Re: Blair F. Coling
ORB File No: 6954
Hearing held on: Thursday, May 8, 2025
Place of hearing: Centre for Addiction and Mental Health
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Ms. L. Banks
Members: Dr. T. Verny Dr. G. Nexhipi Mr. K. McKenna Mr. W. Apted
Parties Appearing:
Accused: Blair F. Coling Counsel: Ms. C. Whillier
The person in charge of hospital: Counsel: Ms. M. Warner
Attorney General of Ontario: Counsel: Mr. M. Feindel
REASONS FOR DISPOSITION
(Dated June 18, 2025)
Introduction:
On May 11, 2016, Mr. Blair Coling was found not criminally responsible on account of mental disorder (“NCR”) on charges of mischief not exceeding $5,000 and assault causing bodily harm, all contrary to the Criminal Code of Canada.
Mr. Coling is currently subject to the terms of a Disposition of the Ontario Review Board dated June 17, 2024. That Disposition requires him to be detained in the General Forensic Unit of the Centre for Addiction and Mental Health (“CAMH” or the “hospital”), with privileges up to and including living in the community in supervised accommodation approved by the person in charge.
On May 8, 2025, the Board convened to hold Mr. Coling’s annual hearing pursuant to s. 672.81(1) of the Criminal Code. This hearing was held via video teleconference due to the ongoing pandemic. Mr. Coling was represented by counsel, Ms. Whillier.
At the outset of the hearing, the Board was advised by Dr. Van that Mr. Coling was not interested in attending his ORB hearing as he believes it has no relevance to him. Ms. Whillier advised that she had instructions and was prepared to proceed in her client’s absence. The Board conducted the hearing in Mr. Coling’s absence and he was excused from attending the hearing pursuant to s. 672.5(10)(a) of the Criminal Code.
The issues to be considered at this hearing are whether Mr. Coling is a significant threat to the safety of the public as now defined in s. 672.5401 of the Criminal Code and, if he is found to be a significant threat 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 concluded that Mr. Coling continues to represent a significant threat to the safety of the public. This Board is satisfied that Mr. Coling’s continued detention at CAMH within a General Forensic unit on the same terms and conditions as are set forth in his existing Disposition remains necessary and appropriate.
Positions of the Parties:
At the commencement of the hearing, the parties were canvassed as to their, without prejudice, recommendations to the Board.
The hospital’s representative advised that the hospital was recommending that Mr. Coling continue to be subject to the terms of his existing Disposition.
Counsel for the Attorney General was supportive of the hospital's position.
Ms. Whillier indicated that her client no longer posed a significant threat to public safety and should be Absolutely Discharged. In closing submissions, Ms. Whillier indicated her client’s request for an Absolute Discharge was driven, in part, by his desire not to have to return for any reason whatsoever to CAMH.
Index Offence:
- The circumstances giving rise to the index offence are set out in last year’s Reasons for Disposition dated July 8, 2024, as follows:
“On May 16, 2015, Mr. Coling, who was an involuntary psychiatric patient at the Freeport Hospital in Kitchener, Ontario, exited his room. When he was directed to return to his room, he became agitated and caused approximately $300 in damages to his room.
Approximately two hours after damaging his room, when a male nurse told Mr. Coling that it looked like he had had a difficult night, he became enraged and an altercation ensued during which he bit the nurse once in the chest, breaking the skin and punched him several times in the stomach and head. Other staff intervened and restrained Mr. Coling. As the victim was being taken away for treatment, Mr. Coling stated "I'm going to kill your children".”
Personal Background/Psychiatric History
The Hospital Report dated April 29, 2025 (the “Hospital Report”) sets out in detail the background and psychiatric history of Mr. Coling and need not be repeated here. Briefly, Mr. Coling is a 44-year-old man who was born in Waterloo, Ontario.
Mr. Coling reported that he did not always get along with his father, who his mother described as being physically and verbally abusive towards herself and her son. His parents eventually separated and Mr. Coling spent the majority of his childhood and adolescence in structured residential treatment facilities.
Mr. Coling began presenting with behavioural problems at a very early age. Between the ages of 6 and 19 he was placed at different programs including the St. Agatha Community and Home Support Program, the Charlestown Residential School for two years, an assessment and residential treatment centre called Lutherwood for six months when he was 16 and the Pioneer Group Home at age 16 for the next three years.
