Re: Ronnie Acuna-Aguirre
ORB File No: 7954
Hearing held on: Thursday, April 24, 2025
Place of hearing: Waypoint Centre for Mental Health Care Via Zoom Video-conference
Pursuant to: Section 672.81(2.1) of the Criminal Code
Before:
Alternate Chairperson: Ms. L. Banks
Members: Dr. R. Kunjukrishnan Dr. G. Nexhipi Ms. C. Murray Mr. A. Mete
Parties Appearing:
Accused: Ronnie Acuna-Aguirre Counsel: Mr. D. Embry
The person in charge of hospital: Counsel: Mr. J. Thomson
Attorney General of Ontario: Counsel: Ms. S. Curry
REASONS FOR DECISION
(Dated May 21, 2025)
Introduction:
On September 23, 2021, Mr. Ronnie Acuna-Aguirre was found not criminally responsible on account of mental disorder (“NCR”) on a charge of second-degree murder, contrary to the Criminal Code of Canada (“Criminal Code”). Mr. Acuna-Aguirre is currently subject to a Disposition of the Ontario Review Board (“ORB” or the “Board”) dated December 30, 2024, ordering that he be detained at the Waypoint Centre for Mental Health Care – High Secure Provincial Forensic Programs, Penetanguishene (“Waypoint”). Pursuant to this Disposition, he is granted discretionary hospital and grounds privileges, beyond the secure perimeter, escorted by staff.
By letter dated March 6, 2025, Waypoint notified the Board that, pursuant to s. 672.56(2) of the Criminal Code, Mr. Acuna-Aguirre ’s liberty had been restricted as he entered seclusion on February 26, 2025 and this seclusion continued until April 7, 2025.
On April 24, 2025, a panel of the Board convened a hearing by Zoom video-conference to review the restriction of Mr. Acuna-Aguirre’s liberty, pursuant to s. 672.81(2.1) of the Criminal Code. Mr. Acuna-Aguirre attended the hearing with the assistance of his counsel, Mr. Embry.
The issue at this hearing is whether the hospital’s decision to restrict Mr. Acuna-Aguirre’s liberty was necessary, appropriate and the least onerous and least restrictive intervention available to the hospital in the circumstances, both initially at the time of the imposition of the seclusion order and throughout its duration.
For the reasons set out below and based on the expert evidence and opinions before it, the Board concluded that the initial restriction of liberty was warranted, necessary and appropriate, as was Mr. Acuna-Aguirre’s ongoing restriction of liberty until April 7, 2025. The Board found these restrictions were necessary for public safety, and they represented the least onerous, and least restrictive, intervention available in the circumstances, both initially and ongoing.
Position of the Parties:
At the outset of the hearing, the parties were canvassed as to their positions. Counsel for the hospital and for the Attorney General submitted that the initial restriction of Mr. Acuna-Aguirre’s liberty occasioned by placing him in seclusion was warranted, necessary and appropriate, as was the ongoing restriction of his liberty throughout its duration until April 7, 2025.
Counsel for Mr. Acuna-Aguirre advised he was not opposing the restriction of his client’s liberty from February to April 7, 2025.
All parties confirmed that there was no request to review the terms of Mr. Acuna-Aguirre’s current Disposition. Further, all parties maintained their joint recommendation to the Board in closing submissions.
Index Offence:
- The incidents giving rise to the above noted charges are extracted from the Board’s Reasons for Disposition dated January 10, 2025, as follows:
“On March 8, 2021, Ronnie Acuna-Aguirre was released on a community treatment order from Ontario Shores Centre for Mental Health Sciences to the care of his family.
On March 9, 2021, after returning home from a family drive, an argument ensued between Arturo and his son Ronnie Acuna-Aguirre, about Arturo not allowing him to book a flight out of the country. As Arturo went out to the driveway, his son Ronnie Acuna-Aguirre retrieved a knife from the basement of the home and proceeded to attack him. An emergency call was received for a stabbing at 36 Hearst Circle, North York. Police and paramedics services arrived on scene and located 70-year-old Arturo lying in the driveway of his home. Ronnie Acuna-Aguirre’s mother, having witnessed some of the incident, woke her other son who restrained his brother until the first responders arrived. Arturo had sustained injuries to the area of his head and a significant wound to his neck and was pronounced dead at the scene. Also located in the driveway was Arturo’s, Ronnie Acuna-Aguirre. He had suffered a significant laceration to his left hand and was transported to Sunnybrook Health Sciences for treatment.”
