Ontario Review Board
Re: Tony Tshibangu
ORB File No: 8549
Hearing held on: Wednesday, May 14, 2025
Place of Hearing: Southwest Centre for Forensic Mental Health, St. Thomas
Pursuant to: Section 672.81 (1) of the Criminal Code
Before:
Alternate Chairperson: Mr. M. D. Segal
Members: Dr. A. D. Jones Dr. S. Wiseman Mr. E. Siebenmorgen Ms. M. McKinnon
Parties Appearing:
Accused: Tony Tshibangu Counsel: Ms. N. Circelli
The person in charge of hospital: Counsel: Ms. J. Zamprogna
Attorney General of Ontario: Counsel: Mr. D. Rows
REASONS FOR DISPOSITION (Dated June 13, 2025)
Introduction
On April 10, 2024, Tony Tshibangu, now 21 years old, was found not criminally responsible on account of mental disorder (NCR) on charges of assaulting a peace officer causing bodily harm (x2), resisting or obstructing a peace officer, robbery, and mischief not exceeding $5,000.00 (x2), all contrary to the Criminal Code. Mr. Tshibangu was most recently subject to his initial Disposition of the Ontario Review Board (“ORB” or “the Board”) dated July 9, 2024, pursuant to which he was ordered detained at the Southwest Centre for Mental Health Care (“Southwest” or “the Hospital”) subject to several conditions, including that he be permitted indirectly supervised passes into the community of Elgin County.
On Wednesday, May 14, 2025, a panel of the Board convened in person at the Hospital to conduct a review of Mr. Tshibangu’s Disposition and to make a new Disposition pursuant to section 672.81 (1) of the Criminal Code. Mr. Tshibangu was present and represented by his counsel, Ms. Circelli. Mr. Tshibangu’s maternal grandfather, mother, and brother, Ariel, were also in attendance.
The issues to be determined at the hearing were whether Mr. Tshibangu continued to represent a significant threat to the safety of the public as defined in section 672.5401 of the Criminal Code and, if so, what was the necessary and appropriate Disposition that was also the least onerous and least restrictive taking into account the factors set out in 672.54 of the Criminal Code.
Positions of the Parties
- At the commencement of the hearing the parties were asked to provide their initial and “without prejudice” positions with respect to the issues before the Board. The parties jointly submitted that Mr. Tshibangu should continue to be subject to a Detention Order on the same terms and conditions as those contained in his existing Disposition, with the following changes to reflect an expansion of the “envelope” of his privileges:
- passes up to 36 hours to enter the community of Elgin and Middlesex Counties, accompanied by staff or a person or delegate approved by the person in charge;
- community living in Elgin County in supervised accommodation approved by the person in charge;
- an exception to the clause prohibiting the possession of incendiary devices or materials, for the purpose of smoking; and
- as an adjunct to the community living privilege, a minimum reporting requirement of four times monthly.
The parties maintained their positions at the conclusion of the evidence.
Evidence at the Hearing
- The evidence at the hearing consisted of the Hospital Report dated March 21, 2025 (with attachments) and the oral evidence of Dr. B. Robertson, a senior psychiatric resident working under the supervision of Dr. J. Quinn, Mr. Tshibangu’s attending psychiatrist. Appended to the Hospital Report are the following documents:
- a criminal responsibility assessment report by Dr. Elizabeth Coleman dated April 3, 2024;
- a psychosocial report from Ontario Shores Centre for Mental Health Sciences, dated March 30, 2024;
- a psychology report from Ontario Shores, dated March 28, 2024; and
- a fitness to stand trial assessment report by Dr. J. Quinn, dated March 30, 2022.
Findings
- The Board accepted the parties’ joint recommendation and found, independently on the evidence, that Mr. Tshibangu represents a significant threat to the safety of the public. A new Disposition, in the form of a Detention Order reflecting the agreed-upon changes, was issued, as the panel found that a Detention Order with the addition of 36-hour passes and the opportunity for community living was necessary and appropriate. These are the Reasons for the panel’s findings.