Mr. Coling had significant behavioural and academic problems in school and eventually quit during his first year of high school.
His only employment history was working for approximately two months at McDonald's restaurant when he was 19.
Mr. Coling has a significant history of substance abuse starting in his teens. He has used a variety of substances including crack cocaine, heroin, acid, marijuana, ecstasy and alcohol.
Legal History:
- Mr. Coling’s criminal offence history is taken from the Hospital Report, as follows:
| Date & Location | Charge(s) | Disposition |
|---|---|---|
| 2005.12.08 Kitchener, ON |
1) Possession of Weapon 2) Uttering Threats 3) Assault |
1-3) Suspended sentence & probation 2 years on each charge concurrently & (41 days pre-sentence custody) & Discretionary Prohibition Order S.110 CC for 5 years |
| 2007.08.28 Kitchener, ON |
Failure to Comply with Probation Order | Suspended sentence & probation 18 months |
| 2013.05.09 Midland, ON |
Assault Cause Bodily Harm | 60 days Conditional Sentence Order (to be served at Waypoint Centre for Mental Health Care or other mental health institution) & Mandatory Prohibition Order S.109 CC for 10 years |
| 2014.01.21 Kitchener, ON |
Mischief Under $5000 | Suspended sentence & probation 1 year |
- In addition, Mr. Coling has incurred the following charges with varying Dispositions:
| Date & Location | Charge(s) | Disposition |
|---|---|---|
| 2005.12.08 Kitchener, ON |
Assault with a Weapon (2 charges) | Withdrawn |
| 2007.08.28 Kitchener, ON |
1) Theft under $5000 2) Failure to Comply with Probation Order |
1-2) Withdrawn |
| 2011.09.28 Kitchener, ON |
Mischief Under $5000 (2 charges) | Unfit to Stand Trial (Disposed of 2014.01.21) |
| 2014.01.21 Waterloo, ON |
Mischief Under $5000 | Withdrawn |
| 2016.02.02 Kitchener, ON |
Mischief Under $5000 | Dismissed |
- Following his NCR finding, Mr. Coling was detained at Waypoint until his transfer to CAMH on September 28, 2018.
Psychiatric History:
- Mr. Coling has a long and complex psychiatric history which is set out in considerable detail on pages 8-12 in the Hospital Report.
Current Diagnoses:
- Mr. Coling’s current diagnoses are: Autism Spectrum Disorder; Intellectual Disability, mild; Schizoaffective Disorder, bipolar type; Polysubstance Use Disorder, in remission in controlled environment; and Possible Antisocial and Borderline Personality Traits.
Evidence at the Hearing:
Dr. L. Van, Mr. Coling’s forensic psychiatrist since January 2025, testified at the hearing to supplement the evidence contained in the Hospital Report.
Mr. Coling spent the first part of the past year as an inpatient on LGUB, a General Forensic unit at the hospital. While at CAMH, Mr. Coling used level 7 passes, allowing him indirectly supervised access on a daily basis, on hospital grounds and the community. To his credit, all of his indirectly supervised community passes which were exercised while he remained an in-patient over the past year, were used without incident. Further, there was no suspicion or evidence of substance use while utilizing these passes and he managed same appropriately.
Mr. Coling was discharged from the hospital on January 13, 2025 to Reena housing, supported by Developmental Services Ontario (“DSO”). He shares his 2-bedroom apartment with one other roommate. Mr. Coling shares a bathroom, kitchen and common areas of the apartment with his flatmate. The home is locked and clients cannot leave without staff accompaniment.
His residence at Reena provides 24/7 staff supervised accommodation. There are 2 to 1 staffing at his home and he is escorted with staff when he accesses the community. Reena housing staff provide meals and transportation for all residents. This residence offers intensely supportive accommodations that address his psychiatric and neurodevelopmental needs within the disability service housing area.
Dr. Van stated that Mr. Coling does not have any independent access to the community at this point in time. His two assigned staff are developmental service workers and they are able to facilitate his attendance at off-site programming and activities. Dr. Van stated that it is hoped that over the course of the upcoming reporting year, that Mr. Coling will be successful in progressing to less supervision when accessing the community. She stated that he could potentially progress to indirectly supervised community access. His placement at this residence is not contingent on him being under the ORB’s jurisdiction.
