Ontario Review Board
Re: Alfredo Forte
ORB File No: 4898
Hearing held on: Tuesday, March 25, 2025
Place of hearing: Centre for Addiction and Mental Health
1001 Queen Street West, Toronto
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Ms. L. Banks
Members: Dr. P. Prendergast
Dr. L. O. Lightfoot
Ms. M. Labrosse
Mr. A. Bouvier
Parties Appearing:
Accused: Alfredo Forte
Counsel: Mr. D. Embry
The person in charge of hospital: Counsel: Ms. S. Zelaya
Attorney General of Ontario: Counsel: Ms. S. Burton
REASONS FOR DISPOSITION
(Dated May 6, 2025)
Introduction:
On September 27, 2007, Mr. Alfredo Forte was found not criminally responsible on account of a mental disorder (“NCR”) on one count each of assault with a weapon, assault, and possession of weapon for a purpose dangerous to the public peace, all contrary to the Criminal Code of Canada (the “Criminal Code”).
Since his NCR finding, Mr. Forte has been subject to Dispositions of the Ontario Review Board (“ORB” or the “Board”), most recently a Disposition dated April 3, 2023 which orders him detained at the Forensic Service of the Centre for Addiction and Mental Health, Toronto (“CAMH” or the “hospital”), with privileges extending to living in the community in supervised accommodation approved by the person in charge. The Disposition also requires, among other terms, that he refrain from contact or communication with Allan Kernohan and that he report to the person in charge of CAMH not less than once per week.
On March 25, 2025, a panel of the ORB convened to hold a hearing to conduct an annual review of Mr. Forte’s existing Disposition pursuant to s. 672.81(1) of the Criminal Code. Mr. Forte attended the hearing and was represented by his counsel, Mr. Embry.
The issues to be considered at this hearing are whether Mr. Forte is a significant threat to public safety as now defined in s. 672.5401 of the Criminal Code and, if he is found to be a significant risk to the community, the determination of the necessary and appropriate Disposition in the circumstances bearing in mind the factors enunciated in s. 672.54 of the Criminal Code.
For the reasons set out below, this Board has concluded that Mr. Forte continues to pose a significant threat to public safety. It is our view that the necessary and appropriate Disposition in the circumstances is that he be discharged subject to the terms and conditions set forth at the conclusion of these Reasons.
Index Offences:
- The circumstances giving rise to the index offences are set forth in detail in the Hospital Report to the ORB dated March 10, 2025 (the “Hospital Report”) and may be summarized as follows:
In October of 2006, Mr. Forte, while armed with a knife, attacked a fellow resident of a home for persons with mental health issues. The complainant suffered minor injuries.
Positions of the Parties:
- All parties were canvassed as to their initial recommendations to the Board. Counsel for the hospital submitted that Mr. Forte met the significant threat test and that the necessary and appropriate Disposition was a discharge on conditions to contain the following terms:
he report to the person in charge of CAMH, or his or her designate, not less than once a week;
he reside at 1674 Eglinton Ave West, Toronto, Ontario;
he advise the person in charge of the hospital or his or her designate, in advance, of any absence from his/her residence of 24 hours or more;
on his consent, agree to take treatment/medication as prescribed by the person in charge of the hospital, or his or her designate, in accordance with s.672.55(1) of the Criminal Code;
he not leave the Greater Toronto Area except after obtaining prior approval of his itinerary, and with the consent of the person in charge, or his or her designate; and
upon notice, he attend before the ORB as required.
Crown counsel indicated support for the hospital’s recommendations.
Mr. Embry indicated his client was also in support of the hospital’s recommendation for a Conditional Discharge and that his client consented to the inclusion of the treatment condition.
All parties maintained their joint recommendation to the Board in closing submissions.