Index Offences
- The index offences arose from a series of events that occurred on July 14, 2023, when Mr. Tshibangu was 19 years old. The circumstances of those offences are taken from the initial Reasons for Disposition, dated July 25, 2024. The summary therein is reportedly taken from the transcript of proceedings in the Ontario Court of Justice and is reproduced as follows:
There are four victims in this matter [names of the two (2) civilian victims redacted]. The accused and the victims in this matter are not known to one another.
On Friday, July 14, 2023 at 9:08 p.m., London Police were contacted by several bystanders reporting a[n] hysterical male shouting suicidal ideations in the area of 1570 Adelaide Street North, in the City of London.
At 9:15 p.m., that same male, who was later identified as the accused before the court, began to intentionally punch and kick the windows and bodies of unoccupied vehicles in the parking lot at 1560 Adelaide Street North, in the City of London. The three vehicles included a 2009 Santa Fe, a 2004 Ford pickup, and a 2021 Mazda CX-5, which all sustained damage. Multiple witnesses from that location either heard or saw the accused cause damage to those vehicles. The estimated cost was $2000.
In addition to the property damage, the accused displayed an obvious, visible, heightened state of emotion. He was observed shouting and yelling in a loud tone, directed at no one in particular, and he was overheard indicating that he wanted to be involved in a physical altercation with everyone in sight. He was then seen leaving the parking lot on foot in a southwest direction.
At 9:21 p.m., police were detailed in a priority fashion to investigate at 1570 Adelaide Street North, in London.
At 9:22 p.m., the accused had aggressively entered the Circle K Convenience Store at 1536 Fanshawe Park Road East, in London. He began to become irate towards store personnel [being two of the victims in this matter]. He approached the counter and attempted to deliver a punch towards [a victim] but was unsuccessful. He then selected chocolates on display and threw them directly at [the victims], striking them in the head and body.
At 9:23 p.m., police officers and subsequent victims, Constable Lang and Constable Avalo-Barrera, entered the store. The accused presented in an agitated state and was swiftly approached by Constable Lang. Physical manipulation was utilized to try and subdue the accused who began to actively resist arrest.
At 9:23 p.m., the accused assaulted Lang by driving his fist directly into the head of the officer, causing him to fall backward onto the floor. Constable Avalo-Barrera then interjected and attempted to physically subdue the accused, yielding negative results. At 9:23 p.m., the accused…then proceeded to apply direct force with his foot against the head of Constable Lang, who was still on the ground. He then gave additional strikes with his fists, directed at Constable Avalo-Barrera’s head, which caused her to fall backwards to the ground.
At 9:24 p.m., both officers alerted additional units to attend the scene in…an emergency fashion. At 9:24 p.m., Constable Avalo-Barrera initiated her use of force option, using pepper spray, which appeared to merely slow the accused down marginally.
At 9:24 p.m., additional officer[s] arrived on scene, and at that time, the accused began to remove money from the cash register. Police used communication and de-escalation techniques while creating a safe distance to converse with the accused, and at 9:25 p.m., the accused was arrested and removed from the store by multiple officers, before being placed with handcuffs to the rear.
He continued to behave erratically, shouting nonsensical communications and continuing to resist. He also exhibited extreme sweating and an inability to comprehend the severity of the situation. Because of that, he was not immediately read his rights to counsel or caution.
At 9:29 p.m., emergency medical services were requested for further assessment, and at 9:48 p.m., two additional emergency medical service vehicles were requested for both Constable Lang and Constable Avalo-Barrera, who were exhibiting concussion systems [sic].
