Re: Sandra Alexander
ORB File No: 7561
Hearing held on: Tuesday, April 29, 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: Mr. B. Garrow Members: Dr. P.E. Cook Dr. H. Moulden Ms. C. Finley Mr. S. Duffy
Parties Appearing:
Accused: Sandra Alexander Counsel: Mr. A. Rai
The person in charge of hospital: Counsel: Ms. J. McIntyre
Attorney General of Ontario: Counsel: Ms. D. Moskovitz
REASONS FOR DISPOSITION
(Dated June 10, 2025)
Introduction
[1]. On June 14, 2019, Sandra Alexander was found not criminally responsible (NCR) on charges of assault with a weapon (x3), uttering a threat to cause death or bodily harm, and assault (x3), contrary to the Criminal Code of Canada. She is currently subject to a disposition of the Ontario Review Board (ORB/the Board) dated May 22, 2024, detaining her at the Forensic Service of the Centre for Addiction and Mental Health, Toronto (CAMH/the hospital), with the discretionary privileges up to and including the ability to reside in the community in accommodation approved by the person in charge.
[2]. On April 29, 2025, the Board convened to conduct the annual hearing of Ms. Alexander’s disposition pursuant to s. 672.81(1) of the Criminal Code. Ms. Alexander did not attend the proceedings. Her counsel, Mr. Rai, indicated that he had instructions to proceed in her absence. His request for Ms. Alexander to be excused from the proceedings pursuant to s. 672.5(10) was granted.
[3]. At the outset of the proceedings, all parties were canvassed as to their positions on the two issues to be determined by the Board: whether Ms. Alexander continues to represent a significant threat to the safety of the public, and if so, the necessary and appropriate disposition having regard to the criteria set out in s. 672.54 of the Criminal Code.
[4]. Mr. McIntyre, on behalf of the hospital, submitted that Ms. Alexander continues to represent a significant threat to the safety of the public and the necessary and appropriate disposition is a discharge with terms and conditions similar to her current disposition with a reduction in reporting to not less than once every two weeks. Ms. Moskovitz, on behalf of the Ministry of the Attorney General, and Mr. Rai concurred in the hospital’s positions. Thus, a joint recommendation was put before the Board.
Findings
[5]. For the reasons that follow, the Board finds that Ms. Alexander continues to represent a significant threat to the safety of the public and the necessary and appropriate disposition is a conditional discharge with the terms as recommended by the parties.
The Evidence
[6]. The evidence at the hearing consisted of the Hospital Report, dated April 5, 2025 (ex. 1), and the viva voce evidence of Dr. Kravtsenyuk, Ms. Alexander’s treating psychiatrist.
The Index Offences
[7]. The circumstances of the index offences have been taken from last year’s Reasons for Disposition:
“In summary, the first three index offences occurred on July 6, 2018. Ms. Alexander was causing a disturbance at a Tim Hortons store in Mississauga. When asked to leave, she burned a customer with a cigarette and threatened to burn another person who attempted to assist the first victim. She also spat on a third customer. Police arrested her a short distance from the store.
Ms. Alexander was detained in custody at the Vanier Centre after her arrest. On July 10, 2018, she was transferred to the Oakville Trafalgar Hospital, where she presented as manic with disinhibited behaviour. She reported auditory hallucinations and paranoid persecutory delusions. She was verbally abusive to staff and correctional officers. Once stabilized with treatment, she was returned to the Vanier Centre on July 20 and was discharged from that facility on July 26, 2018.
On July 29, 2018, Ms. Alexander was causing a disturbance at a bus shelter in Mississauga. She uttered racial slurs to one of the victims and flicked a lighter at her, threatening to burn her. The second victim tried to intervene, and Ms. Alexander attempted to rip off that person’s hijab. Ms. Alexander then turned to the third victim and tried to take away her sunglasses. When she was unsuccessful in doing so, she spat on that person. She was arrested by police, charged and released on a promise to appear.
On August 5, 2018, Ms. Alexander was brought to the ER at Trillium Health Partners, presenting with bizarre behaviour secondary to polysubstance use and medication noncompliance. Her urine toxicology screen was positive for methamphetamine, MDMA, amphetamine, cannabis and benzodiazepines. She was prescribed her “usual” antipsychotic medications and discharged home two days later.
On August 18, 2018, Ms. Alexander confronted and then punched a person who had just finished a purchase at a lottery booth.
All of the victims of the index offences were strangers to Ms. Alexander.”
