Ontario Review Board
Re: Adrian Gbenle
ORB File No: 7406
Hearing held on: Wednesday, January 29, 2025
Place of Hearing: Ontario Shores Centre for Mental Health Sciences
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Mr. C. Flanagan
Members: Dr. R. Sheppard Dr. M. Kalia Ms. J. Greenwood Mr. J. Cyr
Parties Appearing:
Accused: Adrian Gbenle Counsel: Mr. T. Whillier
Person in charge of hospital: Counsel: Ms. A. Marshall
Attorney-General of Ontario: Counsel: Ms. N. MacDonald
REASONS FOR DISPOSITION
(Dated April 9, 2025)
Introduction
On August 28, 2018, Adrian Gbenle was found not criminally responsible on account of mental disorder (NCR) on charges of assault and assaulting a peace officer, both contrary to the Criminal Code.
Mr. Gbenle is currently subject to the terms and conditions of a Disposition of the Ontario Review Board (“ORB”) dated November 14, 2023, discharging him into the community subject to certain conditions.
On January 29, 2025, a panel of the Board convened to review the Disposition in accordance with the requirements of s. 672.81(1) of the Criminal Code. Mr. T. Whillier, counsel for Mr. Gbenle, attended the hearing, as did Mr. Gbenle, his mother and grandmother. A Hospital Report dated October 31, 2024, and a Safety Plan (undated), were filed as exhibits at the hearing.
The issue to be determined is whether Mr. Gbenle continues to represent a significant threat to the safety of the public, as defined in section 672.5401 of the Criminal Code, and if so, the necessary and appropriate Disposition to manage that risk, having regard to the criteria set out in s. 672.54 of the Criminal Code.
Initial Position of the Parties
At the outset of the hearing, the parties were canvassed as to their recommendations to the Board.
Ms. Marshall, on behalf of the Hospital, submitted that Mr. Gbenle continues to be a significant threat to the safety of the public and recommended no change to the existing Disposition.
Ms. MacDonald, on behalf of the Attorney General of Ontario, supported the recommendation of the Hospital.
Mr. Whillier, on behalf of Mr. Gbenle, requested an Absolute Discharge Disposition.
Index Offence
- The circumstances of the index offences are taken from last year’s Reasons as follows:
“Assault
On Wednesday, June 7, 2017, at approximately 9:05 p.m., the complainant, [female complainant’s name], left her residence, located at [street address] in Thorold, with the victim, [male victim’s name], and was followed by a vehicle driven by the accused. [The male victim] turned south onto Sunset Way in [an] attempt to flee the following vehicle; however, the accused followed [the male victim] and [the female complainant] into the dead end of [a] housing complex. At this time, the accused parked his vehicle; then exited and approached [the male victim], who was outside of his vehicle. The accused proceeded to yell at [the male victim] and call him a paedophile. [The male victim] had no idea what the accused was referring to and attempted to deescalate the situation. The accused then punched [the male victim] in the face with his right hand. [The male victim] was able to defend himself, while [the female complainant] dialed 9-1-1, and pinned the male on the ground until police arrived. As a result of the accused punching [the male victim] in the face, he was charged with Assault, contrary to Section 266 of the Criminal Code.
Assault Peace Officer
On Wednesday, June 7, 2017, at approximately 9:18 p.m., police responded to an assault in the area of Barker Parkway and Sunset Way in Thorold. Upon arrival, they observed the accused being physically held by the victim, [male victim’s name]. As police investigated and split the two up, the accused immediately got to his feet and continued to try assaulting [the male victim], yelling, “You’re a paedophile”. Police attempted to communicate with the accused but were met with negative results and had to restrain him in order to prevent a continuation of the offence. As attempts were made to gain control of the accused, he elbowed Constable Critelli [in] the shoulder and continued to be combative. Many efforts were made to control the accused; however, none of them were successful. As a result of this, a conductive energy weapon was used and assisted in physically controlling the accused. As a result of the accused elbowing Constable Critelli on the right shoulder, he was further charged with Assaulting a Peace Officer, contrary to Section 267(1)(a) of the Criminal Code.
The accused was subsequently transported to Niagara Health System at 2147 hours to be medically assessed. The accused [was] advised he was under arrest at 10:35 p.m. for Assault and Assault Police. The accused was read his rights to counsel and caution, which he demonstrated he understood, and requested to speak with [counsel]. The accused was medically assessed and later taken to central cells to await a bail hearing.”
