Re Kishoyan Emmanuel Kipusi, 2025 CanLII 72925

Ontario Review Board

Re: Kishoyan Emmanuel Kipusi

ORB File No: 8448

Hearing held on: Monday June 9, 2025

Place of hearing: Royal Ottawa Mental Health Centre 1145 Carling Avenue, Ottawa, Ontario

Pursuant to: Section 672.81(1) of the Criminal Code

Before: Alternate Chairperson: Ms. M. Labrosse Members: Dr. S. Prat Dr. R. Cormier Mr. D. Sandor Mr. R. Rainboth

Parties Appearing: Accused: Kishoyian E. Kipusi Counsel: Ms. S. Brass

The Person in charge of Hospital: Representative: Dr. M. Strike

Attorney General of Ontario: Counsel: Ms. M. Dufort

AMENDED REASONS FOR DISPOSITION

(Dated July 21, 2025)

Please see underlined change to original reasons made July 28, 2025 at paragraph 25.

Introduction:

1On December 18, 2023, Kishoyian E. Kipusi, was found not criminally responsible on account of mental disorder on the following charges:

• 2 counts of fail to comply
• 1 count of uttering threat to cause death or bodily harm
• 2 counts of repeatedly communicating directly or indirectly with a person
• 1 count of watching a dwelling house or place where a person resides or works
• 1 count of interference with the lawful use of property
• 1 count of criminal harassment

all contrary to the provisions of the Criminal Code of Canada. At the time of the finding Mr. Kipusi was 28 years old. He is currently subject to a disposition of the Ontario Review Board, dated February 28, 2024, detaining him at the Secure Forensic Unit of the Royal Ottawa Mental Health Centre (hereinafter referred to as “the Hospital”) with privileges up to and including that of living in the community in accommodation approved by the person in charge of the Hospital. That disposition also subjects him to certain conditions, including that of abstaining absolutely from the non-medical use of alcohol or drugs or any other intoxicant and that of submitting samples for the purpose of monitoring his compliance with the abstention condition.

2On June 9, 2025, a panel of the Ontario Review Board convened a hearing to review that disposition pursuant to section 672.81(1) of the Criminal Code. Mr. Kipusi was present for the hearing, represented by his lawyer Ms. Brass.

3The record for the hearing included the Revised Notice of Hearing, the most recent Disposition (as mentioned, dated February 28, 2024), the Reasons for that Disposition, and Reasons for Decision of the Ontario Court of Appeal dated October 31, 2024. On the consent of all parties, a Hospital Report, dated February 25, 2025, was entered into evidence as an exhibit. Counsel for Mr. Kipusi provided three documents that were also entered into evidence together as exhibit 2, namely two certificates – one Certificate of Achievement for completion of the Risk and Recovery Group, and one Certificate of Participation for completion of the Feeling Safe: Boosting Self-Confidence group, as well as a letter from Rockwood Residence, Mr. Kipusi’s place of accommodation, explaining that Mr. Kipusi has been doing well, is rule-compliant, and has not experienced any disruptions or conflict with his roommate or other residents.

4The parties were canvassed for initial positions at the outset of the hearing. Dr. Strike, Mr. Kipusi’s treating psychiatrist spoke for the Hospital. She expressed the position that Mr. Kipusi continued to represent a significant threat to the safety of the public as that term is defined in section 672.5401 of the Criminal Code and as it has been explained by the Supreme Court of Canada in Winko v. British Columbia (Forensic Psychiatric Institute), 1999 CanLII 694 (SCC), [1999] 2 S.C.R. 625. She also expressed the position that it was necessary and appropriate, having regard to the objectives set out in section 672.54 of the Criminal Code, for Mr. Kipusi to continue to be the subject of a detention disposition. Dr. Strike indicated that the Hospital was seeking conditions that Mr. Kipusi report to the person in charge of the Hospital or that person’s delegate a minimum of twice weekly and that he also be subject to a condition that he does not operate a motor vehicle without the permission of the person in charge.

5The representative of the Attorney General agreed with the Hospital on all issues, subject to questioning.

6Counsel for Mr. Kipusi reserved and indicated that the threshold issue of significant threat was in issue for this hearing.

