index offence arose in Mr. Coulson’s Deep River apartment building. On March 2, 2018, a female victim was helping her brother move into one of the apartment units. She was in the main lobby speaking with the building superintendent who was seated in her office. Mr. Coulson approached them. The victim thought nothing of it until she saw Mr. Coulson had a hatchet in his hand.
He was carrying it at his side, with the blade pointing toward the victim. Mr. Coulson immediately began to yell and scream, cursing and swearing. He stated “I’m going to kill those fucking dogs. I can’t fucking sleep with those fucking dogs barking outside all night. This is my apartment, and I deserve to get some fucking sleep”. He added, “I have had enough of this f’ing bullshit”. During this time, Mr. Coulson was tapping the axe against the wall. When Mr. Coulson returned to his apartment, the superintendent grabbed the victim and brought her into the office. Locking the door, they called 911.
Police officers quickly arrived. After speaking to the two female complainants, they made their way to Mr. Coulson’s apartment. They heard a very large bang sound which sounded like a gun shot. Mr. Coulson came out of the apartment door. It became evident that the bang was the result of Mr. Coulson driving his axe through the apartment door.
Police officers spoke to Mr. Coulson, trying to convince him to come out and speak to them. They repeatedly asked him to put down the axe. Instead, he raised it and yelled at the officers “shoot me, shoot me”. He told the police to “not fucking come near” him. He went back into the apartment and closed the door.
During the exchange, the officers had secured the fire doors between themselves and Mr. Coulson out of concern that he might rush at them. Mr. Coulson broke off further communication with the officers.
The apartment building was put under containment. Backup was requested with the OPP emergency response team, tactical rescue unit, arriving soon after. Residents of the apartment building and the immediate area were evacuated from their homes. The local street was shut down to pedestrian and vehicle traffic and a command post was set up.
After six and a half hours, Mr. Coulson was taken into custody when police breached the door and arrested him as he was lying on his bed.
In Mr. Coulson’s version of the events, he spoke of regularly hearing a dog in his apartment building yelping. This had somehow “triggered him” to the earlier loss of his own dog. He began to have dark thoughts about his future and contemplated ending his life. Mr. Coulson’s account was very disorganized and delusional. He believed he had ended his life and yet believed he was also still alive. He made references to being the son of God, Jehovah’s son and that he was a “royal descendant”. He also referred to angels telling him to kill himself and that he was drinking Jennifer’s ashes (according to Mr. Coulson, this would be a reference to his already deceased girlfriend).
Course following the 2018 NCR Verdict
Following the July 2018 court appearance, Mr. Coulson remained on inpatient status at the ROMHC. On February 12, 2019, he was discharged to the community. He took up residence in the hospital’s approved group home in Vars, Ontario, where his medication administration was supervised. Within weeks, he no longer wished to live there but instead wanted his own apartment.
On July 13, 2020, Mr. Coulson was transferred to the Lebreton Transitional Housing Program in Ottawa. He continued to struggle with notable negative and cognitive symptoms of his mental illness and was described as unable to recognize symptoms when they arose. In terms of substances, while Mr. Coulson was saying he was no longer interested in consuming substances, he was described as unable to draw the link between substance use and the potential for a return of psychotic symptoms.
In May 2021, having progressed at the Lebreton Residence toward more independent living, Mr. Coulson was looking at moving to an independent apartment sponsored by the Salus supportive housing organization. He had been largely, but not completely, compliant with oral psychiatric medication, Clozapine. By August 2021, the regular Salus worker reported that Mr. Coulson seemed to be doing well and was not showing evidence of active symptoms of psychosis, apart from some negative symptoms. After moving to his Salus-sponsored apartment, Mr. Coulson remained involved in outpatient appointments and programs at the ROMHC.
In the Spring of 2022, difficulties arose following Mr. Coulson’s reported non-compliance with his regime of prescribed psychiatric medications. He was hospitalized at the Ottawa Hospital from April 28 to May 5. Soon after discharge, Mr. Coulson had to be again hospitalized, this time at the ROMHC Crisis Unit, from May 11 to June 1, 2022.