Personal Background:
The Hospital Report contains details of Mr. Forte’s personal background, legal and psychiatric history and need not be repeated in detail here as it was entered as an Exhibit at the hearing. Briefly stated, Mr. Forte is a 47-year-old single man. He was born and raised in Toronto. His parents separated when Mr. Forte was about 10 years old. Mr. Forte does not have any children.
Mr. Forte completed Grade 13 and then attended the University of Waterloo pursuing a computer science degree. He completed one semester before dropping out. He then went to Humber College for one semester, but began to experience panic attacks and did not complete the program. He had no further schooling after the age of 20 due to the onset of his psychiatric illness. He has not been employed since age 20.
Mr. Forte does not have a history of problematic alcohol or drug use.
Legal History:
At the age 21, Mr. Forte was charged with assault cause bodily harm, after an incident at the College Street Site of CAMH. The victim was a female nurse. The charge was ultimately managed by a court diversion.
Mr. Forte was charged with assault at age 22, involving a nurse at the Mississauga Hospital. He was suffering from psychotic symptoms at that time and he received court diversion once again. His CPIC indicates no prior convictions.
Psychiatric History:
Mr. Forte has a significant psychiatric history, and was first diagnosed with depression at age seventeen. His first psychiatric admission occurred in 1998. He presented at CAMH as he had been experiencing paranoid delusions believing that government agents were following, poisoning and controlling him. As a result of same, he was experiencing severe anxiety and intermittent suicidal and homicidal ideation. He was admitted as a voluntary patient, but was ultimately placed on a Form 3 under the Mental Health Act (“MHA”). While in hospital, he seriously assaulted a member of the nursing staff, punching her in the face and head and was charged with assault, causing bodily harm. He also engaged in other acts of property aggression and attempted to assault another staff member with a sharp end of a piece of wood, prompting his transfer to Mental Health Centre Penetanguishene, Oak Ridge Division (now known as “Waypoint”) for treatment in a more secure setting. He remained there for months.
In 1999, he was admitted to hospital on several occasions when suffering from hallucinations. He engaged in self-harm.
Mr. Forte had a lengthy admission at CAMH between March, 2000 and December, 2002. There were numerous instances of aggression against staff. He was admitted to hospital several more times between then and 2006. He was also receiving out-patient care. Mr. Forte suffered hallucinations. The Hospital Report sets out many instances of both self-harm and attacks on others (pages 6 - 7). Many of these attacks were significant.
After the index offences, Mr. Forte remained detained in hospital. He remained psychotic, delusional and violent. It was necessary to place him in seclusion on multiple occasions. When medicated, he was able to show some improvement.
After being found NCR in 2007, he remained in hospital for approximately one year, until he was able to be discharged into the community. He remained delusional, but was not violent.
Over the years, there have been many hospital readmittances of various durations prompted by noncompliance with medication and episodes of behavioural dysregulation. He continued to experience active symptoms of his illness but did not engage in violence.
His treatment condition improved with medication compliance and in November 2020, he was able to move out of hospital to high support community housing. In 2021/2022, he remained in housing but for a re-admission to hospital of just over two weeks. However, Mr. Forte continued to suffer from significant symptoms of psychosis, consistent with ultra-treatment-resistant Schizophrenia. He experienced auditory hallucinations on a daily basis. He engaged in obsessive-compulsive behaviours.
His mental status largely remained unchanged, with a diagnosis of ultra-treatment resistant schizophrenia. He is treated with antipsychotic medications, primarily Clozapine.
Current Diagnosis:
- Mr. Forte’s current diagnoses are:
Schizophrenia; and
Obsessive Compulsive Disorder (“OCD”).
Evidence at the Hearing:
Dr. L. Van testified at the hearing to supplement the documentary evidence before the Board. Dr. Van adopted the contents of the Hospital Report and indicated there were no significant updates thereto.
Mr. Forte continues to reside in the community at Oakwood ARCH residence, where he was initially discharged in November 2020. This is a high-support residence with staff on site 24-hours and supervised medication administration. Mr. Forte has his own bachelor apartment with a washroom and kitchen. The facility provides daily meals, some programming and assistance with laundry and keeping residents’ units clean.