7For the following reasons, the Board accepts and finds that Mr. Kipusi continues to represent a significant threat to the safety of the public. It has further concluded that a detention disposition with an increased reporting requirement is necessary and appropriate to manage the Mr. Kipusi’s risk having regard to the primary objective set out in section 672.54 of the Criminal Code, namely to ensure the safety of the public and having regard to the other objectives set out in the same section pertaining to ensuring that Mr. Kipusi’s mental health and other needs are met, including the ultimate objective of reintegrating him back into the community. Respectfully, the Board does not agree that it is necessary or appropriate to impose a condition barring Mr. Kipusi from operating a motor vehicle without the permission of the person in charge of the Hospital.

Evidence at the hearing

8The evidence for the hearing came from the exhibits mentioned and from the live testimony offered by Dr. Strike. The contents of exhibit 2 have already been described. Turning then to exhibit 1, the Hospital Report, it is cumulative in nature and includes a summary of the index offences:

The victim and the accused have known each other since high school. They began a relationship in while the accused was incarcerated and continued their relationship following the accused's release from the Royal Ottawa. They have been dating since 2019 and never lived together. Neither the accused nor the victim has any children. The relationship ended in September 2022. The accused and the victim have been attending the same church and did have some contact between September 2022 and December 2022 due to attending the same church services. There are concerns for the accused's mental health.

Mischief/Obstruct Property

On September 19th 2022 the accused, Kishoyian KIPUSI, and the victim, Dorothe KANKU, were celebrating the accused's birthday. They went to the accused's home at 315-1975 St Laurent Blvd., Ottawa, to have cake. The accused became hostile towards the victim and declined to drive her home as previously arranged. The victim's purse containing her cellphone was in the accused's car. The victim asked the accused to unlock his car so that she could retrieve her purse and cellphone, in order to arrange her own ride home. The accused refused to unlock the car for her, stating that she was being disrespectful towards him.

After approximately 15 minutes, the accused unlocked his car for the victim in order for her to retrieve her purse and cellphone and arrange her ride home. The accused and the victim broke up a few days after this altercation.

Between the time they broke up in September 2022 and around December 2022, the accused and the victim maintained a cordial relationship as they attended the same church. The accused continued to contact the victim, who did maintain some communication with the accused.

On January 5th 2023, the victim communicated to the accused to stop all communication with her. The accused continued to call the victim, send her text messages, and voicemails through "WhatsApp", using blocked numbers and different phone numbers as the victim had blocked his phone number from receiving any calls or messages from him.

On January 8th 2023, the accused sent a message to the victim's friend, MiaROSE-MIGHTY, asking for forgiveness.

On January 13th 2023, the accused attended 1500 Caldwell Ave, the home of the victim's parents, to drop off a letter for the victim and was told to leave. On January 20th 2023, the accused left the victim a voicemail message and then emailed the victim saying that he needs someone to talk to.

On February 17th 2023 the accused called the victim from an unknown number and then sent a text message saying, "I'm in a better place, I'll text you in 2 weeks".

On February 20th 2023, the accused called the victim from unknown numbers and then sent a text message to the victim.

On March 4th 2023, the accused sent a text message to the victim's mother to wish her a happy birthday.

On March 11th 2023, the accused was trespassed from 1485 Laperriere Ave., Ottawa, the church where he and the victim attended, as he continued to harass the victim during services.

On March 16th 2023, the accused sent the victim's friend, Mia ROSE-MIGHTY, as message to convey to the victim.

On March 18th 2023, the accused sent the victim's friend, Mia ROSE-MIGHTY, photos of himself and the victim.

On March 19th 2023, the accused attended church after being trespassed and approached the victim. The accused was physically removed from the church.

On March 23rd and 24th 2023 the accused emailed the victim after being trespassed from the victim's condo building.

On April 1st 2023, the accused sent the victim's friend, Mia ROSE-MIGHTY, a photo of a book and said, "make sure she sees".

On April 2nd 2023, the accused sent the victim's friend, Mia ROSE-MIGHTY, a message explaining to her that the victim is supposed to love him. The accused also sent a video collage of photos of the accused and victim together. The accused was told that the victim was not willing to talk to him.

On April 3rd 2023, the accused sent the victim's friend, Mia ROSE-MIGHTY, a message to convey to the victim. The accused made attempts to call the victim's friend but was denied. The accused was told to stop communicating with her.

On April 6th 2023, the accused contacted the victim through a newly created Instagram account with the handle, silkysmooth7_, as he was otherwise blocked from contacting the victim. The accused wrote messages to the victim including, "Don't start what you can’t finish keep that same - energy" and "I'll make you submit babe" and "The bible is revealing to me back-to-back. You still need to repent. Check your morals or you won't end up with me or with your father". The accused sent the victim a voice note through this account saying, "I'm done with you... you chose not to communicate..."

