Ontario Review Board
Re: Nathaniel Presta-Hislop
ORB File No: 7789
Hearing held on: Wednesday, April 2, 2025
Place of hearing: Ontario Shores Centre for Mental Health Sciences 700 Gordon Street, Whitby
Pursuant to: Sections 672.81(1) and 672.81(2.1) of the Criminal Code
Before:
Alternate Chairperson: Mr. J. Goldenberg
Members: Dr. P. Prendergast Dr. T. Stirpe Ms. N. Nathanson Mr. A. Mete
Parties Appearing:
Accused: Nathaniel Presta-Hislop Counsel: Ms. M. Perez
The person in charge of hospital: Counsel: Mr. K. Dow
Attorney General of Ontario: Counsel: Ms. N. MacDonald
REASONS FOR DECISION AND DISPOSITION
(Dated April 23, 2025)
On October 20, 2020, Nathaniel Presta-Hislop was found not criminally responsible by reason of mental disorder on charges of aggravated assault.
Mr. Presta-Hislop is currently subject to a Disposition of the Ontario Review Board dated March 18, 2024, by which he was ordered to be detained at a General Unit of the Forensic Program of Ontario Shores Centre for Mental Health Sciences (“Ontario Shores”) with a number of prohibitions and a number of privileges including the privilege of living in the community in supervised accommodation approved by the person in charge.
On Wednesday, April 2, 2025, the Ontario Review Board convened a hearing at Ontario Shores in order to conduct Mr. Presta-Hislop’s annual hearing.
In addition, by letter dated February 20, 2025, the Clinical Forensic Coordinator at Ontario Shores advised the Board as follows:
“Mr. Presta-Hislop is currently under the jurisdiction of the Ontario Review Board at Ontario Shores Centre for Mental Health Sciences. His annual Ontario Review Board was last held on March 7, 2024. He is currently an inpatient on the general Forensic Community Reintegration Unit (FCRU).
On January 6, 2025, Mr. Presta-Hislop was discharged from hospital to CMHA CREATE housing.
On February 12, 2025, Mr. Presta-Hislop was admitted to the FCRU after group home staff reported concerns regarding a change in Mr. Presta-Hislop’s mental status. Mr. Presta-Hislop denied substance use despite a recent positive urine screen and having cannabis in his possession. Since his return to hospital, Mr. Presta-Hislop has been restarted on clozapine and his dose is currently being titrated.”
- As a result, and with the agreement of all parties, the Board conducted both the Restriction Of Liberty hearing and Mr. Presta-Hislop’s annual review.
Position of the Parties
At the outset of the hearing, the parties were canvassed as to their recommendations to the Board.
Mr. Dow appeared for Ontario Shores. He advised of the hospital position that Mr. Presta-Hislop remains a significant threat to public safety, and if the Board so finds, the hospital is recommending a continuation of the Detention Order Disposition with the exact terms set out in last year’s Disposition.
Mr. Dow also advised of the hospital position that there was a restriction of liberty but that the restriction of liberty was totally warranted. The hospital had no choice but to return Mr. Presta-Hislop to hospital and Mr. Presta-Hislop’s ongoing stay in hospital does represent the least onerous and least restrictive decision available to the hospital.
Ms. MacDonald appeared for the Attorney General. Ms. MacDonald advised that she supported the hospital’s recommendation entirely both with respect to the annual review and with respect to the Restriction of Liberty hearing.
Ms. Perez appeared for Mr. Presta-Hislop. Ms. Perez first stated that she and her client are taking “no position” with respect to the restriction of liberty.
Ms. Perez advised that her client is requesting that he be subject to a Conditional Discharge rather than a Detention Order. Ms. Perez indicated that if the Board felt it necessary, her client would consent to a residence clause and would also consent to a take treatment clause.
Ms. Perez’s final request, on behalf of her client, is to remove the restriction against the use of alcohol. She made that request whether the panel continues with a Detention Order or agrees with a Conditional Discharge.
Index Offence:
- “The Peel Regional Police Service Arrest Report outlines details of the index offence, summarized as follows:
On February 15, 2020, police responded to an address in Mississauga. They located the victim, the accused's mother, suffering from several wounds caused by a bladed weapon. The victim resides with her son, the accused, at 32 Talbot Street in the City of Brampton. She related that she was seated in the living room when her son then abruptly came towards her with a large kitchen knife attempting to stick it repeatedly into her left side. A struggle ensued and Ms. Presta was able to remove the knife from the accused's hand, but he once again came towards her attempting to squish her with a wooden bar stool. Ms. Presta managed to barricade herself in her bedroom and called 911. The accused continued his attack by forcing his way into the bedroom and wrapping his hands around Ms. Presta's throat, choking her. He discontinued his attack and left the room, but re-entered, once again attempting to strangle his mother. The accused then left the room again, returning with a pair of scissors which he used to stab various parts of Ms. Presta's body, including her stomach, back and chest. He abruptly stopped this attack and then the police arrived at the home. Ms. Presta believed that her son was attempting to kill her.
