Ontario Review Board
Re: Wadea Al-Lala
ORB File No: 8471
Hearing held on: Thursday, March 13, 2025
Place of hearing: Centre for Addiction & Mental Health
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Ms. S. Clapp
Members: Dr. R. Sheppard Dr. S. Lessard Mr. D. Sandor Mr. J. Cyr
Parties Appearing:
Accused: Wadea Al-Lala Counsel: Ms. M. Perez
The Person in charge of Hospital: Counsel: Ms. A. Marshall
Attorney General of Ontario: Counsel: Mr. D. Brandes
REASONS FOR DISPOSITION
(Dated May 6, 2025)
Introduction:
On January 19, 2024, Wadea M. Al-Lala was found not criminally responsible on account of mental disorder on a charge of second-degree murder, contrary to the provisions of the Criminal Code of Canada. He is currently subject to a disposition of the Ontario Review Board detaining him at the Forensic Service of the Centre for Addiction and Mental Health, Toronto (hereinafter referred to as “the Hospital”). That detention disposition permits him privileges up to and including that of entering the community of the Greater Toronto Area, accompanied by staff or a person approved by the person in charge of the Hospital. It also subjects him to certain conditions, including that of abstaining absolutely from the non-medical use of alcohol, drugs, or any other intoxicant, and that of submitting samples of his breath or urine for the purpose of monitoring compliance with the abstain condition. He is also prohibited from having weapons in his possession, and from contacting the parents of the victim of the index offence.
On March 13, 2025, a panel of the Ontario Review Board convened a hearing to review that disposition. Mr. Al-Lala was present for the hearing, represented by his lawyer Ms. Perez. Also in attendance was Dr B. Chan (Mr. Al-Lala’s treating psychiatrist), Mr. Al-Lala’s parents, and two friends of the victim of the index offence Ms. Maryanne Blandizzi. An Arabic-English interpreter was provided to assist Mr. Al-Lala’s parents with simultaneous translation.
The record for the hearing consisted of the Notice of Hearing, the last Disposition, and the Reasons for that Disposition. On the consent of all parties, a Hospital Report, dated February 18, 2025, was entered into evidence as an exhibit. Two other documents were also entered into evidence as exhibits, namely, a Victim Impact Statement authored by Maryanne Blandizzi’s father and mother, Giuseppe and Lila Blandizzi, dated March 7, 2025, and a Victim Impact Statement of her friend Raegan Burrage, also dated March 7, 2025. These Victim Impact Statements both consisted of elements that fell outside of the purview of section 672.5(14) of the Criminal Code. All parties agreed that the Board could accept the Victim Impact Statements and disabuse itself of the portions of each that did not relate strictly to the harm and loss suffered by the victims of the index offence. Paragraph 51 of the decision of the Ontario Court of Appeal in Re Klem, 2016 ONCA 119 was referenced in this regard by Ms. Perez for Mr. Al-Lala.
Accordingly, though the Victim Impact Statements consisted of several statements that could be considered to be inflammatory and irrelevant, the Board received the same. It was mindful nonetheless to entirely disabuse itself of opinions expressed in each about the offender and the punishment the victims clearly feel he should receive. This was especially the case where the victims expressed opinions that fell within the core exercise of the panel’s expertise, namely, those objectives of the forensic mental health care system set out in section 672.54 of the Criminal Code.
A final document was entered into evidence by Mr. Al-Lala’s lawyer on the consent of all parties as exhibit 4. This was a letter dated January 3, 2025, authored by Ms. Megan MacDonald, the director of an educational program Mr. Al-Lala has engaged well with through Amadeusz. That letter provides positive details associated with Mr. Al-Lala’s level of participation with that program.
Following this, the parties were canvassed for initial positions. All parties agreed that Mr. Al-Lala continued to represent a significant threat to the safety of the public as that term is defined in section 672.5401 of the Criminal Code and as it has been explained by the Supreme Court of Canada in Winko v. British Columbia (Forensic Psychiatric Institute), 1999 CanLII 694 (SCC), [1999] 2 S.C.R. 625. They all also agreed that a detention disposition was necessary and appropriate to manage the threat posed, having regard to the objectives set out in section 672.54 of the Criminal Code.
There was disagreement however regarding the scope of privileges that would form part of the detention disposition. The Hospital proposed, at the hearing’s outset, that Mr. Al-Lala be granted firstly the privilege of indirectly supervised access to the community. It further took the position that the detention disposition should grant him the privilege of living in the community in accommodations approved by the person in charge of the Hospital. Counsel for Mr. Al-Lala joined with the Hospital in that position. The representative of the Attorney General expressed clear concerns regarding both proposed privileges and submitted that the detention disposition should be maintained without change.
For the reasons that follow, the Board finds that Mr. Al-Lala represents a significant threat to the safety of the public and that a detention order is necessary to manage that risk. In coming to this conclusion, the Board has specifically turned its attention to its mandate to ensure the safety of the public, which remains the primary objective under s. 672.54 of the Criminal Code. It has also considered the other objectives set out in that section, being the need to ensure that Mr. Al-Lala’s mental health and other needs are met, including the ultimate objective of reintegration into the community. The Board agrees with the Hospital and with counsel for Mr. Al-Lala that the extension of privileges to include indirectly supervised access to the community can be undertaken while assuring the safety of the public. It agrees that the evidence at this stage supports the conclusion that this extension satisfies the objectives of assuring that Mr. Al-Lala’s mental health and other needs are met, including that of reintegration into the community. It strongly disagrees, however, that either the primary objective or the other objectives of s. 672.54 of the Criminal Code are satisfied by coupling this privilege with that of living in the community in accommodations approved by the person in charge of the Hospital. The Board has denied the granting of this privilege.
Evidence at the hearing
The evidence at the hearing came from the exhibits mentioned and from the live testimony offered by Dr Chan, Mr. Al-Lala’s treating psychiatrist. Dr Chan is a senior psychiatry resident who has been directly involved in Mr. Al-Lala’s care.