As has been the case in past years, Mr. Forte’s personal hygiene has been an issue. While he is independent with self-care, he requires much prompting and regular reminders. He has adhered to a schedule where he showers and changes his clothes once a week and does his laundry every two weeks with the help from his out-patient team.
Mr. Forte is also supported in the community by the Extended Forensic Out-patient Service (“EFOPS”) team which includes Dr. Van and Ms. Hazelaar (his case manager). He meets with his case-worker on a weekly basis and she assists him in navigating and addressing many of the concerns of his housing provider. He meets with Dr. Van approximately once every two. Weeks. Mr. Forte has complied with all follow-up appointments with members of the EFOPS.
Mr. Forte’s parents continue to have regular contact with him and they are important supports for him. He typically sees them separately on a weekly basis.
Mr. Forte has minimal social interaction with his co-residents and he primarily keeps to himself. He spends most of his days inside his apartment, often working on his “manifesto”. He will not show the contents of this document to his team members. Dr. Van stated that the team regularly checks in with Mr. Forte to discuss the subject matter of the manifesto. He has advised that it does not contain any threats to others nor does it contain advice on how to make weapons, including bombs. He has indicated that the manifesto has not been published and that it has not been sent to any government agencies. Mr. Forte is regularly probed by the clinical team to assess whether there is any increase in his level of paranoia.
Mr. Forte has declined engagement in structured programming and activities but he goes out several times a week to run errands or go for walks. He also attends the local library independently and the team will continue to encourage him to engage in community activities and programs.
Dr. Van advised that Mr. Forte continues to be assessed as incapable to consent to treatment for his psychiatric illness and his father acts as substitute decision maker (“SDM”). Under his SDM’s consent, he is treated with two antipsychotic medications (Clozapine and Aripiprazole/Abilify) which he takes orally every day under direct supervision. The doctor confirmed that Abilify is used in Mr. Forte’s case as an adjunct medication to enhance the efficacy of Clozapine, which is the mainstay of his treatment. Mr. Forte also receives a daily oral dose of the antidepressant, Fluoxetine, to assist with his management of his OCD symptoms. In response to questions from a panel member, the doctor advised that despite treatment, Mr. Forte continues to experience OCD symptoms but that they are not problematic for him. Dr. Van stated that he has declined an increase in his Fluoxetine medication and the team has not pressed the issue.
Mr. Forte continues to suffer side effects from these medications including sedation and drooling but he has refused other medications to alleviate these symptoms. In response to a question posed by a panel member, the doctor advised that the team considers that his medication regimen is currently optimized.
Despite compliance with his prescribed medications, Mr. Forte continues to experience chronic symptoms of his illness. His mental status has remained largely unchanged from previous years, and he continues to suffer from treatment–resistant Schizophrenia. He is often observed to be internally preoccupied and will acknowledge conversing telepathically with various people or agencies. He continues to express various grandiose delusions, including being part of an intelligence agency, or an immortal figure. At his baseline, he reports daily auditory hallucinations with multiple voices. He believes that the voices he hears, help him to make decisions, and that they have his best interest in mind. He also believes he has the ability to read the minds of others, or to put thoughts into other people’s heads. He continues to experience long-standing paranoid ideation about various governments that he believes are targeting him. He has consistently denied self-harm, suicide or violence, directed at others.
As has been the case in the past, Mr. Forte often presents as unkempt and malodorous and he can become quite escalated with staff when his personal hygiene is discussed with him. To his credit, Mr. Forte’s verbally aggressive interactions with housing staff have attenuated over the year in review and he has continued to be encouraged to engage his EFOPS team members to assist him in mediating any disputes with his housing staff. Dr. Van reported that this plan has been rather effective and that no significant verbal conflicts between Mr. Forte and his housing workers have not been reported over the past year.