Ms. Presta received multiple wounds including multiple puncture and slash wounds to her abdomen and chest, severe bruising to her abdomen and chest area, numerous cuts and slashes to her right hand and thumb and a severed ligament on her right thumb. She required reconstructive surgery to her right hand."
Evidence at Hearing:
The Board admitted into evidence the Hospital Report dated March 10, 2025 and a copy of the ROL Report dated March 26, 2025. In addition, the Board admitted into evidence the Ontario Shores letter of February 20, 2025 and finally, the Board admitted into evidence a copy of a note authored by Dr. Pallandi relating to the decision to return Mr. Presta-Hislop to hospital. The Hospital Report provides a great deal of information concerning Mr. Presta-Hislop, his personal history, his mental health history, details of prior admissions to hospital and details of the index offence.
As the Hospital Report was made an exhibit in this hearing, it is not necessary to reproduce the information contained in the Hospital Report in these Reasons. We do note, however, the stated diagnoses of:
Schizophrenia
Alcohol Use Disorder, moderate, in early remission
Cannabis Use Disorder, mild, in early remission
Cocaine Use Disorder, mild, in early remission
Tobacco Use Disorder, moderate
In addition to the documentary evidence, the Board heard from Dr. Pallandi. Dr. Pallandi first noted that he has only recently become involved with Mr. Presta-Hislop. Dr. Pallandi believes his involvement has been approximately one month. Dr. Pallandi, however, has reviewed the Hospital Report and authored the Restriction of Liberty Report. Dr. Pallandi adopts and accepts the contents of both Reports.
The doctor provided one update. Just recently (March 31, 2025) Mr. Presta-Hislop was discharged from the hospital and returned to his community residence. Dr. Pallandi first dealt with the return to hospital. As noted, Mr. Presta-Hislop was discharged to the hospital on January 6, 2025. As a result of information received from the hospital and information from the Forensic Outpatient Team, a decision was made to return Mr. Presta-Hislop to hospital on February 12, 2025. The doctor noted the contents of a note he authored.
We note the following:
“I wanted to bring to your attention some odd behaviours at CREATE staff have observed with NP-H over the past two days. Client threw up in the bathroom and did not clean up after themselves sometime in the early morning yesterday. When asked about this, client stated that they threw up two days ago and reported to be well. Client did not admit to throwing up in the bathroom and another client had to clean up same. At house meeting yesterday, we discussed cleaning up after yourself and I brought up the fact that someone threw up in the bathroom and left it for peer to clean, client was visibly uneasy when I brought this up but stayed quiet. Client does not take accountability even though staff has been trying to encourage client to do same.
Another peer at the house next door stated that they noticed puke on the snow bank near their door, and a few other spots at the back deck. I went to check said spot. There was puke in the snow closer to the back door at the K2 house, there was another set on the back deck closer to the K1 house as well. The third spot had what appears to be urine in the snow, close to the K1 back door where the clients and staff go in and all the time. Peers have reported seeing client behaviours as well.”
The letter asks “Are these signs of decompensation? We are very concerned about client’s behaviours”. As well, the letter noted that Mr. Presta-Hislop tested positive for cannabinoids from a sample collected on February 10, 2025. All of the above resulted in the hospital decision to bring Mr. Presta-Hislop back to hospital. Another reason supporting the return to hospital was Mr. Presta-Hislop’s lengthy history of using and misusing substances.
Dr. Pallandi was asked about his position on the issue of significant threat. Dr. Pallandi simply noted that he is satisfied that his patient remains a significant threat. Mr. Dow drew the doctor’s attention to page 42 of the Hospital Report and the Clinical Assessment of Risk set out therein. We note the following:
“It is the unanimous opinion of the treatment team that Mr. Presta-Hislop remains a significant threat to the safety of the public.
The most salient risk factor is his diagnosis of treatment resistant schizophrenia. In the past, when psychotic, he has exhibited both verbal aggression and physical violence, culminating in a very serious index offense. He has a history of noncompliance with treatment, despite being involved with assertive community treatment teams, and subject to community treatment orders. He did very well with treatment with clozapine. On this medication, he was able to complete university level courses, and was able to regain his driver's license, eventually earning a full G license. However, he insisted on changing this medication to Invega due to concerns re side effects. With the switch, staff began to notice subtle changes indicative of psychosis. For example, they began to observe him responding to internal stimuli. However, he adamantly denied any psychotic symptoms, and none were obvious on examination. His last dose of clozapine was on December 4, 2024. He will need to be carefully monitored in the community to assess for any signs of decompensation as a result of this medication change.