Dealing firstly with exhibit 1, the Hospital Report, it sets out the circumstances of the index offence as drawn from a draft Agreed Statement of Facts. The index offence set out at page 11 of the Hospital Report aligns with the summary provided in last year’s Reasons.
Mr. Wadea AL-LALA met Ms. Maryanne Blandizzi approximately two weeks prior to November 22, 2020. He met her through Mr. George Altounhain, who also resided in that building. She had agreed to assist Mr. Al-Lala with his immigration issues. On November 19, 2022, Mr. Baldeep Bath, Inland Enforcement Officer with the Canada Border Services Agency, spoke to Mr. Al-Lala and advised him that there were arrangements being made for his deportation.
On November 22, 2020, at approximately 11:37 am, Mr. Al-Lala, met with Ms. Blandizzi at her apartment.
At 1:27 pm on this same date, Mr. Al-Lala made a call from his phone to the phone number of his girlfriend Ramandeep Kaur. The call lasted 17 seconds.
Shortly after this phone call ended, Mr. Al-Lala attacked and assaulted Ms. Blandizzi with a knife, stabbing her multiple times in her apartment. The attack continued into the public hallway on the 5th floor of the building. Ms. Blandizzi was seriously injured in this attack and, later that same day, died of the injuries.
Throughout the attack on her, Ms. Blandizzi was yelling and screaming for help. A number of her neighbours from the fifth floor of the building heard her screams and opened their apartment doors in response. A number of these neighbours witnessed the continued attack by Mr. Al-Lala on Ms. Blandizzi, and some of them acted to intervene and stop the assault.
One of the neighbours from the 5th floor, Mr. Michael Campbell, brought a wooden baseball bat from his apartment and struck Mr. Al-Lala numerous times, in an attempt to stop his assault on Ms. Blandizzi. One of the blows damaged the knife Mr. Al-Lala was holding. Another blow knocked Mr. Al-Lala unconscious for a short period of time. Mr. Al-Lala then regained consciousness, picked up the broken knife, and continued his assault on Ms. Blandizzi.
Once Mr. Al-Lala had ended his attack on Ms. Blandizzi, he discarded the knife that he had used, leaving it on the floor, and he fled from the public hallway on the 5th floor of the building. He went down the stairs to the lobby and exited the building. At that time, he was wearing socks but no shoes, and he was wearing a white T-shirt that was heavily stained with blood.
After he exited the building, Mr. Al-Lala approached a grey minivan being driven eastbound along Rowena Drive by Mr. Ahmed Sido. Mr. Al-Lala moved to stand directly in front of Mr. Sido’s car, causing him to stop. Mr. Al-Lala spoke with Mr. Sido and then moved to pen the rear passenger door of the minivan. Mr. Al-Lala attempted to get into the minivan, but Mr. Sido drove on, preventing him from gaining entry.
At approximately 1:30 pm on this same date, P.C. Burnside of the Toronto Police Service arrived and saw Mr. Al-Lala standing in the road. P.C. Burnside detained Mr. Al-Lala, put him into handcuffs, and placed him into the back of his police scout car.
Mr. Al-Lala had injuries and was bleeding from lacerations on his palms. He was attended to and bandaged by a paramedic from Toronto Paramedic Service. He was transported to Scarborough General Hospital in an ambulance. He received medical treatment for the injuries to his hands at the hospital and he was eventually discharged from the hospital and into police custody.
The Hospital Report contains significant details regarding Mr. Al-Lala’s personal and developmental history. He is a 25-year-old single man of Palestinian heritage but was raised primarily in Saudi Arabia. He came to Canada in 2017 when he was 17 years old and attended the University of PEI. While he has not reported a history of physical or sexual abuse or neglect as a child, he did describe instances of some severe physical discipline at his mother’s hands. Even so, Mr. Al-Lala has a supportive family that stood by him as he completed his high school diploma in Saudi Arabia with a 97% average. There are no indications that he struggled with any mental health or behavioural issues over the course of his childhood.
By 2018, Mr. Al-Lala was living in Toronto. Here, he took ESL at the International Language Academy of Canada, and he began experiencing difficulties. According to the Hospital Report, he advised that he “had problems… started smoking marijuana and I had schizophrenia, and I went back to Jordan for treatment.” He began experiencing auditory hallucinations and paranoid delusions. He experienced delusions of grandeur and believed at one point that he was Jesus Christ and at another point that he was Moses. He persisted in significant daily use of cannabis and was hospitalized in Jordan. There, he was treated with antipsychotic medication for a period of two months before transferring to a public hospital, following which he returned to Toronto to live with his family and, importantly, became noncompliant with his prescribed medications. This noncompliance is a concern noted on page 4 of the Hospital Report (“Mr. Al-Lala’s father stated that he believed his son stopped taking his medications soon thereafter”), and page 8, seemingly in reference to the same general period of time. Surrounding that, the Hospital Report discloses two scenarios of medication noncompliance. At one point, it states that “He discontinued the medications after one to two months as he was unable to pay for the medical care.” Then on page 6, Mr. Al-Lala is reported as saying that “it made him too sleepy ‘so I just threw it away.’” Mr. Al-Lala’s father reported that “his son’s behaviour took a turn after he ran out of the medications prescribed to him at St. Michael’s Hospital.”
In April 2019, Mr. Al-Lala presented with his mother at the Rapid Access Clinic for a mental health assessment. A history of cannabis use disorder was noted. He was experiencing grandiose delusions and manifesting irritability. It was noted that his similar episodes in Jordan were resolved with antipsychotic medications. Mr. Al-Lala attended addictions groups but was disorganized and disruptive to other group members. At that time, it was agreed that Mr. Al-Lala’s symptoms seemed to be mental health related and not substance induced.
Mr. Al-Lala’s medication noncompliance aligned with increasing difficulties with the criminal justice system. The Hospital Report indicates that Mr. Al-Lala was unable to finish further schooling as he threatened to kill another student. He pled guilty to uttering threats but indicated he had no memory of what was said in court. He minimized the seriousness of the charge and said that the threat was made in a way of joking. He acknowledged using cannabis and experiencing paranoia at the time. He was given a sentence of 6 months house arrest and probation for 6 months.