Personal History:
Mr. Acuna-Aguirre’s background and personal history are set out in detail in the Hospital’s Report to the ORB dated November 4, 2024 (the “Hospital Report”) and in the Board’s Reasons for Disposition dated January 10, 2025. Briefly summarized, he is a 36-year-old man who was born in Peru. At age 4, he immigrated to Canada with his mother and four siblings. The family settled in Toronto where his father, Arturo, had already been residing for several years.
Mr. Acuna-Aguirre generally did well academically and graduated from high school. In his final year of school, his family noticed that he began to care less about his appearance, which was unusual for him. As well, Mr. Acuna-Aguirre struggled with his sexuality, which caused him “depression and anxiety”. He attempted suicide for the first time at age 18.
He eventually left post-secondary education (possibly at York University) as his medications left him tired and inattentive, and he struggled with the symptoms of his mental illness.
Mr. Acuna-Aguirre historically has not held employment for any extended duration of time, and typically left these jobs shortly after starting. He has been supported during the past several years by the Ontario Disability Support Program, which affords him a living allowance when in the community.
Mr. Acuna-Aguirre has suffered at different stages in his life anxiety and depression, paranoid delusions and hallucinations, schizophrenia, obsessive-compulsive disorder, and bipolar disorder. As well as periods of agitation and aggression both in the community and when admitted to hospital, Mr. Acuna-Aguirre has attempted on numerous occasions to complete suicide, using various means including hanging, cutting/stabbing himself and by drinking bleach.
Psychiatric History:
Mr. Acuna-Aguirre has been admitted to a psychiatric hospital at least once per year since 2007. He has been prescribed a number of antipsychotic medications but he would become non-compliant soon after discharge, complaining of side-effects.
At age 20, Mr. Acuna-Aguirre expressed believing that his father was either homosexual or the devil and that his father was not his real father. The Hospital Report indicates that “Mr. Acuna-Aguirre has a very complex ‘delusional world’ which is comprised of many firmly held, deeply entrenched beliefs, which when unwell caused him to view the world irrationally.” He has delusional beliefs about is father, leading him to become aggressive and violent, both verbally and physically.
Mr. Acuna-Aguirre’s sister reported that he began consuming alcohol at the legal age and was not known to overindulge. Over time, his cannabis use increased. After returning home from hospital admissions, Mr. Acuna-Aguirre stated he believed that marijuana would cure his Schizophrenia. His sister reported that cannabis use generally worsened Mr. Acuna-Aguirre’s progress or mental health status.
Legal History:
In 2017, Mr. Acuna-Aguirre was charged with assault with a weapon, uttering threats, and possession of a weapon arising out of conflict with his father during which he raised a knife. Charges in relation to that incident were withdrawn.
Mr. Acuna-Aguirre’s family has reported numerous conflicts with his family that were not reported to police. These incidents are referred to at pages 6 -7 of the Hospital Report.
Following his NCR finding, Mr. Acuna-Aguirre was admitted to Waypoint where he continues to be detained.
Current Diagnoses:
- The Hospital Report indicates that “Although the diagnosis has varied Mr. Acuna-Aguirre has suffered at different stages in his life with anxiety and depression, paranoid delusions and hallucinations, schizophrenia, obsessive-compulsive disorder, and bipolar disorder.
Over the course of his lifetime, these illnesses have manifested themselves in several different ways including periods of poor/maladaptive coping, emotional dysregulation, stress, suicidality, homicidality, agitation, aggression, irritability, delusional thought content, hallucinations, and sleep disturbances. As is made clear in hospital reports as well as in reports form family, Mr. Acuna-Aguirre has most recently struggled with positive symptoms of his diagnosed psychotic disorder including perceptual disturbances and a complex delusional belief system.”
- Mr. Acuna-Aguirre ’s current diagnoses are:
Schizoaffective Disorder;
Borderline Personality Disorder; and
Unspecified Personality Disorder, Dependent Traits.
Evidence at the Hearing:
The evidence at this hearing consisted of the Hospital Report, the Restriction of Liberty Report dated April 4, 2025 (“ROL Report”) as well as the viva voce evidence of Dr. A. Mishra, who is Mr. Acuna-Aguirre’s attending psychiatrist and is a co-author of the ROL Report which was filed as an exhibit.