Background Information
[8]. The Hospital Report includes information about Ms. Alexander’s background and psychiatric history and need not be reviewed in these reasons beyond the following material facts. Ms. Alexander is a 42-year-old woman who is currently supported by the Ontario Disability Support Program. She has a nine-year-old son who resides with his father in Barrie and a daughter who resides in Muskoka with her two children.
[9]. Ms. Alexander experienced trauma as a child, resulting from a sexual assault by a friend of her mother’s. She moved out of her family home at the age of 14 or 15. She had her daughter when she was 19.
[10]. Ms. Alexander has reported that she used various substances as a teenager but stopped after the birth of her daughter. At the time leading up to the index offences, she was using cocaine and crystal methamphetamines.
[11]. Between 2014 and 2018, Ms. Alexander had had multiple admissions to hospital in the context of non-adherence with medication, substance use, and aggressive and/or bizarre behaviour in the community. She reported experiencing sleeplessness, agitation, anger, confusion and paranoia. When she felt stress or went through a major life event, she would experience insomnia and her symptoms would return.
[12]. In April 2016, Ms. Alexander was arrested for robbery and assault and brought to hospital by police. She was admitted pursuant to a Form 1 under the Mental Health Act. She had demanded medication at a pharmacy in Mississauga. She used a knife to stab the pharmacy attendant in her hand and ransacked the pharmacy causing significant damage. Her presentation and behaviour were considered the result of a combination of poor medication compliance, substance use and ongoing hypomania.
[13]. After being found NCR in late June 2019, Ms. Alexander did not attend her initial ORB hearing nor the hearing on the rescheduled date in mid-January 2020. On the second date, the hearing proceeded in her absence and the Board determined that the necessary and appropriate disposition was a detention order. On January 25, 2020, police apprehended Ms. Alexander after she was reported to be destroying property in a convenience store. She was admitted to CAMH. She was noted to be manic, agitated and aggressive toward staff, uttering threats of harm and xenophobic slurs. She required both chemical and mechanical restraints. Ms. Alexander’s test results indicated a presence of cannabis, cocaine and MDMA. On the morning of January 26, 2020, Ms. Alexander began to escalate, with increasing agitation, culminating in aggressive and threatening behaviours and the calling of a Code White. She was placed in seclusion.
[14]. Ms. Alexander improved with treatment and her mental status stabilized. She was transferred from a secure forensic unit to a general forensic unit and ultimately discharged back to the community to her apartment in Mississauga in November 2020.
[15]. Ms. Alexander continued to reside in her apartment until her readmission to hospital for a week in March 2021. She was charged with criminal harassment for contact that she made with her son and her son’s father. She was admitted again in May 2021 and remained in hospital until her discharge in July 2021. During that time, she had a number of incidents of agitation and aggression and required mechanical restraints and locked seclusion. Following her discharge, Ms. Alexander returned to her apartment. She remained compliant with prescribed medication. Since then, there have been no incidents of physical aggression, violence, or threats.
[16]. In 2022 and 2023, Ms. Alexander had multiple, mostly brief, preventative readmissions to mitigate the risk of deterioration of her mental state. These admissions were voluntary. She reported various stressors such as relationship problems, death of a friend, changing residence, which led to sleep and mood disturbances. She endorsed symptoms of low mood, decreased energy, hopelessness and helplessness, and reduced hours of sleep. Of concern, Ms. Alexander continued to consume cannabis on a daily basis.
Course Since the Last Disposition
[17]. Ms. Alexander’s current diagnoses are Bipolar 1 Disorder, Substance Use Disorder and Borderline Personality Traits.
[18]. Since her discharge in January 2023, Ms. Alexander has continued to reside in her independent apartment in Mississauga. She has remained compliant with treatment including all requirements of attending for outpatient appointments, taking her medication and has successfully abstained from any abuse of illicit substances. She has had no readmissions. She has continued to work well with her forensic outpatient team.
[19]. Ms. Alexander’s insight into her mental illness is reported to be excellent. She is aware that poor sleep and non-compliance with her medication have contributed to decompensation in the past. She has strong insight into the need to take medication. Of continued concern is Ms. Alexander’s sporadic cannabis use, primarily in the form of cannabis gummies, which she states help her sleep. She continues to minimize the potential risks associated with cannabis use, notwithstanding education from the treatment team.
[20]. Ms. Alexander has reconciled with the father of her son and spends time with them in their residence in Barrie. She also has a good relationship with her daughter and provides childcare support to her.
[21]. Dr. Kravtsenyuk testified before the Board. She indicated that Ms. Alexander remains a significant threat to the safety of the public. When unwell, Ms. Alexander is prone to act out in an aggressive and hostile manner. She has a history of non-compliance with treatment and substance use resulting in decompensation of her mental status and violent behaviour.