Meanwhile, Mr. Al-Lala presents as a very intelligent individual. This is noted in exhibit 4 as well as in the Hospital Report where it is explained that, following his period of house arrest, Mr. Al-Lala completed a Business Fundamentals course and was working on a course in Accounting Principles. His employment history is unremarkable, though he notes that he occasionally went to work high – something he stopped because he felt he did not function well at work when intoxicated.
Mr. Al-Lala’s use of substances worsened in conjunction with his noncompliance with recommended treatment. One to two months prior to the index offence, he began using cocaine, magic mushrooms, MDMA, Xanax and Percocet in addition to cannabis. He began experiencing delusions of grandeur and paranoia as well as persecutory delusions that someone hated him and wanted to attack him. He reported doing “crystal” on one occasion that led to increased paranoia a few weeks before the index offence and admitted that he was under the influence and, apparently, not taking prescribed medications when he killed Maryanne Blandizzi. This led to Mr. Al-Lala’s father blaming the victim for her own murder, alleging that she had given Mr. Al-Lala drugs.
Following his arrest after the index offence, Mr. Al-Lala was seen by Dr. Chaimowitz in jail. He was noted to be experiencing anxiety, was disoriented and had illogical thought pattern. Concerns were expressed that he was struggling with a possible adjustment disorder – a personality disorder that as of the date of the hearing has not been adequately psychologically assessed. Over the course of his stay in custody, he had various contacts with psychiatry but there was no clear indication of psychosis throughout the period. He did report hearing voices, and that “shadows” had “taken him by the neck.” It is notable that, at that time, he was not taking any psychiatric medications besides lorazepam.
Symptoms improved when Mr. Al-Lala began taking aripiprazole, olanzapine, and prazosin. It is notable that Mr. Al-Lala was also not using drugs while in a highly controlled setting. Mr. Al-Lala raised this while in custody in a context that suggests a minimization of his psychosis and possible personality disorder. The Hospital Report notes that on February 29, 2024, Mr. Al-Lala reported that he was diagnosed with psychosis, but then specified that it was a drug-induced psychosis without mentioning the concerns raised regarding a possible adjustment disorder or the diagnosis received in Jordan of Schizophrenia. He has displayed little insight into his need for medications.
Mr. Al-Lala’s course in the Hospital following the NCR finding is set out at page 13 of the Hospital Report. Inasmuch as this information is contained in the most recent Reasons for Disposition, it is unnecessary to duplicate the summary contained there. It is sufficient to note that from the time of his last review board hearing, Mr. Al-Lala has complied with medication in a controlled setting and, over the last review period, progressed slowly but steadily in terms of pass progression.
Mr. Al-Lala was transferred from the secure Forensic Assessment and Triage Unit (FATU) unit at the Hospital to the Forensic Secure Unit B (FSUB) unit on June 18, 2024. He transitioned to a long-acting injectable antipsychotic medication. Then, in January 2025, he transitioned further to a long-acting injectable antipsychotic medication that was administered every three months. In the highly controlled secure environment, the Hospital was assured he abstained from the use of substances, including cannabis. While he demonstrated some volatility, irritability, defiance and rule-breaking, he did not endorse thoughts of self-harm or suicidality or violent ideation.
He did, however, display multiple problematic behaviours while on the FSUB. He had difficulty adhering to rules and maintaining appropriate boundaries. He required repeated reminders and interventions from staff. He showed little insight into the importance of boundaries, rules and parameters set by the Hospital so as to manage the risk all have agreed he continues to pose to members of the public, including co-patients and staff in the Hospital. His interpersonal conflicts with both staff and co-patients were common. He engaged in intimidating behaviours directed to staff and engaged in verbal altercations with other patients. He indicated at times that he felt targeted and unsafe. He was observed displaying behaviours that instigated and provoked co-patients.
Mr. Al-Lala’s insight, according to the Hospital Report, has been inconsistent. He has minimized his behaviours and shifted blame to others – a concerning trend given that his father has engaged in victim blaming. This does not add much pragmatic encouragement of Mr. Al-Lala’s insight into the role his major mental illness, medication noncompliance and substance abuse played in her murder. The Hospital Report is clear that, while substance use was acutely proximate to the commission of the index offence, it was accompanied by distinct and purposeful decisions made by Mr. Al-Lala to cease taking the antipsychotic medications he had been prescribed in Jordan, and then again in Toronto. Notably, as Mr. Al-Lala began taking the longer-acting injectable, his insight seemed to improve as he showed more consistent behavioural regulation and less frequent issues with staff and co-patients. The correlation between this medication and the improvement is notable. What was constant over this reporting period is Mr. Al-Lala’s abstinence from substances while in a highly controlled Hospital setting. What changed, factually, that correlated with the improved behaviour and insight was, as in Jordan, the move to the long-acting injectable antipsychotic medication and compliance with that recommended treatment.
Of importance when considering the issue of expansion of Mr. Al-Lala’s privileges to indirectly supervised community passes is what the Hospital Report describes regarding Mr. Al-Lala’s engagement in groups, programming, and pass (aka privilege) progression over the course of the last review period. In this respect, Mr. Al-Lala has done very well. He attained numerous structured groups, a comprehensive and impressive list of which is found at page 17 of the Hospital Report. He engaged in education by enrolling in an Organizational Behaviour course with Centennial College and completed the Business Management Marketing Program. In the Therapeutic Neighbourhood programs, he engaged in Cognitive Behavioural Therapy, Discharge Readiness, Rising with Resilience and Peer Support groups. In his role as a canteen operator four days a week, he worked independently and contributed to the unit environment. This is encouraging, particularly in a review setting where indirectly supervised community passes are proposed by the Hospital, to take place with a potential experimental cessation of the antipsychotics that have correlated with behavioural stability in the Hospital, and with the increased risk of relapse into the use of substances that will arise with indirectly supervised community access.
