Ontario Review Board
Re: Mavis Alexander
ORB File No: 5224
Hearing held on: Tuesday, May 13, 2025
Place of hearing: Centre for Addiction and Mental Health (Via Zoom Video Conference)
Pursuant to: Section 672.81(2.1) of the Criminal Code
Before:
Alternate Chairperson: Mr. G. Beasley Members: Dr. P. Prendergast Dr. G. Nexhipi Ms. C. Murray Mr. A. Bouvier
Parties Appearing:
Accused: Mavis Alexander Counsel: Ms. M. Murphy
The person in charge of hospital: Counsel: Ms. M. Warner
Attorney General of Ontario: Counsel: Ms. V. Culp
REASONS FOR DECISION
(Dated June 17, 2025)
Introduction
On November 27, 2008, the accused Mavis Alexander, was found not criminally responsible on account of mental disorder on charges of arson - disregard for human life, contrary to the Criminal Code of Canada. By reason of a Disposition of the Ontario Review Board (“ORB”) dated July 24, 2024, Ms. Alexander was ordered to be detained at the Women's General Forensic Unit of the Centre for Addiction and Mental Health (“CAMH”), Toronto. The Disposition included a full range of privileges up to and including residing in the community in accommodation approved by the person in charge.
On March 4, 2025, the manager of the Office of the Person in Charge of CAMH advised the ORB that Ms. Alexander had been admitted to the hospital on an inpatient basis. Her detention in hospital had exceeded seven days.
On May 13, 2025, the ORB convened a hearing via video conference for the purpose of reviewing the circumstances surrounding Ms. Alexander’s readmission to the hospital pursuant to s. 672.81(2.1). Ms. Alexander was in attendance at the hearing and represented by counsel, Ms. Murphy. Ms. Culp appeared as counsel for the Attorney General of Ontario and Ms. Warner as counsel for CAMH.
Index Offence
- The circumstances of the index offence as taken from the Hospital Report are as follows:
"According to the police synopsis dated January 17, 2008, the Toronto Fire Services responded to a residential call to 32 Bushell Avenue, a house owned and operated by House Link community Homes. Four other residents were in the house. Upon arrival, members of the fire department located a couch on fire in the basement apartment belonging to Ms. Alexander. District Chief Paul Halls determined the cause of fire as arson and notified the Toronto Police. The officers located Ms. Alexander a short distance away from her residence, at which time she was placed under arrest, facing charges of Arson Disregard for Human Life x4.”
Current Diagnosis
- The current diagnosis as taken from the Hospital Report is as follows:
Schizoaffective Disorder, Bipolar type
Criminal Record
- Ms. Alexander’s criminal record is unclear. The hospital report indicates a history of charges, but Ms. Alexander denies any convictions. A CPIC report was not available as per the hospital report and none was provided at the hearing.
Personal History and Background
Ms. Alexander was born in Vancouver. She reached developmental milestones at age-appropriate intervals. According to her mother, Ms. Alexander was the victim of abuse during her childhood. This included sexual abuse by her stepfather when she was 12 years old. She completed high school at the age of 17 and then enrolled in a culinary course in New York City but quit after six months due to the course load being too heavy. Ms. Alexander has no employment history. The onset of her mental illness was when she was 16 years old. She was admitted to hospital at that time and diagnosed with schizophrenia and discharged to be treated with antipsychotic medication. Ms. Alexander had three siblings, an older brother and sister and a younger sister. Her brother died of a drug overdose. It was reported that her father also suffered from a mental illness which ultimately led to his suicide. Her father’s grandmother also suffered from mental illness.
Ms. Alexander has a history of admission to hospital for mental health treatment. Between the ages of 18 and 21 she had a number of admissions to St. Michael’s Hospital in Toronto. She was being followed by an Assertive Community Treatment Team (ACTT) and subject to a Community Treatment Order (CTO) in 2007. The team lost contact with her shortly before the commission of the index offences. Ms. Alexander also had a history of admissions to CAMH including an assessment for fitness to stand trial on unrelated criminal charges in 2005. She has a history of cannabis, alcohol, and cocaine use.
Following her arrest on the index offence, Ms. Alexander was originally found unfit to stand trial. After being found fit she was kept in hospital, subject to a series of “keep fit” orders. Following the finding of not criminally responsible on November 27, 2008, Ms. Alexander was ordered to be detained on the General Unit at CAMH. Between 2008 and 2015, Ms. Alexander had a number of unauthorized absences from the hospital. On January 28, 2015, she was discharged to the community to supportive housing with a moderate level of support. Following her discharge, Ms. Alexander had multiple readmissions to hospital between 2015 and February 26, 2018. The list of readmissions is set out in detail in the Restriction of Liberty (ROL) Report, which was filed as an exhibit. On February 26, 2018, Ms. Alexander was readmitted to the hospital where she remained until her discharge to high support housing on February 5, 2025.
Position of the Parties
- At the outset of the hearing, all counsel submitted that the decision to admit Ms. Alexander to the hospital on February 25, 2025, was necessary and appropriate and the least restrictive alternative available to the treatment team at the time that it occurred and on an ongoing basis.
Reasons for Original Restriction
Following her discharge to the community, Ms. Alexander attended her outpatient appointments regularly and seemed to be adjusting well to her housing arrangement. She denied any substance use in the community and two urine drug screens (UDS) were negative.
However, on February 23, 2025, housing staff reported Ms. Alexander began declining her medication, stating she did not need it. She also appeared confused about the day of the week. Later that day, Ms. Alexander disrobed and went into the common area – a known sign of mental deterioration.
On February 24, 2025, when staff attempted to explore her behaviour and medication refusal with her, Ms. Alexander stated, “I don’t know what came over me.” She continued to try to refuse medication that day, insisting she did not want to take them and gazing blankly. She asked who her doctor was, and when provided with that information, argued that it was incorrect. Housing staff contacted the EFOPS team with their concerns about the change to Ms. Alexander’s mental state.