- Mr. Tshibangu’s self-reports concerning the index offences were summarized in the initial Reasons for Disposition, as follows:
In later self-reports, Mr. Tshibangu indicated that it was difficult for him to remember much about the days leading up to the Index Offences or the circumstances of the Index Offences themselves. He remembered “trying to smoke cigarettes and weed” and being unsure of having taken his [psychiatric] medication. He later admitted to having used cannabis a few hours prior to the Index Offences, and also that he had been using cannabis for four days in a row leading up to them. On another occasion, he reported that he had not been taking his Abilify or olanzapine for about a week prior to the Index Offences. He thought he went to the gas station to “buy gas and blow up a few cars” but was unsure as to why, denying having wanted to do this in the past. He remembered being pepper-sprayed. He also “somewhat” remembered robbing the gas station but could not remember why, stating “I do not think I went there to rob it; I went there to blow up a few cars”. He denied having pre-planned the events of that day (“I think it just happened when I went out”). He did, however, remember “slapping or punching” one of the officers, “probably to get arrested” and that he had called the police before the Index Offences to “get help” as he had been feeling suicidal. He recalled being mad or upset about something on the day of the Index Offences but was unable to remember what it was. When asked why he was yelling in the street when damaging cars or at the convenience store, he stated he could not remember, and added, “I am so lost”.
Diagnoses
- Mr. Tshibangu’s psychiatric diagnoses are listed in the Hospital Report as follows:
(i) schizophrenia; (ii) substance use disorder; (iii) social anxiety disorder; (iv) intellectual disorder (provisional); and (v) rule out post-traumatic stress disorder (PTSD).
General Background Information
The Hospital Report and its attachments together contain a great deal of information concerning Mr. Tshibangu’s personal and mental health history, his criminal history and other behaviour, and his course following the index offences. As the report was made an exhibit at the hearing and is therefore in evidence, it is not necessary to reproduce the information from all these materials in its entirety for the purpose of these Reasons. However, as these are very early days in Mr. Tshibangu’s course under the ORB, it is useful to highlight certain details for present and future reference. It is noted that as Mr. Tshibangu was identified as a poor historian, much of what follows is synthesized from reports of collateral sources, including his brother, maternal grandfather, and health care records.
Mr. Tshibangu was born in a refugee camp in Uganda after his mother and her relatives fled the Congo due to the civil unrest there. It is reported that his mother consumed alcohol during her pregnancy. Eventually, when he was 6 years old, the family settled in New Brunswick where, according to his brother, life was “good” for a couple of years. Within two years, however, Mr. Tshibangu and his older brother were apprehended by child protection authorities. Children’s Aid involvement continued after the family moved to Ontario.
There is a history of housing instability due to the mother’s transient lifestyle. The family reportedly moved to Quebec, then to Brampton, and finally to London, Ontario when, in 2015, Mr. Tshibangu and his brother moved in with their maternal grandfather. Due to Mr. Tshibangu’s mental health and behavioural issues, including a tendency towards violence and aggression when unwell, the living situation had an “on-again, off-again” character. His history includes reference to living at a Salvation Army shelter prior to one of his psychiatric admissions. From November of 2020 to June, 2021, Mr. Tshibangu lived on his own in apartments, supported by Youth Opportunities Unlimited (YOU). He was evicted after several months due to his behaviour and inability to maintain his residences. He was financially supported by the Children’s Aid Society’s Extended Care Program. He was again living with his grandfather and brother Ariel for approximately a year before the index offences.
From collateral accounts, it is evident that Mr. Tshibangu had a tumultuous and traumatic childhood. He was exposed to conflict at a young age in the Democratic Republic of Congo: it is reported by his grandfather that Mr. Tshibangu was privy to conversations about multiple family members being killed in the conflict, and he may have witnessed his grandmother being murdered1. In Canada, his mother reportedly struggled with substance use and mental health issues of her own. There were concerns of neglect and transience. As a result, his relationship with his mother has historically been somewhat strained. Mr. Tshibangu has no relationship with his father, who did not accompany the family out of Congo. However, he does maintain a relationship with his maternal grandfather, described in the Hospital Report as “the only stable adult figure in the family” but who is described by Mr. Tshibangu’s older brother, Ariel, as somewhat inclined to be overly protective of him. Ariel reportedly does not struggle with mental health or substance abuse issues and, by all accounts, is a positive support in Mr. Tshibangu’s life. This is elaborated upon below.