Personal Background/Psychiatric History
Mr. Gbenle’s personal background and psychiatric history are reviewed in the Hospital Report filed as an exhibit at the hearing.
Briefly, Mr. Gbenle was born in Toronto and at the age of two, he moved with his mother to the Niagara Region, following his parents’ divorce. Mr. Gbenle’s mother reported that her son was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) when he was eight years old. He responded well to medication, until 16 years of age, when he chose to discontinue it. At that time, he got involved with the wrong friends and began using illicit substances. He reported using marijuana on a casual basis, approximately one to three times a month. Mr. Gbenle has worked in such fields as landscaping, welding, auto mechanics, and general labour. He quit various jobs as he did not get along with co-workers.
About four years prior to the index offences, Mr. Gbenle lived in his own apartment in Niagara Falls, Ontario. His mother reported that during this time, her son expressed paranoid thoughts about his neighbours, including that they could “hear his thoughts”, “see him typing on the computer”, and that they had “super power hearing”. He lived at this residence for about three weeks before he decided to move back in with his mother. His paranoid beliefs and bizarre behaviour became more apparent when he came to live with her.
In late 2016, Mr. Gbenle began to demonstrate behaviours consistent with signs of mania. He was persistently irritable and dismissive with his mother and others when they did not agree with his conspiratorial beliefs or adopt his lifestyle. He began sleeping on the floor in the laundry room and covering electronic devices with foil at night. He became suspicious of people entering the home, and his social interest and interpersonal functioning declined.
By Easter 2017, his mother observed that her son was increasingly vocal about his beliefs concerning pedophile networks and told her that their neighbours were pedophiles. She recalled her son’s constant rants about the neighbours and pedophilic activity. On several occasions, Mr. Gbenle either warned or accused different neighbours of activity related to child molestation.
Two months before the index offences, Mr. Gbenle’s “ranting” increased from about 45 minutes to four hours daily, and the level of intensity, anger and agitation increased dramatically. He claimed to hear voices of children telling him about various pedophiles in the neighbourhood. His mother grew increasingly fearful of her son’s behaviour and the consequences of his outbursts.
In May 2017, Mr. Gbenle started keeping a journal of his activities. The journal entries detailed times and dates that he would patrol his neighbourhood, in search of those he believed were hosting deviant activities, such as ritual sacrifices, child prostitution or slavery. Mr. Gbenle’s behaviour escalated sufficiently for his mother to notify the police and mental health crisis services. On June 7, 2017, Mr. Gbenle was arrested for index offences.
Mr. Gbenle had no psychiatric admissions prior to the index offences. He has no criminal record. Following his arrest on the index offences, Mr. Gbenle was released on a court recognizance. He breached the terms of his recognizance on three separate occasions when he failed to report as required. On June 8, 2018, he was charged with failure to comply with recognizance, which was withdrawn on August 28, 2018.
On August 28, 2018, Mr. Gbenle was found NCR on the index offences. On November 7, 2018, he was transferred to the Waypoint Centre for Mental Health Care (Waypoint) pursuant to an ORB Disposition, dated October 19, 2018. He was subsequently transferred to Ontario Shores by the ORB on November 8, 2019. At the time of this hearing, Mr. Gbenle was living in the community pursuant to a Conditional Discharge Disposition.
Diagnosis
- Mr. Gbenle’s current diagnoses are Schizoaffective Disorder, Bipolar Type and Cannabis Use Disorder, moderate.
Evidence at the Hearing
The Hospital’s evidence was presented through the oral testimony of Dr. D. Pallandi to supplement the Hospital Report, filed as an exhibit at the hearing.
Dr. Pallandi has been Mr. Gbenle’s attending psychiatrist since 2022. During most of the reporting year, Mr. Gbenle’s interactions with the treatment team have been negative, reticent and hostile. The doctor advised that since October 2024, Mr. Gbenle has been working with a Peer Support Worker (PSW), obtained through the hospital. Since that time, Mr. Gbenle’s interactions with the treatment team have improved. Dr. Pallandi noted it was still early but hoped these positive interactions would continue.
Dr. Pallandi confirmed that Mr. Gbenle is using cannabis recreationally, with no observable impact on his mental health, and there is no evidence suggesting an increase in such use.
Mr. Gbenle is capable of consenting to treatment. On November 26, 2024, he elected to switch his antipsychotic medication, Abilify, from a long-acting injection to an oral tablet. Dr. Pallandi stated that Mr. Gbenle had expressed concerns about feeling a loss of energy, which according to Mr. Gbenle, has improved since switching to oral medication. Dr. Pallandi advised that, although he has remained stable, it is too soon to determine the long-term effect on his mental state and the treatment team is currently evaluating whether he will maintain his mental stability.