In October 2022, Mr. Coulson came to the Ottawa Hospital – Civic Campus. He was admitted under a Form 1 under the Mental Health Act after relating that he had attempted to commit suicide two days earlier. The Civic discharged Mr. Coulson soon after on October 23, 2022. It was noted that his delusions had “cleared up quickly” on the unit. Mr. Coulson did not feel he had a substance use issue; he refused recommended addiction support. This was despite his stating he had decided to use amphetamines again because it was “something an addict does”.
Mr. Coulson was admitted to hospital once again, under the Mental Health Act, for three days at the end of October 2022. He soon after signed himself out, contrary to medical advice. The same pattern repeated itself at the end of November 2022 when Mr. Coulson was again admitted to hospital under a Form 1.
The 2023 reporting period saw further hospital admissions for Mr. Coulson. These involved reports of increasing thoughts of suicide and increasing use of stimulants, along with misuse of certain medications. Through December 2023 and January 2024, Mr. Coulson continued to regularly use crack cocaine. Suicidal thoughts were intermittently present. To help him with mood regulation, he was connected to an individual psychotherapist.
In February 2024, Mr. Coulson agreed to return to hospital because of suicidal ideation driven by delusions experienced in the context of ongoing stimulant use. While in hospital, he reported withdrawal symptoms and cravings. He became resistant to medications. At a restriction of liberties hearing held before the ORB in March 2024, it was found that Mr. Coulson’s restriction of liberties was justified, necessary and appropriate. It was noted that in the previous year, Mr. Coulson had been admitted to hospital on four occasions. The Board’s Reasons described his substance use as a “persistent concern” regarding the threat presented to public safety.
Recent Course: March 2024 to February 2025
- The hospital report documents a newly repeated pattern of substance abuse and destabilization throughout the year. The following passage comes from a recent set of Board Reasons following one in the series of Mr. Coulson’s hospitalizations:
Mr. Coulson has a complex profile where the primary psychiatric diagnosis is layered by his concurrent severe substance use disorder. Even though he is subject to a detention order, and in a controlled environment, his mental state remains unstable because he continues to use more crack cocaine and recently, has been using more often. Despite the use of antipsychotic medications, his mental state decompensates very quickly.
Following Mr. Coulson’s last admission to the ROMHC in October 2024, he remained on inpatient status. On January 14, 2025, he was transferred from the Forensic Rehabilitation Unit to the Concurrent Disorders Unit. The intention was to provide Mr. Coulson with inpatient rehabilitative therapy for his severe stimulant use disorder.
The forensic addictions counsellor, Ms. Heather Potter-Gilmour has been supporting Mr. Coulson for four years. In her most recent report, Ms. Potter-Gilmour notes that Mr. Coulson agreed to apply to a 28-day inpatient community-based addiction treatment program, Sobriety House. He completed a telephone interview and was placed on a wait list.
By December 4, 2024, Mr. Coulson was showing more insight about the connection between his substance use and his increased difficulty with mental health symptoms. He was forthcoming about a crack cocaine relapse, which had occurred while he was in the community on an off-ward pass. Admission into the intensive five-week Addiction Treatment Program at the hospital’s Concurrent Disorders Unit was swiftly granted when Mr. Coulson shared his opinion that he would “get more out of the program” if he were to be helped on an inpatient basis. He was admitted to the Concurrent Disorders Unit program on January 14, 2025.
Unfortunately, in the following days and weeks, things did not go as well as was hoped.
Evidence at the Hearing
Dr. Hwang testified that Mr. Coulson had relapsed on February 3 and 4, 2025. While on the Concurrent Disorders Unit, he used crack cocaine. Dr. Hwang described the treatment team’s concerns that Mr. Coulson had not been honest with them. The relapse to drug use saw Mr. Coulson transferred back to the Rehabilitation Unit on February 4.