Mr. Tshibangu’s highest level of education is grade 8; his school experience has been punctuated by academic difficulties, truancy in his high school years and interpersonal difficulties (fighting). He has never worked nor been in a relationship.
Mr. Tshibangu’s older brother, Ariel, provided biographical information for the Ontario Shores psychosocial assessment in March of 2024. He advised that Mr. Tshibangu’s behaviour started to change in 2018 after they moved in with their maternal grandfather in London. He started smoking cannabis and began talking to himself, as well as engaging in aggressive behaviour that included attempts to fight with Ariel.
Mr. Tshibangu has a serious criminal record, for a person his age, spanning the period from June of 2018 to June of 2022, a year before the index offences. Most convictions occurred when he was a youth, with his first convictions (for assault and assault with a weapon) registered when he was 14 years old. The record contains multiple convictions for serious offences of violence against persons, including assault causing bodily harm to a peace officer. His most recent convictions were in June 2022, as an adult, for assault causing bodily harm and assault. He was on probation for these matters when the index offences took place.
Beyond what is provided in his criminal record, there is information from collateral sources describing several of Mr. Tshibangu’s behaviours. The origin of the information documenting some of these incidents, noted briefly in the current and previous psychological risk assessments, was the subject of comments at para. 41 of last year’s Reasons. Most of these incidents are not yet included in the Hospital Report itself but are referenced in one or more of the attachments. It would be helpful if future iterations of the Hospital Report could incorporate this information so that it is not lost over time. The incidents are listed below, along with their sources for reference purposes:
- In a CMHA progress note on September 24, 2021, Mr. Tshibangu’s YOU worker reported that earlier in the year, he had stabbed a random stranger on the street in apparent response to command hallucinations and had been charged with an offence arising from this (Report of Dr. Coleman, p. 14; Psychosocial History, Ontario Shores, pp. 5, 15);
- An admission to hospital on June 21, 2021, was preceded by Mr. Tshibangu yelling in the community about killing a specific person while punching a mailbox, and then becoming violent toward police who intervened at the scene (Hospital Report, p. 9; Psychosocial History, Ontario Shores, p. 16);
- On February 1, 2022, it was reported that Mr. Tshibangu seriously assaulted a security guard at a YOU apartment building, resulting in the guard’s hospitalization for several days; the injuries are not specified (Report of Dr. Coleman, p. 14; Psychosocial History, pp. 5, 12);
- In February of 2022, while in custody at the Roy McMurtry Youth Centre on charges arising out of the assault upon the previously mentioned security guard, Mr. Tshibangu was twice admitted to hospital following incidents of assault and threatening directed at staff of the Centre (Hospital Report, p. 12; Psychosocial History, Ontario Shores, p. 12; Psychology Report, Ontario Shores, p. 9; Fitness to Stand Trial Report of Dr. J. Quinn, p. 5);
- Threatening to stab and kill people, including children, earlier on the day of the index offences (Report of Dr. Coleman, p. 13; Psychosocial History, Ontario Shores [Collateral report from Ariel Tshibangu], p. 5); and
- Threatening to obtain police officers’ guns, upon waking up in hospital following sedation by EMS after apprehension for the index offences (Report of Dr. Coleman, p. 11).