The Hospital Report includes a Risk Assessment at page 19. It summarises that, in addition to historical risk factors that are immutable, Mr. Al-Lala manifests clinical risk factors that were deemed “present and highly relevant,” including recent problems with Treatment and Supervision Response. Risk management factors were also deemed “present and highly relevant” included future problems with treatment or supervision response and stress or coping. These are important considerations, again, when the Hospital’s proposal is to expose Mr. Al-Lala to increased stress and challenges to coping by virtue of the expansion of community access privileges. The Hospital Report notes that Mr. Al-Lala’s passes were held twice fairly recently, including just a month before this hearing.
When discussing ongoing uncertainties associated with Mr. Al-Lala’s major mental illness, the Hospital Report states:
The psychotic symptoms experienced by Mr. Al-Lala in the past all occurred in the context of heavy cannabis use, in addition to the use of other substances. His presentation at the time of the index offence, in which his symptoms appeared suddenly, and appeared to resolve very rapidly, are most consistent with a substance-induced psychotic disorder rather than a primary psychotic disorder such as schizophrenia. Even when reporting possible psychotic symptoms while in jail in 2021, there were no objective signs of psychosis. Furthermore, there was no evidence of psychosis during this admission, when Mr. Al-Lala would not have had access to substances.
However, it is possible that Mr. Al-Lala’s stable mental state since his arrest and incarceration is due to treatment with antipsychotic medications. As such, it is not yet possible to rule out a primary psychotic disorder, and this diagnosis should continue to be considered over time.
This is important given the limited narrative asserted in the Hospital Report’s description of Mr. Al-Lala’s Re-offence Scenario where it indicates only that “Mr. Al-Lala was found NCR for a violent offence, which occurred secondary to psychotic symptoms in the context of substance use.” The omission of Mr. Al-Lala’s noncompliance with antipsychotic medication that had stabilized him in Jordan, the cessation of which preceded his return to use of substances and continued to reign as a factor at the time of the commission of the index offence is a concern. This concern was made poignant when Dr. Chan testified with confidence that Mr. Al-Lala had “never been non-compliant with medication” – an assertion Dr. Chan was obliged to recant and correct when directed to the contents of the Hospital Report that set out clearly that Mr. Al-Lala required antipsychotic medications in Jordan, was stable while using them, either “threw them out” in Canada or stopped being able to afford them, and experienced changes in his mental wellness that were observed by his father. The omission of this history from the Hospital Report’s Re-offence Scenario, in the absence of an explanation for the omission, is a concern, particularly where it is being proposed that an experimental cessation of medication be attempted, either in the Hospital or, possibly, in a context of community accommodation.
Turning then to Dr Chan’s evidence, he first indicated that he had reviewed the Hospital Report and agreed with its contents. He admitted that currently, Mr. Al-Lala was on a secure forensic unit and had not yet been transferred to a general forensic unit. His opinion differed to some degree from the Hospital Report as he suggested that Mr. Al-Lala’s rule-breaking behaviour seemed to be based on personality construct and lack of maturity. The Board did not, in this regard, have the benefit of a personality assessment.
Dr Chan testified that he wanted to see more progress in Mr. Al-Lala’s ability to follow rules before he could be discharged to the community. He testified that he considered Mr. Al-Lala’s supportive relationship with his family a protective factor, though he acknowledged in response to questions from the panel that the supportive qualities of that relationship required some improvement given the family’s history of blaming the victim of the index offence and the minimization of Mr. Al-Lala’s substance use that preceded the index offence.
Dr Chan confirmed that Mr. Al-Lala’s working diagnoses are:
- Schizophrenia
- Substance-induced psychotic disorder.
He indicated that it was difficult at this early stage to determine whether either-or, or both, of these major mental illnesses contributed to the index offence, given the facts that he is both abstaining from the use of substances in a highly controlled setting and is medication compliant with his long-acting injectable. For this reason, Dr Chan confirmed that a trial that takes Mr. Al-Lala off of his antipsychotic medications may be considered, however that decision will ultimately be up to the new treatment team that takes over Mr. Al-Lala’s care on a general forensic unit when he is transferred there.
Dr Chan testified that Mr. Al-Lala is expressing increased insight into the risks his substance use poses to the safety of the public. In the highly controlled environment, the Hospital and the most recent disposition provides, Mr. Al-Lala has expressed repeatedly that he plans to abstain from all substances moving forward. Dr Chan confirmed that Mr. Al-Lala recognizes that substance use played a significant role in bringing out psychotic symptoms and now understands that there may also be a primary psychosis (schizophrenia) (until recently Mr. Al-Lala adamantly denied that there may be a primary psychotic disorder involved and thought it was all drug-induced psychosis). He confirmed that in general, and notwithstanding the challenges described in the Hospital Report, Mr. Al-Lala’s relationship with the treatment team is positive, particularly since January 2025 (again, a period correlating with Mr. Al-Lala’s transition to his current long-acting injectable medication).
When questioned on the topic of community living, Dr Chan testified that in the next year, Mr. Al-Lala “may” be considered suitable for community living, but that he would have to follow the pass ladder and rules while in Hospital. He would also have to continue with programs for treatment and management of both his symptoms and his behavioural concerns. At this stage, the process has not started in terms of exploring community living options for Mr. Al-Lala. Mr. Al-Lala has not yet progressed along the pass ladder in a manner so as to assess what type of accommodations would or could be approved. Availability of approved and appropriate accommodations also has yet to be considered. Dr Chan stated that all of these decisions would be made by the new treatment team on the general forensic unit when he is transferred there. On Dr Chan’s evidence, this is not a situation where a community living privilege is needed to obtain or maintain a place on a waiting list. The waiting list itself has not yet even been identified.
Dr Chan had reference to pages 23-24 of the Hospital Report and Mr. Al-Lala’s Risk Management Plan. He testified that the team is still getting to know him, given that he has only been under the Board’s jurisdiction for a year and has only been on the unit since June 19, 2024. Dr Chan confirmed again that there is still diagnostic uncertainty surrounding Mr. Al-Lala. He testified that it was difficult to predict how quickly Mr. Al-Lala would decompensate if he became non-compliant with his long-acting injectable, though he admitted that part of this consideration was informed by his error in concluding that Mr. Al-Lala had never been on or fallen noncompliant with antipsychotic medications in the past.