[22]. Dr. Kravtsenyuk stated that, in her opinion, a conditional discharge is the necessary and appropriate disposition. Ms. Alexander has demonstrated that she can be trusted to take her medication. She has been diligent in connecting with the treatment team and has continued to work collaboratively with them. She regularly seeks the team’s advice. In the doctor’s opinion, given Ms. Alexander’s positive relationship with members of the treatment team, the Mental Health Act would be adequate should she require an admission to hospital. Further, Dr. Kravtsenyuk testified that “when Ms. Alexander gets sick she gets very sick” and in those circumstances, the provisions of Mental Health Act would be sufficient.
[23]. Dr. Kravtsenyuk testified that the hospital does not need the ability to approve Ms. Alexander’s accommodation. Ms. Alexander has recently moved to reside with her son and his father in Barrie. She maintains open communication with the team. The doctor sees no reason why Ms. Alexander cannot manage her own housing independently.
[24]. Dr. Kravtsenyuk testified that the team considered an absolute discharge. They concluded that the initial step from a detention order to a conditional discharge was necessary. Ms. Alexander values the support that she receives. This change in her disposition would be significant for Ms. Alexander. She would find being no longer under the auspices of the Board quite stressful and destabilizing. Any destabilization could result in Ms. Alexander becoming quite symptomatic and acutely psychotic and manic.
[25]. The transition to a conditional discharge will provide Ms. Alexander an opportunity for more independence which the treatment team encourages. Hence the recommendation for a decrease in the mandatory reporting. Should Ms. Alexander feel the need to connect with the team, she can always reach out to them. In Dr. Kravtsenyuk’s opinion, the distance afforded by Ms. Alexander’s recent move to Barrie and focus on her family commitments is more therapeutic for her. The team will continue to work with her to foster her sense of resilience and self-confidence.
[26]. In response to questions from the panel, Dr. Kravtsenyuk testified that Ms. Alexander volunteers information about her use of cannabis gummies and is open to education about the associated risks. The team regularly reminds Ms. Alexander of the terms of her disposition and hopes that she will work on abstaining from cannabis use.
[27]. All parties maintained the joint submission.
Analysis and Conclusion
[28]. The Board has carefully considered the Hospital Report and the evidence of Dr, Kravtsenyuk and unanimously concludes that Ms. Alexander remains a significant threat to the safety of the public. Ms. Alexander’s risk arises from her diagnoses of Bipolar 1 Disorder and Substance Use Disorder. She has a long history of medication noncompliance and problematic substance use. Stress and lack of sleep are other contributing factors to her destabilization. When unwell, she becomes manic, agitated and aggressive. The index offences all involved unprovoked assaults on innocent members of the public.
[29]. The Board considered whether an absolute discharge was warranted in this case given the progress that Ms. Alexander has made, particularly over the past two years. We accept Dr. Kravtsenyuk’s expert opinion that at this time, Ms. Alexander would find the complete removal of the support of the treatment team stressful and destabilizing. She sees the forensic services as a stabilizing factor in her life. Better that there be a more gradual transition to an absolute discharge with the expectation that Ms. Alexander will continue to have increased independence and autonomy over the course of the next clinical year. As such, she remains a significant risk.
[30]. Having found that Ms. Alexander continues to represent a significant threat to the safety of the public, the panel must consider the necessary and appropriate disposition taking into consideration the criteria set out in s. 672.54 of the Criminal Code, which includes the need to protect the public from dangerous persons, the mental condition of the accused, the integration of the accused into society and the other needs of the accused.
[31]. The panel unanimously agrees with the joint submission that the necessary and appropriate disposition is a discharge with the conditions as recommended by the parties. Ms. Alexander has had another successful year living in the community. She has been working cooperatively with Dr. Kravtsenyuk and the treatment team and enjoys a good working relationship with them. Ms. Alexander has worked hard to foster good relations with her ex-partner and her son. She also is very involved in assisting her daughter in the care of her two children. These are positive steps in Ms. Alexander’s growing independence from the forensic team.
[32]. The Board congratulates Ms. Alexander and the treatment team for another successful year and her continued path on such a positive trajectory. Accordingly, the Board orders that the Ms. Alexander be subject to a discharge with the terms as recommended by the parties, including a reduction in the mandatory reporting to not less than once every two weeks.
DATED this 10th day of June, 2025, at the City of Toronto, in the Region of Toronto.
Ms. C. Finley Legal Member
__________________ Office of the Registrar Ontario Review Board