- Mr. Tshibangu has an extensive substance abuse history and, during many of his formal psychiatric admissions (noted below), was often diagnosed with substance-induced psychosis. In her criminal responsibility assessment report, Dr. Coleman noted that he may have started using cannabis when in Grade 7. She wrote that he qualified for a diagnosis of polysubstance use disorder. She noted that Mr. Tshibangu had endorsed using crystal methamphetamine at the rate of 8 mg per month, and that his YOU worker reported that Mr. Tshibangu admitted using crystal methamphetamine with his uncle every day during a period of escalating aggression. This worker also observed that his psychotic symptoms intensified when he had been using substances. Mr. Tshibangu also acknowledged a history of cocaine and fentanyl use. During his various hospital admissions, his urine screens tested positive for cannabis, methamphetamines, opiates, and benzodiazepines.
Formal Psychiatric History Prior to the Index Offences
The earliest record of a psychiatric admission for Mr. Tshibangu is in June of 2020 when he was 16 years old. He was admitted to the Child and Adolescent Psychiatry Ward of London Health Sciences Centre (LHSC) after destroying much of the property in his grandfather’s home. His grandfather denied that Mr. Tshibangu had experienced psychotic symptoms prior to this admission. He was discharged to his grandfather’s home but readmitted after a few hours as he had been struck by a truck. It was unclear to clinicians whether this was a suicide attempt or a psychotic episode. He was again discharged to his grandfather’s home.
In her criminal responsibility report, Dr. Coleman provided a summary review of Mr. Tshibangu’s psychiatric admissions. Starting in June of 2020 with the above-noted admission, there were some 13 admissions up to 2022, the majority of which were to LHSC. One admission was a “keep fit” order from a court in May of 2022 to the Southwest Centre.
Dr. Coleman noted that Mr. Tshibangu has often been accompanied to hospital by police who brought him in for assessment following bizarre, aggressive, or violent behaviour. He was frequently placed on a Form 1 and often required chemical or physical restraints while in the emergency room. He has required seclusion on several occasions due to aggressive behaviour in the context of psychotic symptoms. He has presented with notable disorganized thought form and speech, and either acknowledged auditory or visual hallucinations or was observed responding to internal stimuli, often either yelling or shouting.
Dr. Coleman noted that Mr. Tshibangu’s longest period without hospital admissions was from June of 2022 to June of 2023. During that time, he was treated with a combination of long-acting injectable (Abilify Maintena, every four weeks) and oral (olanzapine) medications. According to the Ontario Shores psychosocial history, he was also being supported in the community by a CMHA worker and his probation officer. He continued receiving his injectable medication monthly until his final documented dose in February of 2023. He was being followed by a CMHA London psychiatric clinic.
Working from collateral information sources, Dr. Coleman concluded that approximately five months before the index offences, Mr. Tshibangu stopped attending his clinic appointments and stopped taking his injectable medication. Although Mr. Tshibangu reported continuing to take his oral olanzapine, he acknowledged not taking it during the week prior to the index offences. He was using cannabis regularly during the weeks and months leading to the index offences and self-reported increasing his use during the four days beforehand.
Dr. Coleman reported collateral information from Mr. Tshibangu’s brother, Ariel. He advised that Mr. Tshibangu was behaving oddly on the day of the index offences, just prior to leaving the home. Ariel then heard him yelling behind their apartment building and their uncle told him to stop. Instead, Mr. Tshibangu kept yelling, threatening to kill and stab people, including young children, and was kicking cars.
Mr. Tshibangu’s Initial Review Period Under the Board
After being transferred from the Hospital’s Assessment Unit, Mr. Tshibangu resided on a treatment unit under the care of Dr. N. Mokhber. He remained there until January 13, 2025, when he was transferred to a rehabilitation readiness unit, A1, and his care was subsequently transferred to Dr. Jason Quinn. Mr. Tshibangu reportedly tolerated both transitions well and settled into each ward milieu without incident. He stated he was happy to be on A1 as it was, in his words, the “last step to getting out of the hospital”.
