Ontario Review Board
Re: Roy Bonadonna
ORB File No: 6765
Hearing held on: Thursday, May 22, 2025
Place of hearing: Centre for Addiction and Mental Health (CAMH) 1001 Queen Street West, Toronto
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Ms. S. Kert Members: Dr. L. Cappe Dr. M. Mamak Hon. B. Allen Mr. A. Bouvier
Parties Appearing:
Accused: Roy Bonadonna Counsel: Ms. A. Szigeti
The person in charge of hospital: Counsel: Mr. J. McIntyre
Attorney General of Ontario: Counsel: Ms. L. Earle
REASONS FOR DISPOSITION
(Dated July 8, 2025)
Overview
On May 4, 2015, Roy Bonadonna was found not criminally responsible on account of mental disorder (NCR) on Criminal Code charges of assault and uttering a threat to cause death or bodily harm (x2). He is currently subject to a disposition of the Ontario Review Board dated June 27, 2024, discharging him on conditions.
On May 22, 2025, this panel of the Review Board convened an in-person hearing at CAMH to conduct the annual review of Mr. Bonadonna’s disposition. Mr. Bonadonna was present and represented by his counsel, Ms. Szigeti.
The issues to be decided at this hearing were whether Mr. Bonadonna continues to pose a significant threat to public safety and, if so, what is the necessary and appropriate disposition.
At the conclusion of the hearing, the parties jointly submitted that based on the evidence the test for significant threat is no longer met, and that Mr. Bonadonna should receive an absolute discharge.
We agree with the joint position of the parties. As the threshold test for significant threat is no longer met, Mr. Bonadonna must be discharged absolutely. These are our reasons.
Background and Index Offences
At the time of the hearing Mr. Bonadonna was 56 years of age, having been born in December 1968 in Toronto. After graduating from high school, he received a Bachelor of Arts degree in Italian and a diploma in theology. He also completed a few courses towards becoming a law clerk. He married in 1999 and his daughter was born in 2001.
Mr. Bonadonna’s first reported manic episode was in 1997, and he was given a diagnosis of bipolar disorder at that time or shortly after. Over the next five years, he had multiple admissions to hospital under the Mental Health Act and was inconsistent in following up with his psychiatrist. He often appeared agitated and violent, and reported sleeplessness and intense rage. His family reported that they were fearful of him.
Between 2000 and 2005, Mr. Bonadonna worked as a clerk in a law firm. However, he left that job when he experienced a manic episode. During this time, when he experienced manic episodes, he frequently threatened to kill his wife or his parents because they wanted him to go to hospital. Mr. Bonadonna’s wife asked him to leave in January 2005; at the time, he was becoming manic in the context of decreasing his medication.
Mr. Bonadonna was under the care of a psychiatrist who he saw monthly from mid-2005 until May 9, 2007. At his last appointment , he did not show any signs of psychosis or mania. Five days later, Mr. Bonadonna struck his father in the head multiple times with a hammer, causing his death.
In February 2009, Mr. Bonadonna was found not criminally responsible for the murder of his father. He was admitted to a secure forensic unit at CAMH the following month. In June 2010, he was transferred to general forensic unit. He presented as stable with few significant behavioural concerns. He used indirectly supervised community privileges without incident and engaged in 1:1 anger management sessions. He was eventually transitioned into the community, where he resided without incident. He was followed by the Forensic Outpatient Service (FOPS) at CAMH, was compliant with treatment, showed no signs of mood symptoms and abstained from drugs and alcohol. He was also actively involved in numerous activities involving patient advocacy.
After remaining clinically stable in the community for two and a half years, Mr. Bonadonna was granted an absolute discharge by the Review Board on May 2, 2014. He continued to see his outpatient psychiatrist at CAMH every four to six weeks. The hospital report indicates that he appears to have attended all appointments as expected and showed no signs of mood disturbance. He pursued a year’s training in peer support work and was eventually hired at St. Paul’s Lamoreaux Centre in March 2014.