Given these concerns, a Form 49 was activated, and Ms. Alexander was brought to the CAMH emergency department by police on February 24, 2025.
Evidence
The evidence of the hospital was presented by Dr. Dupré. She is Ms. Alexander’s attending outpatient psychiatrist and had treated Ms. Alexander as an inpatient before her discharge from the hospital. Dr. Dupré stated that she had met with Ms. Alexander the morning of the hearing. She stated that the plan for the treatment team was to gradually reintroduce passes to the hospital and grounds and eventually the community. She said that Ms. Alexander needs to demonstrate stability. She has started exercising passes on the grounds on a limited basis accompanied by her case worker. These have gone well without any issues. Dr. Dupré said that there is a concern about Ms. Alexander’s compliance with her oral antipsychotic medications. Ms. Alexander had asked if she could stop taking clozapine a few days ago. She has limited insight into her need for clozapine, and this is a concern for the treatment team.
In response to a question about Ms. Alexander's current mental state, Dr. Dupré said she is stable and not demonstrating any active mood symptoms or psychosis. She would describe her as “bright and reactive.” Nevertheless, Dr. Dupré stated that Ms. Alexander is currently not at her baseline status that she was when she was discharged to the community. With respect to her placement at Margaret House, Dr. Dupré said it is still available and is secure and will not be lost to Ms. Alexander during her admission to the hospital. Dr. Dupré stated that once issues with respect to compliance with clozapine are resolved and the treatment team has had a chance to meet with the staff at Margaret House, Ms. Alexander will be given the opportunity to access the community on her own with passes. Dr. Dupré said that there were a number of significant stressors on discharge previously.
Ms. Culp asked about what the issues were surrounding medication compliance at Margaret House. Dr. Dupré stated that the staff at the residence did not identify any concerns about Ms. Alexander spitting back her medication although that is a suspicion of the treatment team. Dr. Dupré stated that the staff are not nurses or mental health workers and do not necessarily have the experience of carefully monitoring compliance with medication. This is an area that the treatment team want to discuss with the staff. Dr. Dupré said the only other possible cause was the stress of transition back to the community which was not surprising given the length of time that Ms. Alexander had been detained in the hospital. The treatment team's plan is to continue with both the long-acting injections and clozapine as long as there are no side effects. With respect to insight, Dr. Dupré stated that Ms. Alexander does not believe that she has a major mental illness and does not believe that she has any need for any antipsychotic medication.
In response to questions from Ms. Murphy, Dr. Dupré confirmed that the treatment team plan to start the transition for Ms. Alexander back to the community by providing her with passes to the residence on a test basis. Dr. Dupré also stated that the treatment team will make different arrangements for Ms. Alexander to come to the hospital to avoid the stresses which she found making her own way from Margaret House to CAMH on the TTC. Finally, Dr. Dupré agreed that the treatment team will be providing education to the staff at Margaret House with respect to medication administration and compliance.
In response to questions from the panel, Dr. Dupré said that Ms. Alexander has always had a high level of structure while residing in the hospital. Although there was programming available for her at both Margaret House and the hospital, the treatment team plan to increase the programming at the residence to decrease the stress of travel to the hospital. Dr. Dupré said that as part of the education and training for staff at Margaret House, the treatment team intend to provide them with the same kind of yogurt which Ms. Alexander uses to take her clozapine medication. The team have already met with the staff, and they are willing to cooperate with the training. Dr. Dupré stated that Ms. Alexander’s decompensation of mental health can occur very rapidly after only one missed dose of her antipsychotic medication. The team have begun to supplement the clozapine with a long-acting injectable medication.
Neither Ms. Culp nor Ms. Murphy called evidence at the hearing.
Submissions
- All counsel reiterated the joint submission made at the outset of the hearing that the admission to hospital on February 25, 2025 which was ongoing as of the date of the hearing was warranted and the least restrictive option available to the treatment team both at its commencement and on an ongoing basis.
Analysis and Decision
The Board is unanimous in accepting the joint submission of counsel. As set out in detail in the ROL Report, Ms. Alexander has a long history of difficulties in residing in the community. She has had numerous readmissions to hospital for varying lengths of time culminating in her readmission to CAMH on February 26, 2018. Ms. Alexander remained on the Women's General Forensic Unit until February 5, 2025, when she was discharged to the community. Unfortunately, it would appear that either the stress of the transition or noncompliance with her oral antipsychotic medication led to a rapid decompensation in her mental status. By February 23, 2025, Ms. Alexander began to decline her medication. She also appeared confused, disrobed and went into the common area of Margaret's House. Her refusal to accept medication continued to the next day, and she continued to be confused. As a result, staff at Margaret's House contacted the treatment team who then were responsible for readmitting her to hospital on February 24, 2025.
It is clear from this evidence that the decision to readmit Ms. Alexander to hospital was necessary and appropriate and the least restrictive option available to the treatment team at the time. The treatment team have decided to begin a more gradual transition of Ms. Alexander back to the residence, commencing with passes to the hospital and grounds, with a caseworker. This will lead to passes into the community and ultimately to Margaret's House on a trial basis. The team have also made arrangements to train staff at Margaret's House with respect to medication compliance. With the other steps described by Dr. Dupré in her evidence, it is hoped that the transition on this occasion will be less stressful and more successful. Ms. Alexander's ongoing detention at the hospital is also found to be necessary and appropriate and the least restrictive alternative.
DATED this 17^th^ day of June, 2025, at the City of Toronto, in the Region of Toronto.
Mr. G. Beasley Alternate Chairperson
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Office of the Registrar Ontario Review Board