Mr. Tshibangu was difficult to engage in any meaningful conversation as he was guarded, vague and evasive and only answered questions strictly based on what was asked, with little elaboration; he would often reply with “I don't know” or "I don't want to share" when asked questions about his symptoms or index offences. He generally denied symptoms of psychosis, abnormal beliefs or ideas, grandiose delusions, persecutory delusions, or referential delusions. He consistently denied experiencing suicidal or homicidal ideation, reported feeling safe in the Hospital among staff and patients, but demonstrated what was reported as a disproportionate fear of being in a group setting. His main sources of stress were unknown as he was not forthcoming about this.
Mr. Tshibangu is considered capable of making treatment decisions and has remained adherent to his medications. During the year, his antipsychotic medication was gradually switched to a long-acting injectable (Abilify) and he tolerated this change. In January of 2025, he verbalized that the medication was helpful but was uncertain whether he would continue taking it once outside the Hospital, stating that he might wait and see whether his symptoms returned and if they did, then he would take medication.
Mr. Tshibangu appears to have been abstinent of substances, as all his drug screens returned negative results. He acknowledged that using cannabis destabilizes his mental state but did not agree that cannabis use was a contributing factor to his violence in the community.
Mr. Tshibangu’s insight across all domains is discussed in detail in the Hospital Report at pp. 26-28. It is described as limited or underdeveloped. Notably in relation to the index offences, he fluctuated between recalling the events clearly and expressing remorse, and at other times stating that he could not recall and expressing no remorse or understanding of their impact on other people. On one occasion, in July of 2024, he expressed that he may even repeat the offences, though without explaining why.
Mr. Tshibangu described his mother, maternal grandfather, brother (Ariel) and an uncle as his personal supports. He received occasional visits from family members and was in regular telephone contact with his mother. His brother became an Approved Person in February of 2025.
Mr. Tshibangu completed the Montreal Cognitive Assessment (MoCA) on September 24, 2024. He scored 17 out of 30, indicating moderate cognitive impairment.
A risk assessment conducted on June 4, 2024 determined that if Mr. Tshibangu were to be managed on a Detention Disposition in the Hospital, his risk would be low. If given a less restrictive disposition, such as a provision for community living at that juncture, it was opined that he would likely stop taking medication and use substances, resulting in a decompensation in his mental state, and his risk to the public would become moderate to high. A new HCR-20 v. 3 risk assessment, completed on February 21, 2025, concluded that Mr. Tshibangu’s overall risk for violence would be considered low in the context of a Detention Disposition. If he were to be granted an Absolute Discharge, his risk would be high.
The Hospital Report includes the following re-offence scenario:
Absent forensic support and supervision, Mr. Tshibangu would be at high risk of treatment discontinuation as he has limited insight into his illness and into the impact substance use had on his life and his mental illness. Based on his history, he would likely turn to substances to cope with stress, which would compromise his mental state. He has a pattern of exhibiting aggressive and disorganized behaviours following decompensation and the emergence of psychotic symptoms. He would very likely respond violently to perceived threats in the community under these circumstances, resulting in assaultive behaviour, harm to self, and property damage.
Evidence of Dr. Robertson
As stated above, Dr. Robertson is a senior psychiatric resident working under Dr. Quinn’s supervision. He gave evidence to supplement the information contained in the Hospital Report and adopted its contents.
Dr. Robertson testified that Mr. Tshibangu’s presentation has improved from what it was at the time of his initial Review Board hearing last year. He has been fairly consistent in denying psychotic symptoms and no overt symptoms are being observed. He is seen as more forthright and social, and overall more engaged with his treatment team and family. His insight is seen as developing. Since the changes to his psychiatric medications, no decompensation has been observed and he shows a bit more motivation, engagement, and brightness in his affect. While he is currently stable on his medication, Dr. Robertson cautioned that it is still too early to say that his treatment is optimized.
While Mr. Tshibangu is adherent to his medication, he very much requires the prompting and support of staff to maintain his compliance. Dr. Robertson thought that this may be primarily due to limits on Mr. Tshibangu’s executive functioning.