Dr. Mishra advised that Mr. Acuna-Aguirre is currently assessed as incapable to consent to his psychiatric treatment and his sister, Liz Gale, who acts as his substitute decision maker (“SDM”). Under his SDM’s consent, Mr. Acuna-Aguirre receives a long-acting injection of the antipsychotic medication, Paliperidone Palmate, every 28 days. He also receives daily oral doses of the antipsychotic medication Loxapine and a mood stabilizing medication, Valproate Sodium.
Prior to his placement in seclusion, Mr. Acuna-Aguirre was residing on the Beausoliel A program at Waypoint. The ROL Report indicates:
“In the months prior to his seclusion, Mr. Acuna-Aguirre had been at the highest security level, a C5, which allowed him independent off unit access for up to four hours at a time. He generally kept himself busy. He was attending work in the Thrift Shop twice weekly, and the computer lab once per week, as well as all scheduled groups on the unit. He was, further, participating in weekly psychotherapy sessions, which had begun on January 15, 2025. His level was dropped to a C4 on January 29, 2025, however, then to a C3 on February 17, 2025, this in the context of an increasingly unstable mental status. He had begun to voice bizarre and unusual thoughts, and complained of distressing and persistent auditory hallucinations, at times of a command nature.”
At that same time, on February 20, 2025, he reported to Dr. Mishra that the voices were “stressful and irritating” and they might cause him to “lash out”. His sister advised that her brother had disclosed that he was feeling out of control and that he had decided to lock himself in his room as the voices were telling him to hurt a nurse as well as himself.
Mr. Acuna-Aguirre reported that he did not feel his medications were working and he requested to discontinue his treatment with Clozapine and to discontinue his Aripiprazole medication and switch to Paliperidone.
With his SDM’s consent, on February 20, 2025, Mr. Acuna-Aguirre’s Aripiprazole was discontinued and he started treatment with Paliperidone in its stead. His Loxapine dose was increased from twice daily to three times daily and the frequency of his prn Loxapine was changed from every 12 hours to every six hours.
Concerns were expressed that Mr. Acuna-Aguirre had been intermittently inducing vomiting to inhibit the efficacy of his medications. As a result, and in consideration of his history of significant violence when unwell, his mental state was closely observed and his security level was dropped to an A0 on February 22, 2025. This change required that he remain on the unit. Mr. Acuna-Aguirre’s mental status continued to deteriorate and he was placed on a medication watch on February 24, 2025.
On February 26, 2025, Mr. Acuna-Aguirre requested prn medication as he advised he was not feeling well. He also asked staff to remove items from his room so that he would not ingest them and hurt himself. When staff attended in his room to remove items, Mr. Acuna-Aguirre stated that he felt like he might “hurt someone”. Dr. Mishra attended to check on Mr. Acuna-Aguirre and noted that he had deteriorated further and presented as quite agitated. He threw a chair at his door, and made aggressive and rude comments to staff. He lashed out at Dr. Mishra when his door was slightly opened and he struck the doctor with his fist. He accepted prn injectable medication and a seclusion order was made. He agreed to be transferred to a padded room for his own safety.
Given his history of swallowing items not intended for ingestion, a Crisis Prevention Plan (“CPP”) was developed to prohibit certain items (for example, spoons, pens, crayons and plastic materials) from his room for his own safety. In addition, he was to wear a gown and be monitored on camera in order to manage his risk.
The ROL Report indicates that; “At Waypoint, seclusion orders are reviewed daily. Additionally, to ensure objectivity, secluded patients are seen by an independent psychiatrist (not the patient’s most responsible physician) for review and assessment at the 72-hour post-seclusion mark, seven days post-seclusion, and then every subsequent 28 days thereafter.”
Dr. Mishra commented that Mr. Acuna-Aguirre suffered a rapid deterioration in his mental state most likely due his poor compliance with Clozapine and the changeover of his other antipsychotic medication from Abilify to Paliperidone. He continued to present with distressing symptoms of his illness and on February 27, 2025, he refused as-needed medications.
The ROL report indicates that on March 5, 2025, Mr. Acuna-Aguirre began refusing his scheduled antipsychotic and mood stabilizing medications. The ROL Report notes that “On March 7, he said that “his symptoms have come back and that he is not feeling well” and told staff that he “feels ‘safer’ if he stays in padded room”. He said further that “he ‘feels the way he did’ as ‘when the accident happened;’” according to the note on file, he was alluding to the index offence.”
