Ontario Review Board
Re: James Gushue
ORB File No: 5298
Hearing held on: Monday, March 31, 2025
Place of hearing: Waypoint Centre for Mental Health Care 500 Church Street, Penetanguishene
Pursuant to: Section 672.81(1) of the Criminal Code
Before: Alternate Chairperson: Mr. M.D. Segal Members: Dr. K. Hand Dr. G. Kerry (via Zoom) Ms. M. Chamberlain (via Zoom) Mr. J. Cyr
Parties Appearing: Accused: James Gushue Counsel: Mr. A. McIver
The person in charge of hospital: Representative: Ms. T. Murdock
Attorney General of Ontario: Counsel: Ms. S. Curry
REASONS FOR DISPOSITION
(Dated April 30, 2025)
Introduction
James Gushue, age 37, was found not criminally responsible on account of mental disorder on a charge of attempted murder, on March 10, 2009.
On March 31, 2025, Mr. Gushue appeared before the Ontario Review Board (the “Board”) for his annual hearing from the Waypoint Centre for Mental Health Care (the “hospital”).
In preliminary positions the hospital, supported by Crown counsel, maintained that significant threat was present and that the current Disposition and its conditions continue to be appropriate. Mr. Gushue’s counsel disagreed on the issue of significant threat and articulated that Mr. Gushue wants to improve on the conditions of his stay.
The Board had before it as Exhibit 1, the Hospital Report dated February 27, 2025. By way of background, the Board had the most recent Dispositions and two sets of Reasons for Disposition.
Index Offences
- The circumstances giving rise to the index offences are excerpted from last year’s Reasons for Disposition, as follows:
"On September 2, 2008, Mr. Gushue was living with his two uncles, when he spontaneously got a paring knife from the kitchen, approached one of his uncles and, using the knife, stabbed and cut him. His other uncle intervened and together they managed to get the knife away from Mr. Gushue and subdue him until the police arrived.”
Background
- A brief review appears in the Reasons for a Restriction of Liberty heard February 11, 2025:
“Mr. Gushue’s personal background, legal and psychiatric history is set forth in detail in the Hospital Report dated March 19, 2024 (the “Hospital Report”). As this document was included as an Exhibit at the hearing, its contents will not be duplicated herein; however, we note that Mr. Gushue was raised by his parents, who continue to offer him their support.
Mr. Gushue’s childhood was uneventful. He began using alcohol and drugs at an early age and showed the first signs of mental illness when he was 18 years old. He was soon aggressive with family members and diagnosed with Schizophrenia.
He was moved from jail to hospital (under the Mental Health Act) in 2008, when he was 21 years old, in response to him repeatedly banging his head against the wall. The index offence occurred a couple of months later.
Mr. Gushue has a criminal record that includes many instances of failing to comply with undertakings, as well as theft and assaults.”
Diagnoses
- Mr. Gushue’s current diagnoses are:
- Treatment Resistant Schizophrenia;
- Antisocial Personality Disorder;
- Polysubstance Use Disorder (Alcohol, Cannabis, Cocaine) in sustained remission in a controlled environment; and
- Intellectual Disability, Mild.
Evidence at Hearing
Dr. Ismail, the patient’s attending psychiatrist, testified. Dr. Ismail described the recent changes to medication. Mr. Gushue has treatment refractory schizophrenia. His treatment history is complicated. There have been three consultations with the Medication and Psychology Psychosis Service (MAPPS), a nationally and internationally renowned centre of excellence giving advice on pharmacology and mental health based out of CAMH. The consultations were in 2016, 2021 and most recently on February 7, 2025. The advice arising out of the most recent consultation was to streamline the antipsychotic medications, and to curtail all antipsychotic medications except the olanzapine dose which should be increased. In addition, MAPS also endorsed continuing with electro- convulsive therapy. Mr. Gushue is receiving that once weekly. It would be desirable, according to Dr. Ismail, to have ECT administered twice a week. Mr. Gushue’s substitute decision maker, his mother, has had varying views on the appropriate number of ECT treatments per week.
Mr. Gushue is on the Awenda unit which specializes in persons with both schizophrenia and intellectual disability. A great deal of behavioural support is present there.
Mr. Gushue has a Crisis Prevention Plan. He has had six seclusion this past year. It is possible they may have been contributed to by changes to his medication and treatment regimen.
Mr. Gushue shas been observed to respond to external stimuli.