Dr. Robertson advised the panel that Mr. Tshibangu was being referred to the Psychology department to consider a potential PTSD diagnosis. In anticipation of a potential application for DSO (Developmental Services of Ontario) benefits, there is also a plan to redo previous cognitive assessments.
Dr. Robertson confirmed Mr. Tshibangu’s need to remain abstinent of substances, pointing out that historically, he has become quite violent and his psychotic symptoms increased greatly when he used cannabis. He is very vulnerable to relapse in this regard. He has been referred to the Concurrent Disorders Service and is on a waitlist to begin psychotherapeutic programming to improve his insight and address his risk.
Dr. Robertson advised that Mr. Tshibangu was utilizing Level 6 (indirectly supervised hospital and grounds) privileges and was being oriented to the community. His relationship with his brother (Ariel), his Approved Person, was much better, and Dr. Robertson opined that making provision in the Disposition for 36-hour community passes would foster opportunities for greater family engagement. Dr. Robertson believed that community living in a supervised setting was a realistic possibility for Mr. Tshibangu over the coming year. It would, in any event, provide some incentive for Mr. Tshibangu’s engagement in therapeutic programming, as his engagement is in part externally motivated.
In response to a panel member’s questions concerning family members being fearful of Mr. Tshibangu, Dr. Robertson stated that this is not currently an ongoing issue. However, the Hospital would be careful not to approve overnight passes to the family home unless and until the family became comfortable with this. Dr. Robertson added that Ariel has verbalized that his brother now seems like a very different person from before.
Another panel member asked a question concerning the need to provide, in the proposed Disposition, for a “delegate” that is neither staff nor an Approved Person for the purpose of accompanying Mr. Tshibangu into the community. Counsel for the Hospital fielded this inquiry, advising that the Hospital has a “roster” of community agencies that provide several services to patients and the Hospital may wish to engage one or more of these agencies to support Mr. Tshibangu in off-site activities and/or programming.
No further evidence was led following Dr. Robertson’s testimony.
Analysis and Conclusions
Significant Threat
The panel has borne in mind the parties’ joint submission and the fact that the “significant threat” issue was uncontested. Having considered the evidence independently and in its entirety as is the Board’s duty, the panel had no difficulty in concluding that Mr. Tshibangu represents a significant threat to the safety of the public. The panel makes this finding based upon the expert opinion evidence of Dr. Robertson and the evidence contained in the Hospital Report.
In this regard, the panel accepts the clinical and structured risk assessments and re-offence scenario set out at pp. 33-37 of the Hospital Report, as well as the uncontroverted expert evidence of Dr. Robertson, who has examined and worked with Mr. Tshibangu.
Mr. Tshibangu suffers from a major mental illness (schizophrenia) along with a substance use disorder. Many of his earlier hospital admissions have been associated with substance use. Overall, while he has exhibited psychotic symptoms in the absence of substance use, his use of substances has exacerbated his symptoms in the past. His history shows a clear and recent pattern of violence, demonstrated by the number of instances of serious violent behaviours leading to charges dating back to 2018, as well as threatening behaviour towards family and to staff at a youth custody facility. He has required physical restraints while in hospital and has violently resisted police intervention in the community, causing bodily injury to police officers, including during the index offences. According to file information, he also randomly stabbed someone on the street, an act said to have been driven by command hallucinations.
Mr. Tshibangu’s history includes (though not always) a pattern of behaviour, when he is unwell, that involves the following features: property damage accompanied by or preceding assaults or threats of harm (including to cause death), followed by assaultive behaviour directed at police officers, and in some cases at health care staff, who intervene. Undoubtedly, his treatment teams will bear this history in mind as greater privileges, including into the community, are contemplated.
Mr. Tshibangu’s risk flows from his primary psychotic disorder, schizophrenia, as well as substance use disorder which, operating independently and together, make him highly vulnerable to acting out in serious, criminal and violent ways when mentally decompensated and/or using substances. He has limited insight into his mental illness, need for medication, and need to abstain from psychoactive substances, as well as the role each of these issues played in driving the behaviour that ultimately led to the index offences.