Dr. Pallandi emphasized that Mr. Gbenle has consistently wanted to reduce his antipsychotic medication, with the goal of stopping this medication altogether. The doctor stated that Mr. Gbenle has not wavered from this position. As set out in the Hospital Report, on page 67:
“Of particular importance, has been his enduring wish to reduce the dose of his antipsychotic medication. He began to suggest that we misunderstood his goal of reducing, rather than eliminating his medication. Despite levying our concerns about a dose reduction, he is in the midst of exercising his right to refuse the current dose of his medication (300 mg) in preference for half of the dose (150 mg). As of October 16th, 2024, no changes have been made to the dose, however, he wishes to embark upon this after his annual hearing.”
Dr. Pallandi stated that he has advised Mr. Gbenle to continue his medication indefinitely, stressing its critical importance for his well-being. The doctor highlighted that he has communicated this to him on several occasions, but Mr. Gbenle does not agree.
Dr. Pallandi advised that Mr. Gbenle’s insight is a concern. He does not have insight into his index offences and does not connect the symptoms of his major mental illness with conduct related to the index offences. The doctor highlighted that it was the symptoms of Mr. Gbenle’s illness that directly caused the index offences to transpire.
Dr. Pallandi was asked about Mr. Gbenle’s insight into the role his medication plays in managing his major mental illness. The doctor responded that this is the hub of the issue in considering the threat of safety to the public and the oversight of a forensic team. Mr. Gbenle does not believe he has a diagnosis of schizoaffective disorder and, in fact, goes as far as to say that four psychiatrists, including Dr. Pallandi, who have provided such a diagnosis, are all wrong. The doctor advised that when Mr. Gbenle has struggled with symptoms of his illness, he does not attribute them to an underlying mental condition. In this regard, he lacks the proper insight to take ongoing antipsychotic medication.
Dr. Pallandi was asked how quickly Mr. Gbenle would decompensate if his oral medication was reduced to half a dose or stopped altogether. The doctor responded that long-acting injectable medication gives a much longer buffer, even to several months to remain well, due to the residual effect of the medication. On oral medication, if medication is stopped, the mental deterioration will be multiple times faster than the long-acting injection. The other practical part is that with long-acting medication, we know the person is getting the medication; however, on oral medication, there is always a question whether the person is taking a lower dose of the medication or at all.
Dr. Pallandi was asked if Mr. Gbenle would seek assistance if he became symptomatic. The doctor stated that “if you asked me in the midst of when the therapeutic relationship was most challenging, I would have said it would be highly unlikely that he would have complied with anything the doctor asked him to do”. The doctor advised that given the recent improvement in the therapeutic relationship, Mr. Gbenle would be more likely, but he would still have concerns given what he knows about Mr. Gbenle’s history, including earlier in the reporting year.
Dr. Pallandi reviewed and concurred with the risk assessment by Cheryl Young, M.A., on pages 70-71 of the Hospital Report, dated October 29, 2024, which stated in part:
“Primary Re-Offence Scenario: The most likely re-offence scenario, considering an Absolute Discharge, would be if Mr. Gbenle were to engage in violent behaviour in the context of a relapse of active psychotic symptoms (e.g., paranoid beliefs related to the safety of himself or others), most likely due to reducing his dose of antipsychotic medication to a subtherapeutic level or ceasing antipsychotic medication entirely. In either case, it is also possible that Mr. Gbenle’s marijuana use may have a greater impact on his mental health, with the possibility to exacerbate his symptoms. In considering past behaviour, violence could include verbal aggression, pushing, striking others, or kicking. Based on his history, the most likely victims would include persons in his vicinity (i.e., neighbours or community members he incorporates into delusional belief system), police officers (i.e., if called to respond to his behaviour), or treatment providers…Overall, in the context of an Absolute Discharge from the ORB, Mr. Gbenle’s risk for violence is considered to be Moderate.”
Dr. Pallandi advised that Mr. Gbenle continues to remain a significant threat to the safety of the public and agreed that Mr. Gbenle would pose a risk to any person in public, including strangers and people coming to assist, as was the case with the index offences. In this regard, Dr. Pallandi adopted his summary of clinical risk on page 72 of the Hospital Report. The doctor stated that given the diagnosis and Mr. Gbenle’s history, which is substantial in the Hospital Report, when untreated, Mr. Gbenle is symptomatic, his risk is higher, and he engages in problematic conduct.