Mr. Bonadonna saw his outpatient psychiatrist on January 28, 2015, and presented as clinically stable. However, over the next 20 days, Mr. Bonadonna decompensated. In early February he began to feel burnt out and took a few days off from work. He had trouble sleeping and advised his psychiatrist, who prescribed an extra dose of medication. He did not report that the medication was not assisting him and returned to work despite having had very little sleep. He started experiencing racing thoughts. After five or six days of not sleeping, he called 911 and was taken to the Toronto East General Hospital (TEGH), where he was prescribed extra medication for sleep and told to follow up with his psychiatrist. Despite continuing to experience symptoms of mania, Mr. Bonadonna did not alert his psychiatrist.
The details of the current index offences are taken from last year’s Reasons for Disposition as follows:
According to the police synopsis, on February 17, 2015, Mr. Bonadonna approached the victim who was vacuuming at the St. Paul’s Lamoreaux Centre, where Mr. Bonadonna was also employed. He then allegedly shoved the victim in the back pushing him into the corner by the door. The accused then grabbed the victim and turned him around until they were face to face. The accused then grabbed the victim by the throat with both hands and held him against the wall. The victim was unable to breathe and began waving for help. The accused told the victim: ‘I am going to fucking kill you.’
Victim #2, seeing the above assault, ran over to help victim #1. As victim #2 approached he yelled: ‘”What the hell are you doing?” At this point, the accused let go of victim #1 and looked at victim #2 yelling: “I am going to kill you. I’m going to kill everyone here.” The accused then left the area and the victims called security.
It was noted that Mr. Bonadonna and the victims interacted at work but “do not know each other on a personal level.”
The executive director of the [Lamoreaux ] centre was not aware of the incident and noted that Mr. Bonadonna was “just in her office having a normal conversation and wasn’t acting like anything was wrong.” PC Deabreu then attended Mr. Bonadonna’s apartment where he had barricaded himself inside but was speaking with the ETF through the door and playing music.
It is also notable that Mr. Bonadonna threatened to jump off his balcony shortly before he was arrested for the index offences, and on the ride to the station he repeatedly told the police officers that they should shoot him in the head.
Following the finding of NCR on May 4, 2015 (some six weeks after the index offences), Mr. Bonadonna was detained at the Ontario Shores Centre for Mental Health Sciences. His clinical status remained stable throughout his inpatient stay and there were no signs of mood disturbance. He participated in unit activities and attended 1:1 programming with a psychologist for anger management.
On November 13, 2015, Mr. Bonadonna was transferred from Ontario Shores to a general forensic unit at CAMH. He showed good insight into his mental illness and the circumstances surrounding his decompensation. He posed no management concerns and used his passes without issue. He was discharged into the community in January 2016, to an independent apartment in east Toronto. He remained compliant with treatment and developed a good rapport with his outpatient treatment team.
Since that time, Mr. Bonadonna has continued to live in the same apartment. He did, however, require readmission to hospital on two occasions. Notably, on both occasions the clinical team was unaware of any deterioration in Mr. Bonadonna’s mental state prior to his admission.
On December 1, 2016, Mr. Bonadonna was readmitted to CAMH after becoming manic and psychotic. The treatment team was alerted by one of his friends who was concerned about his mental state and behaviour. Given the rapidity of Mr. Bonadonna’s decompensation, the treatment team decided that an admission was necessary. At the request of the team, Mr. Bonadonna was brought to CAMH by police. On admission, his affect was irritable and elevated. In hospital he explained that he had been experiencing various stressors and a gradual decline towards his manic state, but did not have insight into the onset of symptoms of mania at the time and did not consider speaking to his team about his experiences, though he was reporting to them three times per week. He was ultimately discharged back to his apartment in late January 2017.
On August 21, 2017, Mr. Bonadonna was readmitted to CAMH, this time on a voluntary basis after he contacted his case coordinator to say that he was experiencing dark thoughts and was concerned that he was at risk of self-harm. A diagnosis of moderate depressive episode was made. With treatment in hospital Mr. Bonadonna’s mental state gradually improved, and he was discharged back to his apartment, and to outpatient care, on September 20, 2017.