In response to questions from the representative of the Attorney General, Dr Chan confirmed that while Mr. Al-Lala has been abstinent from all substances in the highly controlled unit he is currently housed in, substances will become more available to him in a general setting and as he progresses on the pass ladder to indirectly supervised community access. Dr Chan confirmed that Mr. Al-Lala has not yet moved up to level 8 passes and that there is no guarantee that he will attain to that level over the course of the next review period. He explained that Mr. Al-Lala is currently at level 6 passes, which permit him to have indirectly supervised access to the Hospital grounds and passes in the community for specific purposes, usually associated with community programming, accompanied by an approved person. Dr Chan explained that level 7 passes will begin to introduce indirectly supervised access to the community for structured and specific therapeutic purposes. Level 8 passes would ultimately permit Mr. Al-Lala to be in the community for less structured purposes. Dr Chan said that it could take weeks to months before Mr. Al-Lala would be transitioned from the secure to the general unit and, thereby, becoming eligible for level 7 and 8 passes. He testified that, even with regard to movement up to level 7 and 8 passes, it was difficult to provide a timeline as “the transition to a more general unit may lead to an exacerbation of problematic behaviours.”
In response to questions from Mr. Al-Lala’s lawyer, Dr Chan testified that community living is a motivating factor for Mr. Al-Lala. He later testified, in response to questions from the panel on this issue that a number of things need to occur before Mr. Al-Lala would be considered for community living. He would need to progress on the pass ladder. He would need to continue to abstain from substances. He needs to continue to positively engage in programming. He would need to continue his course of mental stability as evidenced by an absence of primary psychotic symptoms, whether on or off antipsychotic medications. And of course, approved and appropriate accommodations would have to became available. At this stage, there are many unknowns. Dr Chan confirmed that if sufficient factors made placement a reality, or if Mr. Al-Lala’s placement on a waiting list would be facilitated by a disposition providing the privilege of community living, the Hospital could bring an application for an early review.
Counsel for Mr. Al-Lala questioned Dr Chan regarding Mr. Al-Lala’s ability to exercise empathy and whether this is a protective factor. Dr Chan said that Mr. Al-Lala was able to show understanding and appreciation for the positions of staff and patients when in difficult situations such as those addressing his oppositional and problematic behaviours. Dr Chan explained this by saying that these behavioural difficulties have been decreasing. When questioned on the extent or quality of the Mr. Al-Lala’s empathy by the panel, Dr Chan testified that while Mr. Al-Lala was able to express some empathy for the circumstances of other patients, he could not recall “any” expressions of empathy or sympathy made by Mr. Al-Lala for his parents or the victim and victims of the index offence. Dr Chan testified that in arriving at his conclusion that Mr. Al-Lala’s level of empathy provided a protective factor, he had neither asked Mr. Al-Lala nor considered the importance of examining these most important elements of empathic feeling and expression.
Counsel for Mr. Al-Lala confirmed that since being on the secure forensic unit, Mr. Al-Lala has consistently tested negative for substances. Dr Chan agreed that substances can be obtained by patients at the Hospital, notwithstanding the highly controlled setting provided by the Hospital – even on the secure forensic unit. He confirmed that Mr. Al-Lala has engaged in the appropriate use of approved-person passes, attending at Mosque in the community with his parents. It was unclear whether this attendance was indicative of a developing protective spirituality and religiosity, or whether Mr. Al-Lala’s engagement with family and the Mosque was driven by other factors of modest importance.
In response to questions from Ms. Perez, Dr Chan also testified that he would characterize Mr. Al-Lala’s cannabis use disorder as “mild.” He explained that this categorization refers to the significance of impact on Mr. Al-Lala’s life “now.” It is not a forecast or representation of what that categorization would be if Mr. Al-Lala were to change current factors such as the highly limited access to the community with its stressors or receipt of a long-acting injectable medication.
In addition, Dr Chan addressed the importance of transitioning Mr. Al-Lala to one-on-one programming associated with substance use-related disorders and other risk factors as privileges increase. He confirmed the progress mentioned in the Hospital Report that supports a conclusion that Mr. Al-Lala’s mental health and other needs require at this stage some “room to grow.” He also clarified that while Mr. Al-Lala did not himself propose a test period of non-medication, he was supportive of it. Dr Chan reiterated that although the experiment could be undertaken in a supervised inpatient setting, it was his opinion that a community setting for the experiment would more closely approximate a “real world setting” and would help confirm Mr. Al-Lala’s diagnoses. As will be addressed below, this raises concerns associated with the Board’s and the Hospital’s obligation under the primary objective described in section 672.54 of the Criminal Code.
There were some other difficulties apparent with the conclusions drawn by Dr Chan that became apparent over the course of questioning from the panel. Dr Chan’s erroneous presumption that Mr. Al-Lala had never before been prescribed, nor become non-compliant with, recommended antipsychotics has already been mentioned. In addition to this, Dr Chan opined, in response to questions from Mr. Al-Lala’s lawyer, that Mr. Al-Lala was simply immature, and that he was not seeing any antisociality driving his rule-breaking and other behaviours on the secure forensic unit. However, in response to questions from the panel he confirmed the following observations found in the Hospital Report that are not necessarily consistent with mere immaturity:
- In the first part of the last reporting period, Mr. Al-Lala engaged in “lots” of rule-breaking, argumentative behaviours, irritability, criticisms of staff, touching of a female co-patient in spite of being told not to, continuation of engagement in sexualized behaviours with a co-patient in spite of education and instruction from staff.
- From June 2024 to the date of the hearing, when laterally transferred to another secure forensic unit, Mr. Al-Lala showed volatility, multiple problematic behaviours and interpersonal conflicts with staff and co-patients and rule-breaking the frequency of which all continued but the severity of which decreased over time.