In the days that followed, Mr. Acuna-Aguirre ’s mental state continued to deteriorate given his refusal to accept his prescribed medications. The ROL Report indicates that “Mr. Acuna-Aguirre’s seclusion remained necessary due to his significantly unstable mental status. He was visibly distressed by auditory hallucinations, which at times were telling him to harm others; though he gets along with staff well, he appeared to be having internal battles. He was distracted and preoccupied. His mood fluctuated from calm and pleasant to angry, tearful, or threatening, without seeming precursor. He was observed staring vacantly at times, and had difficulty focusing. At others times he said his thoughts were racing.”
On March 9, 2025, Mr. Acuna-Aguirre was noted to be in distress. His knuckles were bleeding and blood was smeared on the walls. He made utterances to the effect that he missed his mom and he could kill his mom. He commented to staff that he wished they were his mom because then he could just choke them. He gestured aggressively to Dr. Mishra at a glass window to mimic choking.
Ultimately, hospital staff were able to persuade Mr. Acuna-Aguirre to resume both his scheduled and his as-needed medications following this incident. With the consent of his SDM, a loading dose of Paliperidone Palmitate, an injection, was administered on March 10, 2025. A regular dose of Loxapine at nighttime was also added to his medication regimen. Mr. Acuna-Aguirre continued to refuse treatment with Clozapine.
The CPP included a plan for the use of wrist/waist restraints for seclusion relief periods and a minimum of four staff to facilitate seclusion relief. Secluded relief is available when a patient presents appropriately following assessment of their mental status. Mr. Acuna-Aguirre’s mental status was assessed daily for the appropriateness of seclusion relief opportunities. Though his presentation fluctuated, staff were able to offer seclusion relief on a near-daily basis. To manage his risk of harm to others, Mr. Acuna-Aguirre was required to use wrist-waist restraints while out of his room. No co-patients were to be on the unit at the same time when he used seclusion relief.
Mr. Acuna-Aguirre continued to experience significant symptoms of his mental illness and he would, at times, present with bizarre behaviours, including stripping naked and pacing. At times, when exercising seclusion relief, he would ask to return to his room early as he was experiencing troubling symptoms and needed prn medications. Due to his heavy symptom load, he received a second dose of Paliperidone on March 18, 2025.
On March 21, 2025, he revealed to staff that the spirits/voices were sexually assaulting him. On March 23, 2025, he spoke about numerous delusional ideations and he stated that his mind was racing. His behaviour rapidly fluctuated from elated to agitated. He became extremely sad and was sobbing. The following day when assessed, he was reticent to discuss the content of his hallucinations and thoughts but stated he was beginning to feel safe.
Throughout his time in seclusion, Mr. Acuna-Aguirre was in a single room which has a mattress on the floor and a window. He was secluded on the Beausoleil A unit. Mr. Acuna-Aguirre was afforded opportunities to interact with hospital staff who appear at his door, many times throughout each day. As well, nursing staff conduct visual checks on him many times a day. Mr. Acuna-Aguirre also has meetings approximately 1-2 times weekly with Dr. Mishra. Dr. Mishra commented that the use of a padded room was necessary given his level of agitation and concerns about self-harm.
Dr. Mishra stated that throughout his period of seclusion, Mr. Acuna-Aguirre continued to present a “high risk” of unpredictable, unprovoked, physical violence to others.
The ROL Report indicates that towards the end of March, he presented as more behaviourally settled despite the fact that he remained symptomatic. He would sometimes lightly bang his head against the glass of his door. Over time, he showed more engagement during periods of seclusion relief and he would sometimes stay out of his room for approximately an hour. He would access the shower facilities and walk on the unit, make calls to his family and watch television. He was able to progress to the point of exercising seclusion relief periods without the use of Pinel restraints. By April 3, 2025, Mr. Acuna-Aguirre was stable enough to have seclusion relief while the unit was open and co-patients were present. At that time, he was moved from the seclusion suite to a room in the ‘stepdown’ corridor, closer to the general unit milieu but in a quieter area which allowed for some protection from overstimulation.
Dr. Mishra testified that as Mr. Acuna-Aguirre continued to present as calmer and more settled with an attenuation in his symptoms, the team initiated a step-down process where periods of seclusion relief were longer in duration. Further, on a graduated basis he was able to utilise seclusion relief periods without the use of restraints and, over time, within the open (as opposed to locked) unit. Given his stability and progression, the seclusion order was revoked on April 7, 2025.