Dr. Pallandi reiterated that medication was the most important facet of Mr. Gbenle’s treatment and critical in him staying well, remaining asymptomatic, and keeping his risk low. The doctor emphasized that Mr. Gbenle’s lack of insight and disagreement with the fundamental notion that medication is necessary for the management of his risk remains a core issue to the ongoing significant threat to the safety of the public.
In the context of an Absolute Discharge Disposition, Dr. Pallandi reviewed a safety plan created by Mr. Gbenle who submitted it at the hearing. Although previously discussed, this was the doctor's first time seeing it. Dr. Pallandi found the plan encouraging but specifically noted the absence of medication, which he stated should be at the top of the list. The doctor commented that one of Mr. Gbenle’s hospital supports, identified on the plan, would not be available should he receive an Absolute Discharge Disposition. When asked, Dr. Pallandi confirmed that on such a plan, Mr. Gbenle remained a significant threat to the safety of the public.
Dr. Pallandi advised that at this juncture, an Absolute Discharge was not appropriate. If granted an Absolute Discharge Disposition, Dr. Pallandi advised that Mr. Gbenle would be more likely than not to stop his antipsychotic medication, and it would be highly unlikely that he would continue with any psychiatric services or follow up.
Asked about next year’s expectations, Dr. Pallandi advised he would like to see Mr. Gbenle continue to work with the treatment team, in a productive, respectful and mutually beneficial way. He should work on developing insight into the ongoing need for medication and continue to comply with his medication regimen. The doctor stated that Mr. Gbenle’s plan should be revised to be more realistic. This included a medication component and other means of psychiatric/psychological support in the community, in the event of an Absolute Discharge Disposition.
Dr. Pallandi confirmed that Mr. Gbenle has stable housing and employment and has presently enrolled in courses towards becoming a PSW. He also has support from his family and a PSW, who currently supports him. Although he may now have a family doctor, he does not have a community psychiatrist. The doctor stated that if Mr. Gbenle was to become unstable in the next few months, it was unrealistic for a general practitioner to manage him. Dr. Pallandi advised that with further improvement, Mr. Gbenle can move towards an Absolute Discharge Disposition in the coming year.
No further evidence was presented at the hearing.
Final Submissions of the Parties
Ms. Marshall, on behalf of the Hospital, maintained her initial position that Mr. Gbenle remained a significant threat to the safety of the public and that the existing Detention Disposition should remain in place. She submitted that Mr. Gbenle has a long-standing and ongoing intent to reduce or eliminate his antipsychotic medication which is a concern and impacts risk. She further submitted that in this regard, Mr. Gbenle has only recently switched from long-acting injectable medication to oral and in this context, decompensation can occur quickly. She also highlighted that Mr. Gbenle has maintained his residence, his employment, is pursuing education and enjoys support from his family and Peer Support Worker.
Ms. MacDonald, on behalf of the Attorney General of Ontario, adopted the hospital’s submissions. She acknowledged Mr. Gbenle’s family support and recent education initiative. Based on Dr. Pallandi's evidence and the Hospital Report, Ms. MacDonald submitted that Mr. Gbenle remains a significant public safety threat, and an Absolute Discharge Disposition is not appropriate at this time.
Mr. Whillier, on behalf of Mr. Gbenle, submitted that if there is any doubt that Mr. Gbenle remains a significant threat, he is entitled to an Absolute Discharge. He submitted that the significant risk is speculative, as is that he will discontinue treatment, experience symptoms and act out in a manner that will cause physical or psychological harm. Mr. Whillier submitted that Mr. Gbenle is engaged in the community, has full-time employment, lives independently, and is going to school. He submitted that he has support in the community, as identified in his safety plan, who can identify a decline in his mental state and the plan alleviates any concern should he discontinue treatment and experience the return of symptoms. He submitted Mr. Gbenle no longer represents a significant threat to the safety of the public.
Conclusion and Disposition
Having considered all the evidence presented at the hearing, the Board finds that Mr. Gbenle continues to pose a significant threat to the safety of the public as set out in s. 672.5401 of the Criminal Code. We make this finding based on the evidence of Dr. Pallandi and the evidence contained in the Hospital Report, and Mr. Gbenle’s Safety Plan, filed as exhibits at the hearing.