- Referencing page 16 of the Hospital Report, Mr. Al-Lala had engaged in screaming outside a nursing station, targeted co-patients, caused them to feel unsafe and, contrary to what Dr Chan had previously stated, had in fact engaged in verbal and physical altercations with others, some of which he initiated.
- Underwent a with-holding of passes just one month prior to this hearing as a result of his problematic behaviours.
- Is reported to have acted similarly when discontinuing his antipsychotics in Jordan and then discontinuing them after they were restarted in 2019 as has been discussed above.
Dr Chan conceded that these behaviours over this reporting period had caused the delay in what the treatment team had, the year before, unanimously supported – that is, Mr. Al-Lala’s transfer to a general forensic unit and to obtain indirectly supervised passes. He also conceded that these types of behaviours could be magnified as Mr. Al-Lala begins a transition into a world of expanding privileges and stresses. Dr Chan expressed an informed hope that this would not be the case, given the level of participation Mr. Al-Lala has shown in programming and the lack of symptoms he is seeing while Mr. Al-Lala abstains from substances and receives his current anti-psychotics. He conceded that Mr. Al-Lala’s insight, with these factors being considered, was in fact “partial” as concerned his major mental illness and need for medication.
In all of this, it remains unclear whether Mr. Al-Lala’s psychosis triggering- (or psychosis-aggravating) substance use precedes non-compliance with recommended anti-psychotics or whether it is non-compliance with anti-psychotics that has made him more susceptible to relapse and resultant rapidly decompensating substance use.
Submissions
At the conclusion of the hearing, the parties renewed their submissions as set out at the beginning of the process. All agreed that Mr. Al-Lala continued to represent a significant threat to the safety of the public. They also agreed that a detention order was necessary and represented the only disposition appropriately available given the primary objective of assuring the safety of the public and the other objectives of assuring that Mr. Al-Lala’s mental health and other needs, including that of reintegration into the community, are met.
The narrow issue argued in submissions focused rather on the scope of privileges to be permitted within that detention disposition. Counsel for the Hospital argued that the scope of privileges being sought, including that of residing in the community in accommodations approved by the person in charge, represented the least onerous and least restrictive disposition available under the circumstances. She conceded that, though Mr. Al-Lala had made progress over this review period, it was still uncertain whether he would be discharge. She expressed the importance of crafting a disposition that permits flexibility to grow privileges in accordance with, what is hoped will be, further progress.
The representative of the Attorney General, while concurring with the detention disposition disagreed with the Hospital regarding community living. He argued that the principle of “least onerous and least restrictive disposition available under the circumstances” is a concept that must be informed by a number of factors including the nature of the index offence and the type of risk to the community. He argued that, at this stage we do not have a clear picture of what it is that is ailing Mr. Al-Lala – whether it is organic or functional, what will become of the situation if he is off his meds and what will happen if substances are reintroduced. He recommended caution in the crafting of the terms of the disposition. He pointed to the fact that Mr. Al-Lala is still in the secure unit, has had struggles there, and we do not know what his behaviours will be as he moves up the pass ladder in a general unit. As a result, he indicated that it is premature to consider both community living and indirectly supervised community passes.
Counsel for Mr. Al-Lala agreed with the Hospital. She acknowledged both the seriousness of the index offence and the psychosis that led to it. She argued that while empathy and insight are important considerations when crafting a disposition that satisfies the objectives of s. 672.54 of the Criminal Code, they are not the only considerations. She emphasized the unanimity of the treatment team in its position that Mr. Al-Lala is ready for a transition to a general forensic unit at the Hospital, as well as privileges of indirectly supervised privileges and community living. Like counsel for the Hospital, she emphasized the importance of a disposition that gives Mr. Al-Lala room to progress. She referenced the Ontario Court of Appeal’s decision in Re Kelly, 2014 ONCA 269 and argued that the inclusion of a provision permitting Mr. Al-Lala to live in the community should be considered as to whether it would have a motivational and therapeutic value for her client.
Analysis and conclusion
As mentioned above, the panel agrees that Mr. Al-Lala continues to represent a significant threat to the safety of the public. The importance of this threshold issue, as discussed in Winko, is such that even when assisted by joint submissions offered by counsel of the caliber seen in this hearing, the Board nonetheless turns its attention independently to whether the evidence satisfies the burden of “significance.” The independence of the threshold determination arises from the fact that the individual under the Board’s jurisdiction has not been convicted of the criminal act that informs the index offence. The independent finding by a Board, even in the context of a joint submission on the issue of significant threat, represents an essential safeguard that distinguishes the moral culpability of the mentally ill accused from the individual whose act and intent to commit a criminal act has been proven beyond a reasonable doubt. It represents the starting point in a consideration that does not turn its attentions to factors like those found in section 718 of the Criminal Code but is singularly focused on the definitions found in section 672.5401 and the objectives set out in 672.54. The Board is constantly attentive to the threshold of “significant threat” both in terms of likelihood of occurrence and likelihood of harm flowing from serious criminal conduct stemming from the absence of a disposition.
For Mr. Al-Lala, the finding of significant threat is based on the following:
- Mr. Al-Lala suffers from a major mental illness that has driven irritability, aggressivity and the commission of a serious violent criminal offence.
- That offence (and what could be described as the historic high-water mark of his psychotic symptoms) is fairly recent and these remain early days in receipt of the important and extensive services and supports provided when one is under the jurisdiction of the Ontario Review Board. Mr. Al-Lala’s current trajectory bears some promise, but it is clear that further progress is needed in view of irritability, aggressivity, selective expression of empathy, rule-breaking behaviour and partial insight evidenced over the course of this past review period.
- When weighed against the length of time Mr. Al-Lala has struggled with mental illness (since 2018), his history of treatment compliance is concerning. He has on two separate occasions prior to the index offence gone off his medications for extended periods of time, himself indicating at one point that he “threw them out” because they made him tired. While he has been medication compliant over the course of this review period while in the Hospital, he has expressed only partial insight into his need for medications and the role his nonadherence to treatment recommendations played in the commission of the index offence which resulted in the death of the victim.