Dr. Hwang highlighted three main concerns in her testimony: Firstly, Mr. Coulson was continuing to exhibit psychotic symptoms prior to the most recent use of crack cocaine. He was expressing delusions of telepathy, among other things, to various treatment team members. Insight into the relation between his psychotic symptoms and the risk of violence was not present. Secondly, Dr. Hwang noted the ongoing consumption of crack cocaine. There were at least three occasions when he had used, while on inpatient status. Moreover, according to Dr. Hwang, Mr. Coulson was also currently engaging in rule breaking behaviours following his most recent return to the Rehabilitation Unit. These included smoking in bathrooms. Thirdly, according to Dr. Hwang, Mr. Coulson is not at all ready to enter any form of residential treatment facility. Instead, he requires a much longer period of hospitalization for stabilization.
Dr. Hwang advocated that Mr. Coulson’s psychiatric care would best be served under a transfer from the Royal to the BMHC. He has not been there in the past and would not have the same ability to contact his usual drug supply sources. Dr. Hwang further noted that the BMHC currently has an addictions counsellor on staff who can offer 1:1 counselling service. This same resource is not currently available at the ROMHC.
Responding to questions put to her about possible community access privileges, Dr. Hwang also spoke of treatment challenges relating to oral Clozapine medication. Clozapine is the gold standard psychiatric medication for Schizophrenia. Clozapine would be ideal for Mr. Coulson. However, he does not tolerate any dose higher than 100mg without experiencing significant side effects. The hospital has made several attempts to select and adjust appropriate medications in the most recent months and years. Different combinations of medication still need to be worked out.
Dr. Hwang noted that Mr. Coulson has no family ties to Ottawa. His most recent apartment here was with the Salus organization. The unit is no longer available to him because Salus can no longer support his community living status. According to Dr. Hwang, in the next twelve months, Mr. Coulson will not be ready for discharge to a residential treatment facility. Unfortunately, this is the result of more than just ongoing drug use but is also due to persisting psychotic symptoms.
Dr. Hwang confirmed that the BMHC is prepared to accept Mr. Coulson to their facility. They have advised Dr. Hwang that their wait list leads them to believe they could receive Mr. Coulson on a transfer in April or May.
Dr. Hwang responded to questions posed by Ms. Munsterman on behalf of the patient. Dr. Hwang explained that Mr. Coulson’s parents live in the Pembroke area. There has been no major contact over the past months. Earlier, the parents would come to Ottawa to see Mr. Coulson more frequently. He has done very little to contact them on his own.
Asked about access to illicit substances in Brockville, Dr. Hwang conceded that the same problems exist in that community. However, Mr. Coulson’s ability to access drugs in Ottawa has seen him obtain drugs soon after leaving the hospital grounds on shorter community access visits.
The hospital called no further evidence.
Evidence of Ashley Coulson
Ms. Munsterman invited her client to testify. Mr. Coulson advised that he felt the prospect of going to Brockville severely depressing. Mr. Coulson expressed having had hopes to go to Lebreton house and that he was still interested in doing residential treatment, including Sobriety House. Mr. Coulson expressed the view that he would be better here in Ottawa, where “I know most of the nurses”.
A Board member asked about Dr. Hwang’s concern about increasing use of drugs. Mr. Coulson explained that drugs are everywhere. Mr. Coulson advised that his addictions’ counsellors at the ROMHC were good to work with. Asked about any current ties to Ottawa, Mr. Coulson responded that apart from wanting to get back to skateboarding in the Spring, he does not really have much by way of personal contacts in the City of Ottawa. He described himself as “pretty much a lone wolf”.
The parties presented no further evidence.
Submissions of the Parties
Counsel for the Attorney-General and the hospital representative joined in strongly recommending that Mr. Coulson’s care be transferred to the BMHC. Both parties advised that Mr. Coulson’s recent behaviours render him unsafe to live in the community. In the same vein, it was submitted that travel passes which are set out in the existing disposition should no longer form part of the disposition, having regard to ongoing difficulties.
Counsel for the Attorney- General was prepared to agree that Mr. Coulson be permitted, when he is ready, to attend at a residential addictions’ treatment program in Ontario.