In May 2019, Mr. Bonadonna experienced a brief depressive episode. He initially reported to the covering psychiatrist that he had experienced symptoms of depression for two days, though later advised his attending psychiatrist that the symptoms had been present for two weeks before he reported them. While the episode resolved with medication changes, the team was concerned about Mr. Bonadonna’s non-reporting, or underreporting, of the onset of disturbances of mood.
Mr. Bonadonna has continued to live in his apartment in the community since that time. He has not presented with any behavioural or management issues, has engaged in part-time employment, has remained compliant with his treatment and works cooperatively with the treatment team. He reports being abstinent from substance use, which has been confirmed through urine drug tests. His mental status has remained stable with no evidence of clinically significant disturbance of mood, anxiety or psychosis.
Course Since Last Hearing
At Mr. Bonadonna’s last annual hearing (in June 2024), the treatment team described that he’d had another good clinical year – he maintained an active social life (including regularly attending church and playing in a band), and continued to be employed as a peer support worker. His mental status was stable, he was adherent with medication and complied with all reporting requirements, and he “showed good insight into his mental and was able to identify potential signs of decompensation.” He was also able to identify that a potential factor in his decompensation and current index offences (following his last absolute discharge in 2014), was the lack of sufficient follow-up. Mr. Bonadonna reported that at the time he had declined caseworker follow-up, which likely would have been beneficial to him, and though he attempted to seek help when he was decompensating in February 2015, he did not disclose his prior history under the Board to the psychiatrist who saw him in the ER at TEGH.
In their reasons for disposition last year, the panel accepted the evidence of Dr. Kung (Mr. Bonadonna’s then attending psychiatrist) that: i) when well supported, Mr. Bonadonna’s risk in the community can be managed; and ii) any community support needs to “be robust and include a case manager and psychiatric supports, in order to maintain [Mr. Bonadonna’s] current level of stability.” After noting that such non-forensic follow-up had yet to be established for Mr. Bonadonna, the panel stated: “The Board anticipates that such a support will be identified and a successful transition will occur over the course of the next reporting year.”
At the current hearing we received evidence in the form of an updated hospital report and the oral testimony of Dr. Mark Pearce, who assumed care of Mr. Bonadonna in late 2024. That evidence revealed as follows: Mr. Bonadonna had another good clinical year. He remained psychiatrically stable and was adherent with his prescribed medications, which he took independently. He consistently described his sleep and mood as good and advised that he monitored these issues closely. His living situation remained stable, as did his employment. He continued to work four days per week as a peer support worker, and declined full time employment due to his concern about the potential for increased stress. He played in two bands, participating in weekly rehearsals and regular performances. He maintained an active social life and remained in contact with his daughter, who lives in North Carolina.
The primary concern for the treatment team over the past year has been to secure non-forensic follow-up for Mr. Bonadonna. Despite extensive efforts and multiple referrals, the search was largely unsuccessful due to systemic barriers. At least one program advised that Mr. Bonadonna would not be accepted while he remained under the jurisdiction of the ORB, and other programs offered only short-term support. A referral was made to an ACT team, but Mr. Bonadonna did not meet the required criteria as he is too high functioning. His family doctor submitted a referral to a community psychiatrist (unaffiliated with any hospital), but this was also declined.
Despite these setbacks, Mr. Bonadonna remained cooperative with the treatment team. He continued to express a preference to receive follow-up psychiatric care from a specialist rather than solely through his family doctor. The team supported this position, as they remain of the view that Mr. Bonadonna will benefit from case management level services, namely a psychiatrist and a caseworker to check up on/in with him regularly.
In April 2025, after the hospital report was submitted for review to the Forensic Service administration, Mr. Bonadonna was advised that even if absolutely discharged, he will continue to receive follow-up from the FOPS until an appropriate non-forensic team is found. The plan is to continue to have him seen monthly by the FOPS team, who will be available to him more frequently if necessary. This was confirmed in evidence by Dr. Pearce, who also advised that if non-forensic case follow-up is not found, the forensic program can continue to monitor Mr. Bonadonna indefinitely.
Analysis and Conclusions
Having heard and considered all of the evidence and the submissions of the parties (including the joint submission), we are unable to positively conclude that the evidence establishes that Mr. Bonadonna poses a significant threat to the safety of the public. On that basis, we order an absolute discharge.