Mr. Forte has not engaged in physical violence since 2015. He was discharged to the community in 2020 and has not acted out violently; however, the doctor stated that this stability was in the context of his compliance with prescribed medication and close monitoring by his out-patient treatment team and his housing staff.
In terms of his insight, Mr. Forte will acknowledge his diagnosis of Schizophrenia but Dr. Van advised that he does not believe he actually suffers from this illness. His insight remains quite limited into his symptoms and the impact of his treatment. Mr. Forte continues to deny that his medications help attenuate his symptoms. Also of concern is the fact that Mr. Forte has consistently stated his plan to discontinue this medication when he is no longer under the Board’s jurisdiction.
Given Mr. Forte’s limited insight with regard to the importance of treatment and his history of non-adherence to treatment, Dr. Van testified that the treatment team considers it critical that the proposed Conditional Discharge Disposition include a provision that Mr. Forte consent to treatment. The doctor commented that Mr. Forte has been compliant with his treatment over the past 10 years and he attributes his compliance as being a result of the external “legal” requirements imposed upon him while under the Board’s jurisdiction. The doctor commented that Mr. Forte is quite rigid in his thinking and that he would be highly likely to consider a consent to treatment condition as similarly imposing a legal requirement on him which he would be likely to comply with.
The re-offence scenario included in the Hospital Report indicates:
“Mr. Forte is at risk for psychosis-driven violence, given his ongoing paranoid beliefs despite treatment with clozapine and a medication that boosts clozapine levels. He has impulsively acted out on persecutory and grandiose delusions in the past. The index offence was motivated by auditory hallucinations and delusions similar to ones he continues to experience. He has interpersonal challenges related to his mental health symptoms, both OCD and psychosis, that contribute to him being easily angered. If Mr. Forte did not reside in a highly supervised setting, he would likely develop interpersonal conflicts with staff and co-residents that would result in verbal and physical altercations. Due to his lack of insight and the burden of his psychiatric symptoms, he would almost certainly discontinue his medication absent staff-monitored administration and external oversight by the ORB. This would result in an intensification of his paranoia and affective instability, and further exacerbate his risk for violence.”
Dr. Van testified she was quite confident that if Mr. Forte were to discontinue treatment with Clozapine, he would be very likely to experience a worsening of his paranoid ideas, auditory hallucinations and delusional beliefs. In response to an exacerbation of his psychotic symptoms, the doctor anticipated that Mr. Forte would be likely to suffer a worsening in his interpersonal relations with the result that he would be very likely, over time, to engage in violence as has occurred in the past.
In response to questions posed by panel members about whether or not Mr. Forte’s risk to public safety could be managed under less restrictive Conditional Discharge Disposition, Dr. Van stated that the team carefully considered this option. She noted that Mr. Forte has been living in the community since October 2020 and has only required one brief re-admission to hospital from February 20, 2021 to March 8, 2021. Throughout his readmission, he remained at his baseline which, unfortunately, includes his experience of residual symptoms of psychosis.
Dr. Van advised the Board that since commencing treatment with Clozapine, Mr. Forte has not engaged in any incidents of physical aggression. Notwithstanding his undeveloped insight into the need for medication, he has been adherent with treatment for the last decade. He has also been compliant in attending his appointments scheduled with the EFOPS team and his housing is well supervised and stable. The Hospital Report indicates that: “…he has accepted the possibility of admission to hospital on a voluntarily basis if asked by the treatment team or should his community housing be jeopardized such that alternate housing is needed. If Mr. Forte accepts a consent to treatment clause and becomes non-adherent to treatment, the team could request assistance from the police to bring Mr. Forte to hospital, where he will likely be certifiable under Box B of the Mental Health Act. Mr. Forte’s substitute decision maker, his father, has advised the clinical team that should Mr. Forte become non-adherent to treatment, he would support Mr. Forte’s re-admission to hospital and re-initiation of treatment.” For all of these reasons, the team concluded that the MHA could not be relied on to safely manage his risk.