- Mr. Al-Lala has a significant history of decompensating when using substances. It is unclear as of yet whether medication nonadherence contributed to his relapses. It is clear that, as with his noncompliance with treatment, use of substances figured prominently in the commission of the index offence. Mr. Al-Lala currently seems to be demonstrating insight into his life-long need to abstain from all substances, but this is being expressed in a context where he is in a highly secure and controlled hospital environment and is receiving a long-acting injectable medication. It appears that there may be a trial of discontinuing the antipsychotic medication at some point so as to determine whether the main contributor to the index offence and psychosis was a primary psychotic illness (schizophrenia) or the result of substance use.
- Mr. Al-Lala’s progress through the highly controlled Hospital environment, even with regard to progress on the pass ladder and transition from the Hospital’s secure to its general forensic unit, has been delayed because of his behaviours, including rule-breaking behaviour. The evidence is still unclear as to whether these difficulties are manifestations of immaturity, or secondary and residual symptoms of his major mental illness, or of other concerns that can only be clarified by completion of a personality assessment that the Board would strongly recommend.
All of these factors support the conclusion that Mr. Al-Lala continues to represent a significant threat to the safety of the public.
- In the case of Mr. Al- Lala, it is clear that a detention disposition is necessary, as was agreed to by all parties. This flows from the following considerations:
- Mr. Al-Lala suffers from a major mental illness that was a main factor in the commission of the most serious criminal offence that took place only a few years ago. The length of time itself here is not the important factor, but rather the practical realities of progress in diagnosing, treating, and managing major mental illness and its symptoms. To this point, the nature of Mr. Al-Lala’s major mental illness is still the subject of some uncertainty. Mr. Al-Lala accordingly is likely to go through further medication adjustments that threaten destabilization of his major mental illness. In fact, an experiment discontinuing his antipsychotic medications in spite of the history described in the Hospital Report is being actively considered. The risk of rapid and violent decompensation warrants the imposition of a detention order.
- Mr. Al-Lala seems to have improved insight into the impact of substances on his mental illness but has only partial insight into the nature of his mental illness (something in fairness to him that the Hospital is still trying to ascertain) and, by extension, questionable insight into his need for antipsychotic medications. It is notable that his insight into the impact of substance use on his mental wellness is manifest in a highly controlled setting where he is receiving a long-acting injectable medication. It remains to be seen whether the cessation of his antipsychotic medications will compromise his insight into the danger his use of substances poses to the public. The Hospital needs in this regard as well to be able to respond promptly to early signs of decompensation.
- While Mr. Al-Lala’s comportment has improved over the course of the latter part of this review period as he abstained from substances and received a long-acting injectable medication, it cannot be said that he can be relied upon to return to the Hospital when asked, absent a detention disposition.
- The index offence occurred in circumstances where his family, who are otherwise supportive, minimized the decompensating signs of Mr. Al-Lala’s substance use and medication noncompliance in the periods preceding the index offence. His father engaged in victim blaming following the incident. Mr. Al-Lala himself has expressed empathy to co-patients, but protective levels of empathy have yet to be examined by the Hospital. In these circumstances, the primary and the other objectives set out in section 672.54, means that when the time comes, it will be essential for the Hospital to play an active role in identifying and supporting Mr. Al-Lala’s transition to approved accommodations in the community.
It is clear that the provisions of the Mental Health Act would be wholly insufficient to manage the significant threat Mr. Al-Lala poses to the safety of the public, thereby making a Conditional Discharge disposition unrealistic.
A detention disposition, as recommended, is necessary in satisfaction of the primary objective set out in the Criminal Code pertaining to the not-criminally-responsible accused person. It is also necessary if the Board is to ensure that Mr. Al-Lala’s mental health and other needs are met. Noting again that these are early days under the Board’s jurisdiction, there remain important questions that must be addressed for Mr. Al-Lala’s benefit. One of these, according to Dr Chan will engage an experimental discontinuation of Mr. Al-Lala’s antipsychotic medication. Meanwhile, the Board questions whether the behaviours seen from Mr. Al-Lala over the course of this reporting period are the product of age-related immaturity or are manifestations of secondary symptoms of his major mental illness, or are indications of an undiagnosed personality disorder, or all three. He has manifest troublesome behaviour, entitlement, oppositional defiance, he has been challenging of authority, has disregarded rules even when educated and instructed as to their purpose and importance, he is not accepting of responsibility for his rule-breaking behaviour and its impact, and there are questions associated with both the quality and quantity of his ability to feel and express empathy. A personality assessment would be helpful in ascertaining what these difficulties portend.
The Hospital and counsel for Mr. Al-Lala argued that the next detention disposition should incorporate an expansion of privileges that would permit the Hospital to grow Mr. Al-Lala’s level of reintegration into the community as his progress hopefully continues. They submitted that the possibility of indirectly supervised access to the community would be appropriate, citing Mr. Al-Lala’s medication compliance, abstinence from substances that are still available to at least some degree on the Hospital’s secure forensic unit, absence of psychotic symptoms and level of engagement with programming and psychoeducation. Mr. Al-Lala has exercised accompanied community access with his parents as approved persons to attend the Mosque. These positives place the expansion proposed by the parties squarely within the realm of that contemplated in section 672.54. Under such circumstances, the disposition permitting privileges up to and including indirectly supervised access to the community can be granted without compromising the primary objective and is appropriate to be granted having regard to Mr. Al-Lala’s mental health and other needs.
This does not suggest however that sufficient progress has been made to warrant the granting of a privilege of living in approved accommodations in the community. This is for several reasons. Firstly, the granting of the privilege proposed is not a rubber-stamp consideration that arises simply by virtue of either long waiting lists or the fact alone that it “may” be motivating to a patient. In Re Kelly, cited supra, the Ontario Court of Appeal did not suggest that waiting lists, as a practical reality, should be inundated with “mere possibilities” of individuals that might one day find themselves in a position that would “fit” any particular residence. Such an expansion of the principles expressed in Re Kelly would exponentially increase waiting lists, exasperating what is already an exhausting limitation of resources. In Re Kelly, the court was dealing with a patient that was institutionalized with clear evidence that the granting of the privilege would provide more than a motivational, but rather a therapeutic, benefit.