In coming to a decision on this issue, we have carefully considered the statements of the Supreme Court of Canada in Winko v. British Columbia, 1999 CanLII 694 (SCC), [1999] 2 SCR 625. In Winko, the Supreme Court held that restrictions can only be imposed on an NCR accused's liberty if the evidence before the Board demonstrates that the accused actually constitutes a significant threat to public safety: Winko, at paras. 47-49 and 54.
As courts have repeatedly reminded us, the significant threat standard is an onerous one. Section 672.54 of the Criminal Code does not permit a Review Board to refuse to grant an absolute discharge because it has doubts as to whether the accused poses a significant threat to public safety. Rather, there must be a positive finding of significant threat to support restrictions on an individual's liberty. Something less, for example uncertainty, cannot suffice. If the Review Board cannot resolve the question of whether the NCR accused actually constitutes a significant threat of committing a serious criminal offence, the Board must grant an absolute discharge: Winko, at para. 49. Put simply, absent a positive finding on the evidence that the NCR accused poses a significant threat to the safety of the public, the Review Board must order an absolute discharge.
It goes without saying that the index offences were very serious in nature, and that Mr. Bonadonna's actions at the time caused the victims serious psychological and physical harm. It is also obviously concerning that Mr. Bonadonna reoffended violently less than a year after receiving an absolute discharge in respect of his first NCR offence, involving the murder of his father. His reoffending flowed from his manic symptoms, which recurred despite his apparent adherence with treatment and follow-up.
However, Mr. Bonadonna has now been back in the forensic psychiatric system for 10 years. He has been living in the same independent apartment without incident for at least eight years, and has remained psychiatrically stable since May 2019. He is adherent with his prescribed medications, which he takes independently. He is aware of the importance of sleep hygiene and of abstaining from drugs and alcohol. Over the past few years, his insight has improved and he has been able to identify potential signs of decompensation. His reintegration into the community includes a part-time job and an active social life involving pro-social activities.
Mr. Bonadona has demonstrated that when well supported, his risk while living in the community can be managed. The most recent Reasons for Disposition indicate that at Mr. Bonadonna’s last Review Board hearing (in June 2024), Dr. Kung expressed the view that when Mr. Bonadonna received an absolute discharge in 2014, he was not given adequate support in the community. She said that this time, the team wanted to set Mr. Bonadonna up for success and to provide the robust support he requires. Given his history, this caution was warranted.
Those concerns have now been addressed. Although the treatment team was unable to establish non-forensic community supports for Mr. Bonadonna, the plan is that the FOPS will continue to provide him with follow-up going forward, until other appropriate care is found for him. As described by Dr. Pearce, ongoing care by the FOPS is more risk-reducing than a non-forensic service because the team knows Mr. Bonadonna and his file so well. Mr. Bonadonna will continue to be seen by an FOPS psychiatrist and will have the benefit of a caseworker who can see him more frequently than monthly, if necessary. Importantly, Mr. Bonadonna is agreeable to the plan – he feels he needs ongoing care and likes his relationship with the FOPS clinical team – making it more likely that he will continue his involvement with the team.
There is one other difference this time around that should also be risk-reducing. In the event that Mr. Bonadonna decompensates and again visits an emergency room other than that of CAMH, Connecting Ontario (a central Ontario-based repository of medical care) will show that Mr. Bonadonna is attached to a forensic team CAMH, will give some indication of his history, and is available to any emergency room physician, so that potential problems will (hopefully) be flagged.
As stated by the Supreme Court of Canada in Winko, to support restrictions on the liberty of an NCR accused there must be a positive finding on the issue of significant threat. We do not believe that such a finding can be made in this case. Specifically, based on the evidence before us (as outlined above) we are not convinced that Mr. Bonadonna, in his current mental state and with the proposed supports in place, poses a serious risk of serious physical or psychological harm if he is not subject to a Review Board disposition. As we do not find that the threshold test is met, Mr. Bonadonna must receive an absolute discharge.
DATED this 8^th^ day of July, 2025, at the City of Toronto, in the Toronto Region.
Ms. S. Kert Alternate Chairperson
Office of the Registrar Ontario Review Board