Dr. Mishra advised that approximately a week following Mr. Acuna-Aguirre’s release from seclusion, he disclosed experiencing heightened symptoms of his illness to the point where, on April 22, 2025, the treatment team decided that it was, once again, necessary to seclude him in order to manage his risk of physically assaulting anyone in his proximity.
As at the hearing date, Mr. Acuna-Aguirre had been secluded for two days. Dr. Mishra stated that although Mr. Acuna-Aguirre had been fully compliant with his medications in the weeks leading up to his current period of seclusion, Clozapine is the best medication in attenuating the symptoms of his illness. The doctor advised that on April 23, 2025, Mr. Acuna-Aguirre agreed to accept treatment with Clozapine. The doctor stated that Clozapine will be started as soon as the consent of Mr. Acuna-Aguirre’s SDM has been obtained and the necessary protocols related to treatment with this medication have been conducted, including bloodwork. The doctor testified that this medication would likely be started on April 28, 2025. Dr. Mishra also advised that it will take some time for the Clozapine to be titrated up to a therapeutic date dose and for Mr. Acuna-Aguirre to experience its benefits. This will likely result in an extended period of seclusion for Mr. Acuna-Aguirre.
No further evidence was called by the parties.
Analysis and Conclusions:
Pursuant to the decision of the Ontario Court of Appeal in R v MLC (2010 ONCR 843), as well as Regina v Campbell (2018 ONCA 141), the Board agreed that a restriction of liberty had taken place. The Board found that the initial restriction of liberty, on February 26, 2025, represented the least onerous, and least restrictive, intervention in the circumstances and it remained so throughout its duration until the hearing date. The restriction of liberty was warranted and necessary for public safety.
The Board finds that while secluded at Waypoint, Mr. Acuna-Aguirre’s liberty status is such that he is unable to leave his seclusion room without being permitted to do so by staff. He is unable to move around the unit freely. The Board finds that Mr. Acuna-Aguirre ’s inability to exercise his discretion and to move freely out of the seclusion room within the unit is a significant restriction of his liberties and it has remained so for the duration of his time in seclusion.
The Board finds that Mr. Acuna-Aguirre’s initial placement in seclusion was warranted, necessary and appropriate, as well as the least restrictive and least onerous intervention available in the circumstances to safely manage his risk of harm to others. Mr. Acuna-Aguirre has a documented history of aggression and in the weeks leading up to his seclusion, he had been experiencing an increase in the symptoms of his major mental illness, likely as a result of medication non-compliance and as a result of changes in his medication regimen.
While detained in seclusion, Mr. Acuna-Aguirre has been offered seclusion relief on a near daily basis, typically on more than one occasion daily. On some occasions, he has declined seclusion relief and, on some occasions, he has been assessed as unable to safely exercise seclusion relief due to his behavioural presentation.
The panel notes that throughout Mr. Acuna-Aguirre’s seclusion, the hospital’s seclusion protocols have been implemented and Mr. Acuna-Aguirre’s seclusion has been reviewed regularly by an independent psychiatrist in accordance with those protocols. On all reviews, Mr. Acuna-Aguirre ’s seclusion has been found to be necessary and appropriate to safely manage his risk of harm to others.
The expert evidence also establishes that while in seclusion, Mr. Acuna-Aguirre is supported by regular staff interaction at his door daily. In addition, he has been in contact with Dr. Mishra on a weekly basis and has been regularly assessed by the hospital’s independent psychiatrists.
We note that on all occasions when Mr. Acuna-Aguirre has exercised seclusion relief periods, he has behaved appropriately and he did not present with verbal or physical aggression.
The Board has concluded, based on the evidence before us, that the hospital’s decision to significantly increase Mr. Acuna-Aguirre’s restriction of liberty on February 26, 2025, by placing him in seclusion, and his ongoing detention in seclusion until April 7, 2025, was the least onerous, and least restrictive option, and it was warranted for public safety.
The Board commended Mr. Acuna-Aguirre for his transparency with his care providers in disclosing the symptoms he was experiencing. As well, he is commended for his ongoing ability to work cooperatively with his treatment team and his decision to re-initiate treatment with Clozapine, which has been great benefit to him in the past.
In reaching our decision, we have considered the need to protect the public from dangerous persons, the mental condition of Mr. Acuna-Aguirre, his reintegration into society and his other needs.
DATED this 21st 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