Accordingly, the panel concluded that absent the oversight of the ORB and the structure and supervision provided by a hospital’s forensic service, there is a very substantial likelihood that Mr. Tshibangu would engage in criminal conduct that would result in serious physical and/or or psychological harm to those who encounter him. Potential victims include family members, first responders including police, hospital staff, and members of the public whom he may encounter at random.
The Necessary and Appropriate Disposition
The panel finds, as did last year’s panel, that in the absence of a high degree of structure, intense behavioural support and monitoring, medication supervision and a positive therapeutic alliance, Mr. Tshibangu would, in all likelihood, discontinue taking medication, engage in the use of substances, become increasingly unwell and return to the state of mind that gave rise to the index offences and other violent acts that his history indicates he committed while unwell. He needs treatment and care to manage his complex mental health needs, of the sort that can only be provided within a highly structured and secure forensic setting, pursuant to a Detention Disposition. Nothing short of a Detention Order can adequately manage his risk at this time.
That being said, the panel agrees with the parties that it is appropriate to include expanded privileges, including overnight passes and community living in supervised accommodation, in the Disposition. Mr. Tshibangu has made some strides since coming under the Hospital’s care, including achieving a degree of stability in his mental state while adherent to his antipsychotic medication. Having been stabilized, Mr. Tshibangu can participate meaningfully in other psychotherapeutic programs, such as IMR (Illness Management and Recovery), Cognitive Behavioural Therapy for psychosis (CBT-p) and substance use treatment, so that his overall insight and risk may be addressed. In addition, as noted by Dr. Robertson and pointed out in the Hospital Report, further assessments are to be undertaken in relation to Mr. Tshibangu’s trauma history and DSO eligibility.
The panel considers that community living in the coming reporting year would be a major step for Mr. Tshibangu, considering his very troubled history and the recency of his stabilization. However, given Dr. Robertson’s evidence that the treatment team believes that community living within the year is a realistic possibility, and his assurance that the team would move very carefully, in a stepwise manner, in extending community privileges, the panel is prepared to include this privilege in the Disposition. The panel would stress that currently, it is important to specify, within the Disposition, that Mr. Tshibangu reside in supervised accommodation. In this regard, it is noted that he has lost independent community accommodation twice as recently as 2021, despite being supported by a community worker, due at least in part to challenges in his daily living activities.
The requirement in the Disposition that Mr. Tshibangu refrain from possessing incendiary devices or materials is maintained. However, he may possess those items that are necessary for the purpose of smoking cigarettes, as may be permitted by the Hospital’s rules.
Accordingly, the panel was satisfied that the necessary and appropriate Disposition is a Detention Order containing substantially the same terms and conditions as were included in the previous Disposition, with the additions as previously noted. This Disposition, the panel found, best provides for the management of Mr. Tshibangu’s risk at this time, and therefore the protection of the public, while recognizing his mental condition and other needs and supporting the treatment team’s continuing efforts to move him towards reintegration into the community.
In closing, the panel wishes Mr. Tshibangu the best of success over the next year and would encourage him to continue to strengthen his working relationship with his treatment team. As he becomes less guarded and more open/engaged with them, they will be better positioned to support him on his path to health and living in the community.
DATED this 13th day of June 2025, at the City of Toronto, in the Toronto Region.
Eric Siebenmorgen
Legal Member
Office of the Registrar
Ontario Review Board
Footnotes
- This specific information, though referred to in both the initial and current psychological risk assessments, was not found elsewhere in last year’s initial Hospital Report, as noted at para. 41 of last year’s Reasons. This information is found at p. 5 of the Psychology Report from Ontario Shores dated March 28, 2024, appended to the current Hospital Report. As noted, it was gleaned from notes of information provided by the grandfather during an admission of Mr. Tshibangu to LHSC in June of 2020.