Another major risk factor is his history of substance use. He has been diagnosed with cocaine and cannabis use disorders. There is clear evidence that the use of substances increases his risk of psychosis”
Dr. Pallandi and the clinical team are of the opinion that a Detention Order is absolutely necessary. The hospital needs to be in a position to approve any community residence. In addition, the hospital needs the ability to return Mr. Presta-Hislop to hospital at the earliest signs of any decompensation. The doctor put it succinctly that it is simply too premature to consider a Disposition other than a Detention Order. The doctor noted that Mr. Presta-Hislop was in the community for less than a month and it was necessary to bring him back to hospital.
The doctor and clinical team strongly oppose any Disposition that would permit this patient to use alcohol. The doctor noted the stated diagnoses of Alcohol Use Disorder, moderate, in early remission.
The doctor was asked his opinion about Mr. Presta-Hislop’s insight. The doctor fairly noted that he has been involved with this gentleman for approximately one month and did not feel confident in opining on this issue. The doctor’s attention was drawn to a comment in the Hospital Report that the patient’s insight remains “poor”. Dr. Pallandi simply acknowledged that the issue of this patient’s insight is “an active issue”.
In response to questions from Ms. MacDonald, the doctor agreed that Mr. Presta-Hislop’s behaviour during his initial stay at CREATE is and was extremely bizarre. The doctor agreed with Ms. MacDonald’s comment that this patient does not accept accountability for his actions.
The doctor agreed that CREATE is transitional housing. The doctor also accepted that alcohol would only remain in one’s urine for a limited period of time. The doctor also noted, however, a number of instances when Mr. Presta-Hislop refused to provide samples. The doctor expressed his concern that use of alcohol could lead to use of cannabis and cocaine.
In response to questions from Ms. Perez, the doctor accepted that during Mr. Presta-Hislop’s time in the community there were no positive screens for alcohol. The doctor, however, went on to note the many occasions on which this patient declined to provide samples of urine.
The doctor agreed that the use of cocaine and cannabis played a role in the index offence and the doctor further agreed that he is unable to affirm or deny whether alcohol played a role in the index offence.
The doctor agreed with Ms. Perez’s suggestion that her client has “some level of insight” and he noted that for example he had been found capable of making treatment decisions. The doctor went on to note a number of positive things about Mr. Presta-Hislop. He is in full-time attendance at university. He has plans and hopes of working during the summer months and he has plans of returning to university next year.
No other evidence was heard at this hearing.
Final Submissions:
Each party maintained their original positions. It is the hospital’s position that Mr. Presta-Hislop is a significant threat to public safety and that the necessary and appropriate Disposition is a continuation of a Detention Order including all of the prohibitions set out last year which of course includes the prohibition against the use of alcohol.
Mr. Dow also asked the panel to accept the doctor’s opinion that a return to hospital was warranted and Mr. Presta-Hislop’s ongoing stay in hospital was the least onerous and least restrictive decision available to the hospital.
Ms. MacDonald accepted Mr. Dow’s submissions in their entirety.
Ms. Perez maintained her original position. She repeated that she and her client are not taking any position with respect to the restriction of liberty. She submitted that the Board is under an obligation to make a Disposition that is the least onerous and least restrictive consistent with public safety. In response to a question earlier from the Alternate Chair, we were provided with Mr. Presta-Hislop’s current address in the community.
Findings of the Board:
The Board accepts the evidence of Dr. Pallandi and the evidence contained in the two Hospital Reports. We have no doubt that it was absolutely necessary to return Mr. Presta-Hislop to hospital not only for the inappropriate conduct referred to in the doctor’s note but also from the fact that Mr. Presta-Hislop breached his Disposition by using cannabis within a few weeks of being discharged into the community. We accept without reservation that a Detention Order is necessary and appropriate. We note the current Disposition requires residing in supervised accommodation. The hospital absolutely needs the ability to approve a community residence. The panel also accepts that CREATE will not put up with the inappropriate conduct referred to above and of course would have the ability to terminate his residence in their facility.
We also agree that a Detention Order is necessary to return Mr. Presta-Hislop to hospital at the earliest signs of any inappropriate conduct.
The panel is unanimous that public safety would be compromised should we issue a Disposition that would permit Mr. Presta-Hislop to use alcohol. We are mindful of the doctor’s evidence of Mr. Presta-Hislop’s diagnosis regarding alcohol use.
Accordingly, we do find there was a restriction of liberty but it was warranted and remained the least onerous and least restrictive throughout Mr. Presta-Hislop’s stay in hospital.
We do find that he remains a significant threat to public safety and that a Detention Order with all of the terms set out in last year’s Disposition remains necessary and appropriate.
In reaching our Disposition, the Board has taken into consideration public safety, Mr. Presta-Hislop’s mental condition and his other needs, and Mr. Presta-Hislop’s reintegration into society.
DATED this 23rd day of April 2025, at the City of Toronto, in the Toronto Region.
Mr. J. Goldenberg Alternate Chairperson Office of the Registrar Ontario Review Board