Mr. Gbenle has a major mental illness with a history of engaging in aggressive behaviour in the context of delusions that children in his neighbourhood were being abused by “pedophiles”. Although he has no psychiatric admissions prior to the index offences, the Hospital Report details increasing incidents of bizarre and troubling psychotic behaviour, including “patrolling” his neighbourhood and accusing persons of pedophilic activity, which ultimately led to an assault on an unsuspecting member of the public and police officer who intervened.
His illness has effectively been managed through the employment of pharmacological measures, in the form of antipsychotic medication, which he has been treated with since being under the Board’s jurisdiction. While his symptoms are not currently active, historically, the symptoms have contributed significantly to his risk and problematic behavior.
This Board finds that Mr. Gbenle remains a significant threat to the safety of the public. As stated by Dr. Pallandi, whose evidence we accept, antipsychotic medication is the most important facet of Mr. Gbenle’s treatment and crucial in him staying well, remaining asymptomatic, and keeping his risk low. Mr. Gbenle does not agree. In this regard, Mr. Gbenle is presently capable of consenting to treatment. As reported in the Hospital Report, he intends on reducing the dose of his antipsychotic medication by 50% following the hearing.
This Board notes that it has only been two months since Mr. Gbenle has switched his long-acting injectable antipsychotic medication to the oral dosage. In this regard, it is too soon to determine the long-term effect on his mental state and the treatment team continues to evaluate whether he will maintain his mental stability.
Further, as stated by Dr. Pallandi, whose evidence we accept, if granted an Absolute Discharge, Mr. Gbenle would be more likely than not to stop his antipsychotic medication, and it would be highly unlikely that he would continue with any psychiatric services or follow up. In this regard, it is noteworthy that Mr. Gbenle’s own proposed safety plan, filed as an exhibit at the hearing, does not include taking medication. As stated in the Hospital Report on page 71:
“The most likely re-offence scenario, considering an Absolute Discharge, would be if Mr. Gbenle were to engage in violent behaviour in the context of a relapse of active psychotic symptoms (e.g., paranoid beliefs related to the safety of himself or others), most likely due to reducing his dose of antipsychotic medication to a subtherapeutic level or ceasing antipsychotic medication entirely”.
In addition, Mr. Gbernle does not have a community psychiatrist. In this regard, Dr. Pallandi advised that if Mr. Gbenle was to become unstable in the next few months, it was unrealistic for a general practitioner to manage him.
Mr. Gbenle’s problematic interaction with his treatment team for most of the reporting year is also of some concern. Although this relationship has improved since his engagement with a Peer Support Worker, it is still early days. Should he begin to decompensate, there are still concerns whether Mr. Gbenle would seek assistance from the treatment team, given his past and recent history.
Mr. Gbenle’s insight is underdeveloped and remains a concern. Although a lack of insight is not of itself a basis to deny an Absolute Discharge1, it is clearly a factor in Mr. Gbenle’s significant risk consideration. He does not have insight into his index offences. As such, he does not associate his past inappropriate behaviour, including the index offences, as flowing from the symptoms of his illness. Further, he does not believe he has a diagnosis of schizoaffective disorder and does not attribute his symptoms to an underlying mental condition. His lack of insight and disagreement with the fundamental notion that medication is necessary for the management of his risk continues to be an important determinant of his ongoing significant threat to the safety of the public.
To his credit, Mr. Gbenle has continued to do well while adhering to his treatment regimen. His symptoms are under control, he remains stable, and there have been no episodes of violence. He has stable housing, employment, and has enrolled in school to become a PSW. Mr. Gbenle also enjoys support from his family and, more recently, from a PSW, who has proven to be beneficial.
This Board finds that at this juncture, an Absolute Discharge Disposition is premature. It may be that should Mr. Gbenle remain mentally stable, continue to work productively with his treatment team, adhere to his medication regime with better insight into his ongoing need for medication, and develop other means of psychiatric/psychological support in the community, he can move towards an Absolute Discharge Disposition in the coming year.
For the reasons set out above, we came to the unanimous conclusion that Mr. Gbenle remains a significant threat to the safety of public and that the most appropriate and necessary Disposition is the continuation of the existing Conditional Discharge Disposition on the same terms and conditions.
In reaching our decision, the Board has considered the safety of the public, Mr. Gbenle’s mental condition, his reintegration into society, and his other needs.
DATED this 9^th^ day of April 2025, at the City of Toronto, in the Toronto Region.
Mr. C. Flanagan
Legal Member
Office of the Registrar Ontario Review Board
Footnotes
- Kalra (Re), 2018 ONCA 833.```