In considering the possibility of a Conditional Discharge, it is noted that it is not possible for Mr. Gushue to return to the family home and he has no housing to be discharged to. Then hospital report states that the treatment team needs to be able to approve housing. Dr. Ismail stated that Mr. Gushue requires a specialized group home and needs to have a sufficient period of stability before he can be considered for discharge
Because of profound ongoing medication changes, Mr. Gushue is in a very vulnerable situation.
From time-to-time, Mr. Gushue refuses his medication. There is a noncompliance history. If not in a hospital setting, there would be concerning issues about medication noncompliance. If Mr. Gushue stopped taking his medication, the risk of unprovoked violence would be real. Mr. Gushue has no insight into the risks associated with medication non-adherence or the risk that he poses for violence. The doctor indicated that Mr. Gushue has a propensity to lash out without warning and their staff are very cautious around the patient. Mr. Gushue would always be certifiable under the Mental Health Act. In the doctor’s view, if Mr. Gushue were discharged into the community, the patient would not seek out help.
It was noted that there were two circumstances around the time of the index offences when Mr. Gushue was in the community and stopped his medication.
In the doctor’s view, a Detention Order is the least onerous and least restrictive Disposition.
In the past year, the patient has experienced command hallucinations. He continues to expose himself. Moving the patient to a less supportive environment would be deleterious. He is treated well by staff who know him and who take a redirective approach when conduct issues arise.
Inappropriate behaviours continue to be directed at female staff. There are ongoing issues of him taking off his clothes and then flushing them down the toilet. Mr. Gushue likes some groups. Attendance can be managed by tangible rewards.
If he misses clozapine doses, deterioration can be quite rapid, within a few days.
Ideally, ECT should have a loading period of three times a week for some weeks. Following that what would be ideal would be administering it twice a week. Mr. Gushue does better with ECT administered twice a week, but the SDM would not agree, at least for now.
MAPPS found Mr. Gushue to be “ultra-treatment resistant”.
In the last few weeks, there has been a decrease in aggression toward people. He has been more compliant with redirection.
A major therapeutic goal is to reduce the use of seclusion.
The most recent MAPPS advice is to simplify antipsychotic medications by reducing use of other antipsychotics except for Clozapine medication combined with ECT. The Clozapine should be titrated up to 700 mg/day. A usual therapeutic dose is 700 to 900 units per day.
Mr. Gushue is mostly compliant with medication adherence but noncompliant a few times every year. Mr. Gushue occasionally flat out refuses his medication, or cheeks it.
On another unit without the intense support he receives, it would be difficult to administer his treatments.
When ECT has stopped, behaviours worsen. It is difficult for vocational opportunities to be pursued because of the limitations on privileges that apply to him.
In 2024, there was an instance where Mr. Gushue had to be sent to general hospital because he had an altered level of consciousness. That was at a time when the patient was on three antipsychotic medications. The dosage was reduced and there have been no repeat incidents. In answer to a question from a panel member, Dr. Ismail thought, given the presence of antisocial personality disorder, there may be scope to consider intermediary reinforcers. Mr. Gushue likes to participate in floor hockey, fitness and music appreciation. He has a DVD player and an MP3 player.
Final submissions mirrored preliminary positions.
Analysis
The panel finds that Mr. Gushue is optimally managed on Awenda. The patient's profile is complex. The descriptor “ultra-treatment resistant” appears apt. Antisocial personality disorder is present. While there have been several seclusions, it is observed that they may be tied to the number of medication and treatment changes this past reporting period. These include stops and starts regarding ECT, and, of course, the most recent direction from MAPPS on streamlining the administration of antipsychotic medications.
Mr. Gushue still exceeds the significant threat threshold. Violence and aggression and sexually inappropriate conduct are still regular features of behaviour. Incidents occur without provocation.
The hospital is hopeful that the new medication and treatment plan produces desirable results. Mr. Gushue’s psychiatrist will consider intermediary rewards as part of a menu of responses. Certainly, as sustained stability occurs, Mr. Gushue could be considered for a group home. The hospital needs to retain authority to approve his housing in order to manage the risks he poses to the safety of the public.
Mr. Gushue's medication and treatment is fluid. Very early results are promising. We wish Mr. Gushue well in the current year.
DATED this 30^th^ day of April 2025, at the City of Toronto, in the Region of Toronto.
Mr. M.D. Segal Alternate Chairperson
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Office of the Registrar Ontario Review Board