Mr. Coling is supported and supervised in the community by the expanded forensic outpatient services (“EFOPS”) team. The EFOPS team offers discharged forensic patients a high degree of support and supervision. Dr. Van is his EFOPS psychiatrist and she meets with Mr. Coling every two weeks. Mr. Coling meets with his case manager, Mr. Thorman, weekly. These check-in appointments occur at his home. He has been compliant with all scheduled meetings.
Mr. Coling had one incident since his discharge to Reena where he was assaulted by his roommate on February 3, 2025. He reported being hit on the head and neck but did not suffer any serious injuries and did not require medical attention. Mr. Coling did not retaliate. Dr. Van stated that the two roommates appear to have moved past this incident; however, she commented that these are early days, underscoring the importance of the hospital retaining its oversight into Mr. Coling’s placement in the community.
Dr. Van stated that the EFOPS team is in the early stages of developing a therapeutic relationship with Mr. Coling which, given his complex diagnoses, has been a slow process.
Mr. Coling remains incapable of consenting to psychiatric treatment and he is treated under the consent of his mother, acting as substitute decision maker (“SDM”). Mr. Coling’s illness is treated with antipsychotic and mood stabilizing medications comprised of daily oral doses of Valproic Acid, Olanzapine, and Haloperidol. He tolerates these medications well and no side effects are reported. To his credit, he has been compliant with medication administration within both the structured and supportive environment of the hospital and his supervised residence.
Dr. Van has not consulted with Mr. Coling’s mother as Mr. Coling has not consented to this contact. He continues to harbour delusional thoughts about his mother. Dr. Van stated that treatment optimization would be unlikely to address this fixed delusion.
Despite compliance with his prescribed treatment, Mr. Coling presents with treatment-resistant disorganization of thought, as well as ongoing grandiose and persecutory delusions. Some of his more prominent grandiose delusions involve his beliefs about his wealth, his extensive travel, his family members, and work history across the world. He denies any suicidal or violent ideation. Although he denies experiencing auditory hallucinations, Mr. Coling is intermittently observed to be talking to himself.
Mr. Coling has been treated with Clozapine in the past and he has refused a re-trial of this medication. Dr. Van stated that treatment with Clozapine did not entirely attenuate his symptom load.
When psychiatrically unwell, Mr. Coling presents with aggression, verbal threats, disorganization, and institutional violence.
To Mr. Coling’s credit, all urine drug screens conducted over the year in review have returned negative for the presence of alcohol and illicit substances. He denies ever having used any substances and denies ever experiencing cravings.
As has been the case for years, Mr. Coling expresses extremely poor insight into his mental illness, the need for treatment with medication, and his risk to others. He has been unable to fully grasp his NCR status and he continues to assert that he does not suffer from any mental illness. In the past, he has stated that the index offences are a result of false allegations and he would like to overturn his NCR finding. He has maintained compliance with his prescribed medications albeit likely externally driven by his ORB Disposition and the supervised setting of the hospital and his supervised residence.
In Dr. Van’s assessment, Mr. Coling would be highly unlikely to be medication compliant absent external supervision and support. In the doctor’s opinion, given his complex diagnostic presentation, Mr. Coling is likely to require a high level of intensive supports in perpetuity.
Dr. Van advised that Mr. Coling has not been connected to any civil psychiatric care team at this time. In response to questions posed by Ms. Whillier, the doctor advised that, in her opinion, a community treatment order would be insufficient to manage his risk in the absence of an order of the ORB.
In addressing the issue of significant threat, Dr. Van referenced Mr. Coling’s psychotic and neurodevelopmental disorders, his ongoing and chronic psychotic symptomatology, his history of significant violence stemming back to his youth, problems with compliance and supervision, and his pervasive lack of insight into his mental illness and need for treatment and support. Of note, the Hospital Report indicates that Mr. Coling’s score on the Psychopathy Checklist Revised is 27 out of a possible score of 40, suggestive of strong antisocial personality traits. As well, Dr. Van referred the Board to Mr. Coling’s VRAG score which associated him with the 8th of 9 ascending categories of risk for violent recidivism.