On behalf of Mr. Coulson, Ms. Munsterman opposed the removal of any existing privileges. She also strongly opposed the recommendation for transfer to Brockville. Ms. Munsterman urged the panel to consider that keeping the existing privileges in place can offer the patient a positive motivating influence. While certain privileges can remain in place, it does not mean that Mr. Coulson will be exercising them. The patient will only be able to access such privileges later, once the hospital deems him ready. Otherwise, if he is not ready, privileges will simply not be granted.
By way of alternative submission, Ms. Munsterman stated that in the event a transfer to Brockville is ordered, all existing terms should be maintained.
Ms. Munsterman disagreed with the hospital's position about the reduced availability of illicit substances at Brockville. Ms. Munsterman submitted that drugs are still readily available at both Ottawa and Brockville. Counsel described Mr. Coulson as sufficiently industrious, and functioning well enough, to be able to obtain drugs wherever he ends up, even within a hospital unit at the BMHC.
Conclusions and Disposition
Based on the evidence and the narrow focus brought to the hearing, the Board had no difficulty coming to the unanimous conclusion that Mr. Ashley Coulson continues to present a significant threat to the safety of the public. He suffers from a serious mental disorder which led to the commission of a serious and violent index offence. His condition of Schizophrenia is complicated by the most concerning chronic substance use disorder. Both diagnosed conditions have proved difficult to treat in recent years, and even more so in recent months.
Just as the issue of significant threat is not disputed by the parties, nor is the requirement for a detention order. Such a finding is amply demonstrated by the longstanding psychiatric diagnosis and behavioural history. The Board accepts the expert evidence provided by Dr. Hwang when she advised it is not reasonable to anticipate that Mr. Coulson would be ready to live in the community outside a hospital setting within the next twelve months.
For the last two or three years, Mr. Coulson’s overall mental health condition has significantly deteriorated. This is despite the best efforts of the hospital treatment team, including the outpatient team and the Salus organization. Mr. Coulson’s related risk to public safety has increased. Having him continue the same path will not in any way advance Mr. Coulson’s clinical picture, nor will it promote any real improvement in resolving his most vexing substance use disorder.
While Mr. Coulson did speak well of the ROMHC counsellors who have been helping him, as stated by Dr. Hwang, a new and more concerning level of dishonesty has emerged. It was only a few weeks ago that Mr. Coulson was greatly looking forward to leaving the Forensic Rehabilitation Unit to start residential treatment at the hospital’s Concurrent Disorders Unit. Even under those strict controls, he was not able to refrain from accessing and using crack cocaine.
Unfortunately, things have come to an impossible point, indeed an impasse, for Mr. Coulson at the ROMHC. While he has been provided with some very good supports here in Ottawa, including with the Salus organization, Mr. Coulson has unfortunately burned through those supports. In our view, we do not see any realistic possibility that things will improve, short of transfer to a new hospital setting.
The Board agrees it is necessary and appropriate that Mr. Coulson be transferred to the BMHC as soon as possible. At the BMHC, increased resources will be provided in terms of 1:1 addictions’ counselling. Further, 1:1 psychological counselling service is available.
We are not opposed to maintaining most of the privileges and terms seen in the current disposition, but only after transfer to Brockville is completed. In other words, once Mr. Coulson is accepted at Brockville – and as that hospital may later come to decide - community access privileges, including potentially available travel privileges, could be contemplated within the coming twelve months. However, pending transfer while he remains at the ROMHC, it is not realistic for Mr. Coulson to access the Ottawa community unless strictly accompanied by hospital staff.
For these reasons, having regard to the primary need to keep the public safe, while balancing the patient’s mental condition, his reintegration and other needs, the Board orders that Mr. Ashley Coulson’s care be transferred to the Brockville Mental Health Centre without delay. A detention order will issue. Separate terms and conditions for each respective hospital setting are set out in the formal disposition.
We thank the parties and counsel for their assistance.
DATED this 9th day of April 2025, at the City of Toronto, in the Toronto Region.
Mr. P. Hageraats
Legal Member
Office of the Registrar Ontario Review Board