On April 11th and 12th 2023 the accused sent the victim a text messages from different phone numbers.

On April 13th 2023, the accused attended the victim's residence, despite being trespassed, and was banging on her unit door. The accused left an envelope for the victim with various documents relating to their church. The accused also sent the victim an email to her business account. The email began, "The only reason you should be at Reach Centre is to do Gods business..."

On April 19th 2023, the accused attended the victim's family's home and knocked on the door. He waved at the victim's sister and then was seen loitering in the area.

On April 22nd 2023, the accused attended the victim's residence despite being trespassed from the building and left her written messages under her door including post-it notes stating, "DONT BE NO HOE" and "KISH AINT NO PUSSIE KISH AINT NO SUCK ASS KISH AINT NO BITCH BOY".

On April 27th 2023, the accused sent the victim an email with a subject line of "Recommendation" and the content of the email referred to the victim's work with her church.

On April 28th 2023, the accused attended the victim's residence, despite being trespassed from the building, and slid an envelope under her door. The envelope contained screenshots of YouTube videos of the victim's church and included disturbing comments. The victim was home at the time and observed the accused leaving the building and took a picture.

On April 30th 2023, the accused attended the victim's residence, despite being trespassed from the building, and slid mail under her door. The mail consisted of letter that the victim wrote to the accused while he was in jail.

Between April 30th and on May 1st 2023 the accused sent the victim two emails from the same email address and using the subject line, "This ends now." The content of the email refers to the victim being in a possible relationship with another man from their church.

On May 1st 2023, the accused attended the victim's residence, despite being trespassed from the building, and was banging on the victim's door. Police were called but the accused was not located. Shortly after police left the area, the accused returned to the victim's door and was yelling at her to open up.

The accused has been sending lengthy, nonsensical messages to the victim from various phone numbers and email addresses. The accused has attended the victim's home on multiple occasions to leave her notes under her door; he has been attending her parents' home and her church in attempts to locate her. His harassing behaviour has caused the victim to stop attending church out of fear of an encounter with the accused; she has anxiety every time she hears a knock at her door; and she fears that he will attend her work events which are open to the public. The victim is afraid of the accused and fears for her safety.

On May 7th, 2023, the accused, Kishoyian Kipusi, did attend his former church at 1485 Laperriere Ave, Ottawa, despite being trespassed due to his ongoing harassing behaviour against church members and the victim, Dorothe Kanku. At the time, there was a First Instance Warrant for the accused as he had been evading police and failed to turn himself in for charges of harassment and mischief against the victim. The accused was located by Ottawa Police on May 7th, 2023, and was arrested on the strength of his warrant. The accused was released by the arresting officer on an Undertaking, though was not put on conditions to protect the victim and prevent the repetition of the offence.

On May 10th, 2023, the accused did call the victim from a phone number that is not known to the victim. On answering one of the calls, the accused identified himself by saying, "It's Kish, I'm at the hospital" and attempted to get the victim to meet with him. The victim did not pursue the conversation. The accused left two voicemail messages for the victim following the phone call.

There were approximately 6 phone calls placed to the victim between 3:40pm and 4:15pm.

Later that night, at around 9:50pm on May 10th, 2023, the accused did attend the victim's residence at 1161 Heron Rd., Ottawa, despite being trespassed from the building. The victim's roommate, Aanchal Saxena, was using the gym located on the first floor when she noticed the accused from the window. The accused recognized Saxena and began to bang on the window to let him in. Saxena decline and the accused went to the entrance in attempt to be buzzed into the building. Saxena phoned police and the accused left prior to officer’s arrival.

The victim and Saxena are afraid for their safety as the accused continues (sic) to interfere with their daily lives by phoning and attending the residence, despite being trespassed and despite facing criminal charges for this behaviour.

9The Hospital Report also contains many details pertaining to Mr. Kipusi’s personal history and history of struggles with major mental illness. Mr. Kipusi is a Canadian citizen of Kenyan descent that was raised with his two brothers in Nova Scotia and then in Ottawa by his mother. His father passed away when Mr. Kipusi was an infant. He is a high school graduate that performed well in maths and sciences. He is a talented athlete and played competitive soccer at a very high level. He has no criminal record and no history of aggressive conduct prior to 2018. At that time, he became the subject of a restraining order associated with violence perpetrated against his mother. Shortly prior to this he faced charges of robbery with a firearm and possession of property obtained by crime. The circumstances of that offence were serious. It was alleged that Mr. Kipusi broke into a tow-truck yard and put what seems to have been a replica handgun to the head of a lone female employee there, repeatedly pulling the trigger before fleeing. These charges were subsequently withdrawn as part of a mental health diversion.