To his credit, while in hospital and in the community over the past several years, he has abstained from acts of physical violence.
According to the Risk Assessment contained in the Hospital Report, “Absent the supervision of the ORB, he would be at high risk of becoming non-compliant with medication, administration and other non-pharmacological interventions. In the context of medication non-compliance and psychotic decompensation, he would be at higher risk of using substances as he has in the past, which would exacerbate symptoms of his illness, and in turn place him at even greater risk of violence. Overall, Mr. Coling’s future risk of violence was estimated to be moderate to high in the context of a Conditional or an Absolute Discharge.”
The doctor testified that there were several reasons necessitating a continuation of Mr. Coling’s Detention Order Disposition. These included: (i) the need to approve housing with the appropriate forensic and specialized developmental sector supports to closely supervise and support him; and (ii) the need to intercede at an early juncture and return him quickly to hospital given his history of rapid decompensation. As well, Dr. Van expressed a lack of confidence that Mr. Coling would voluntarily return to hospital, if requested, given his inability to appreciate the symptoms of psychosis. In response to a question posed by a panel member, the doctor advised that in the treatment team’s assessment, a Conditional Discharge Disposition coupled with the mechanisms afforded under the Mental Health Act would be insufficient to effect an early intervention and Mr. Coling’s rapid return to the hospital, if needed.
No further evidence was called at the hearing.
Analysis and Conclusion:
Having heard and considered all the evidence adduced and the submissions of all parties, it is the Board’s finding that Mr. Coling continues to pose a significant threat to the safety of the public as defined by the Supreme Court of Canada in Winko.
Mr. Coling has a significant history of suffering from a treatment resistant major mental illness and he continues to experience residual psychotic symptoms. His presentation is further complicated by his fairly recent diagnosis of Autism Spectrum Disorder as well as by his diagnosis of Intellectual Disability, mild. He has a history of substance use disorder. When unwell, he has acted out with physical violence, as was the case at the time of the index offence. Further, he has a history of violence that pre-dates the index offence. Mr. Coling continues to have severely underdeveloped insight into his mental illness and its symptoms, the need for treatment in perpetuity and his risk when unwell.
Absent the support and structure afforded through a Detention Order Disposition, Mr. Coling would likely fall away from treatment and/or relapse to substance use, with detrimental impacts on his mental condition. This would lead to a likely marked exacerbation of his residual symptoms of psychosis. The intensification of his psychotic symptoms, and/or a return to substance abuse, would predictably lead to significant impairment which would greatly elevate his risk of acting out violently towards others.
This panel finds that a Detention Order remains necessary and appropriate to safely manage Mr. Coling’s risk to public safety. This panel is confident that the Mental Health Act would not be sufficient to manage Mr. Coling’s risk to public safety. A Detention Order is necessary to address Mr. Coling’s risk to public safety. It allows the hospital to retain authority over his placement in the community to ensure that he is adequately supervised, supported and monitored. Mr. Coling requires a supervised, supportive accommodation, like Reena’s Place, to address his psychiatric and neurodevelopmental needs.
The panel is encouraged that it has been a smooth transition to Reena’s Place for Mr. Coling. He has been there for just over four months and he has indicated to his lawyer staff that he is content there. If this residence turns out not to be suitable to meet all of Mr. Coling’s needs then the hospital will require the authority of a Detention Order to find an alternative suitable placement for him.
Further, a Detention Order also gives the hospital the ability to pro-actively and promptly address any mental status deterioration and return Mr. Coling expeditiously to the hospital for re-admission should he become unwell in the community. The doctor was not confident that Mr. Coling would voluntarily return to hospital if he became unwell.
Based upon the evidence presented, the Board finds that the necessary and appropriate Disposition in the circumstances is that Mr. Coling continue to be bound the terms of his existing Detention Order.
In reaching our decision, this Board has considered the need to protect the public from dangerous persons, Mr. Coling’s mental condition, his reintegration into society and his other needs.
DATED this 18th day of June, 2025, at the City of Toronto, in the Toronto Region.
Ms. L. Banks Alternative Chairperson
Office of the Registrar Ontario Review Board