Dr. Van stated that Mr. Forte’s most salient protective factors in the management of his risk are the external oversight provided by his residence staff, his forensic clinical team, and the authority of the ORB Disposition.
No further evidence was called by the parties.
Analysis and Conclusions:
The Board accepts that Mr. Forte remains a significant threat to public safety based upon the evidence of Dr. Van and the evidence contained in the Hospital Report. When non-compliant and acutely unwell, Mr. Forte has become paranoid and agitated and has acted out with significant violence which has seriously compromised public safety. He has a history of noncompliance with medication and it is our view that his risk would significantly increase if treatment were discontinued. Mr. Forte continues to state that if no longer under the Board’s jurisdiction, he will discontinue treatment with Clozapine. The expert evidence before us indicates that discontinuation of this medication would be highly likely to result in and intensification of his psychotic symptoms with the likely result of an escalation in his risk of violence.
In addressing the issue of significant threat, the panel has also carefully considered the decision of the Supreme Court in Winko v. British Columbia. In that case, the Court identified a significant risk as a "real risk of physical or psychological harm to members of the public that is serious in the sense of going beyond the merely trivial or annoying. The conduct giving rise to the harm must be criminal in nature." In Winko, the Supreme Court also outlined that in coming to a conclusion on the issue of significant risk, a Review Board should closely examine a range of evidence including: the circumstances of the original offence, the past and expected course of the accused's circumstances and treatment, the present state of the NCR accused's medical condition, the NCR accused's own plans for the future, the support services existing for the NCR accused in the community and, perhaps most importantly, the recommendations provided by experts who have examined the NCR accused. According to the doctor’s testimony, the clinical team unanimously agrees that Mr. Forte continues to represent a significant threat to public safety.
In light of our finding of significant threat, we must shape a Disposition that is necessary and appropriate, as well as least onerous and least restrictive in the circumstances for the coming year.
The Board has concluded that Mr. Forte can be safely managed under a less restrictive Conditional Discharge Disposition at this time on the terms recommended by the hospital. These terms include stipulating that he continues to reside his current staff supported residence as well as a consent to treatment condition.
We are mindful of the progress Mr. Forte has made over the years. He has not engaged in any physical aggression since 2015 and, despite his limited understanding of the importance of his adherence with his Clozapine treatment, he has remained compliant, albeit under direct supervision and while subject to a Detention Order Disposition. At the present time, Mr. Forte has consented to the inclusion of a treatment condition and has expressed an understanding that he would be required to be readmitted to hospital should his current accommodation not be appropriate for him in the future. In the panel’s assessment, the Box B criteria of the MHA would be sufficient to safely manage Mr. Forte’s risk should he evidence signs of any decompensation in his mental state while residing in the community.
Accordingly, based on all of the evidence and the submissions of the parties, the Board finds that the necessary and appropriate Disposition is a Conditional Discharge that includes the following terms:
he report to the person in charge of CAMH, or his or her designate, not less than once a week;
he reside at 1674 Eglinton Ave West, Toronto, Ontario;
he advise the person in charge of the hospital or his or her designate, in advance, of any absence from his/her residence of 24 hours or more;
on his consent, agree to take treatment/medication as prescribed by the person in charge of the hospital, or his or her designate, in accordance with s.672.55(1) of the Criminal Code;
he not leave the Greater Toronto Area except after obtaining prior approval of his itinerary, and with the consent of the person in charge, or his or her designate;
s.672.91/92(1) return to hospital in event of breach of terms of Disposition; and
upon notice, he attend before the ORB as required.
- In reaching our decision, we have considered the paramount need to protect the public from dangerous persons, the mental condition of Mr. Forte, his reintegration into society and his other needs.
DATED this 6th day of May, 2025, at the City of Toronto, in the Toronto Region.
Ms. L. Banks
Alternate Chairperson
Office of the Registrar
Ontario Review Board