In Mr. Al-Lala’s case, his behaviours have improved over the latter course of this review period, such that his progress on the pass ladder has improved. He is aware that behaviour and rule compliance, as well as treatment compliance and abstention from substances is necessary for further progress. There is no indication that he is institutionalized. Quite to the contrary, he is quite engaged at this stage in programming that is helping him progress. Furthermore, he is at such early days that the Hospital has not yet identified what type of accommodations will be appropriate. They do not have a firm diagnosis. They have a history of substance use that has only been controlled in a highly secure environment while Mr. Al-Lala is on a long-acting injectable medication that the Hospital will likely experiment with in terms of discontinuance. Mr. Al-Lala’s behaviours delayed his progress on the pass ladder such that he is only now at pass level 6 and ready to transition from the Hospital’s secure forensic unit to a general forensic unit (the panel noted that the treatment team thought this would have occurred in the last reporting period). Dr. Chan acknowledged that there was a “large possibility” that Mr. Al-Lala would continue to move slowly as a result of his behaviours. How Mr. Al-Lala does with regard to substance use in that environment remains to be seen. He may or may not progress to level 7 or 8 privileges over the course of the next reporting period, and in that situation, it still remains to be seen how he will cope with an increased ability to find and use substances and how his major mental illness will handle community stresses, on or off his antipsychotic medication. Mr. Al-Lala is intelligent and has generally supportive family that may progress through the concerns otherwise stated in these Reasons. This draws into question just what waiting lists he should be put on for what types of accommodations. Granting a privilege that inappropriately puts him on a waiting list for what may or may not be one or several inappropriate accommodations adds stress to a strained system and complicates practical realities. It is not supported on these facts.
In this regard the panel has not only considered Re Kelly but Re Sookram, 2024 ONCA 823. There, the Ontario Court of Appeal again addressed community living privileges, citing the decision in Re Kelly with regard to the importance under the 672.54 objectives to grant dispositions that facilitated the placement of patients, where factually appropriate, on lengthy waiting lists. It set out the discussion a Board is to have around this issue. At paragraph 17 it said:
…the Board must “consider” a community living term where one is requested. However, it must do so in accordance with the four factors in s. 672.54 of the Criminal Code: the safety of the public, the mental condition of the accused, the reintegration of the accused into society, and the other needs of the accused. Under s. 672.54, the Board’s disposition must be necessary and appropriate in the circumstances, namely, the least onerous and least restrictive of the accused’s liberty consistent with public safety, his mental condition and “other needs,” and his eventual reintegration into society.
It has been pointed out that the privilege proposed is not necessary to Mr. Al-Lala’s mental health and other needs, nor is it appropriate. Mr. Al-Lala is aware that, if he progresses to the point where the uncertainties noted have been resolved, the Hospital may request an early Board Review for the purpose of expanding the privileges in the disposition that will be ordered. The absence of this provision at this time does not impact on his therapeutic relationship with the treatment team and there is no evidence to suggest that it will impact his mental health and other needs.
More notably, by refusing to grant the community accommodations privilege, this panel is expressing its concern associated with the plan to experimentally discontinue Mr. Al-Lala’s medication regimen and the comfort with which Dr Chan suggested this could be undertaken while Mr. Al-Lala is living in the community. There are many reasons why the Board would be concerned about this. Mr. Al-Lala has a demonstrated history of rapid decline into substance use and psychosis when not taking prescribed antipsychotics. Noting this, and the seriousness of the index offence, the Board raises concerns that it is inappropriate, having regard to the primary objective that binds both the Board and the Hospital, to even cautiously discontinue Mr. Al-Lala’s medications while he is living in the community, even if he were living in supervised accommodations. Discontinuing antipsychotic medications, particularly long-acting injectable formulations, requires careful consideration of the setting to ensure patient safety and treatment efficacy.
While 24-hour supervision by social workers, clinicians and allied support staff provides continuous support, there is good reason why the Board, on these facts, would encourage extreme prudence engaging in experimental discontinuation of medication outside of a hospital setting. The Hospital, whether in the secure or general forensic units, is equipped to promptly address acute psychiatric crises or medical emergencies that may arise during medication discontinuation. This immediate access to medical care can prevent complications and ensure patient and public safety. It offers immediate medical intervention. It also offers a collaborative environment where psychiatrists, nurses, social workers, and other healthcare professionals work together. This multidisciplinary approach allows for comprehensive monitoring and management of withdrawal symptoms and potential relapses. It provides continuous, structured observation, facilitating the early detection of adverse reactions or signs of relapse. This structured monitoring is crucial during the sensitive period of medication discontinuation. It provides a controlled environment for analysis by minimizing external stressors and distractions, offering thereby a stable environment conducive to monitoring the effects of medication discontinuation. It also provides immediate access to support services, including crisis intervention and psychiatric consultations, which are essential during the medication discontinuation process.
All of these considerations lead the Board to the conclusion that the granting of community living privileges at this time is inconsistent with both the objective of ensuring the safety of the public and that of ensuring that M. Al-Lala’s mental health and other needs are met, including that of reintegration into the community. Should Mr. Al-Lala progress through the pass ladder and to a point of clarity with regard to diagnosis, insight, and commitment to abstinence and treatment compliance, the Board can reconvene at an early hearing to either facilitate his placement on the right waiting list for him or provide a disposition that will support his transition into appropriate approved accommodations.
An order will issue accordingly.
The Board thanks all who attended today’s hearing both as observers, supporters, witnesses and parties and expresses its thanks to Dr Chan and the treatment team.
DATED this 6th day of May, 2025 at the City of Toronto, in the Toronto Region.
Mr. D. Sandor
Legal Member
Office of the Registrar
Ontario Review Board