10Mr. Kipusi’s history of struggle with major mental illness was first noted by his brother in winter of 2017. According to his brother, around that time Mr. Kipusi began exhibiting disruptive behaviour. He was irritable and aggressive toward family, most notably Mr. Kipusi’s mother. He struggled with homelessness and his increasing lack of organization led to loss of employment. He experienced periods of hospitalization associated with the symptoms of his major mental illness in April 2018 and again in May 2019. Concerns were expressed relative to his level of treatment compliance and ability to engage in group therapy. Progress was made as he received Abilify injections. By January 2020, Mr. Kipusi’s active psychotic symptoms had resolved, and he described more motivation and a higher level of energy. Mr. Kipusi experienced some decompensation however in 2020 that corresponded with some significant financial stressors, leading up to the commission of the index offence. In November 2019 Mr. Kipusi was found not criminally responsible on charges of obstructing a peace officer, possessing break-in instruments and possession of a concealed weapon. He received an absolute discharge from the Ontario Review Boad in February 2022. Leading to the index offences that brought him back under the jurisdiction of the Ontario Review Board, Mr. Kipusi had become noncompliant with his antipsychotic medications, had disengaged with supports with the Canadian Mental Health Association, and had begun missing several appointments with Dr. Strike and his CMHA worker. He was unemployed, had incurred significant levels of debt, and his mother had reached out to Dr. Strike to describe her son’s increasing irritability and bizarre behaviours.

11The Hospital’s update to February 2025 begins at page 22 of the Hospital Report. It explains that Mr. Kipusi has continued to live at the Rockwood group home, which provides 24-7 supervision over the course of this past review period. He has struggled with the group home setting. He has shown aggressivity towards staff and at one point faced eviction owing to behavioural issues. Some of the difficulties were associated with legal limitations placed on Mr. Kipusi as a result of both bail conditions and the conditions of the previous ORB disposition. That disposition was successfully appealed, changing his condition associated with community living from “supervised” to “approved”.

12The Hospital Report explains that while Mr. Kipusi denied psychotic symptoms the treatment team observed somatic preoccupation throughout the year. Mr. Kipusi often complained of jaw tension and would chew objects to relieve anxiety. He described seeing his ex-girlfriend’s friends walking past his group home on multiple occasions. He insisted that sermons that were posted on YouTube by his pastor contained special messages for him. He described feeling tense and believing that the police in the community could be targeting him. Dr. Strike formulated the opinion that these reported experiences appeared to be residual psychotic symptoms and recommended an increase in Mr. Kipusi’s antipsychotic medications. Mr. Kipusi declined this and instead requested that his medications be reduced. He complained of side effects associated with the injection and committed to taking oral medications.

13The Hospital Report expresses concern associated with Mr. Kipusi’s level of compliance with Dr. Strike’s recommendations. Mr. Kipusi’s driving behaviour became a concern for Dr. Strike because of suspected psychotic symptoms and cognitive difficulties Mr. Kipusi was presenting. Though Dr. Strike recommended that Mr. Kipusi refrain absolutely from driving and warned that further driving could oblige her to report her concerns to the Ministry of Transportation, Mr. Kipusi continued to drive.

14This issue was raised by Mr. Kipusi in a conversation with his social worker, Ms. Hartley. Ms. Hartley reminded Mr. Kipusi that driving was not open for discussion at that time because of concerns associated with his lack of compliance with recommended antipsychotic medications and risk of becoming unwell. Mr. Kipusi insisted that he did not need medication, had “almost died” from the injectable formulation previously, and later became irritable at a case conference where the Hospital’s concerns associated with his driving and lack of treatment compliance were raised again. Mr. Kipusi remained noncompliant with treatment, missed several groups and appointments, and repeatedly emailed the treatment team demanding to know whether or not Dr. Strike had reported her concerns to the Ministry of Transportation, threatening malpractice litigation were she to do so.

15According to the Hospital Report, Mr. Kipusi struggled with boundaries, showed irritability when required to provide random samples of his urine consistent with his Board disposition, and persisted in noncompliance with recommended antipsychotic medications as confirmed by his urine drug screenings in October, November, and December. He tested positive for cannabis in December 2024. In this context, Dr. Strike explained to Mr. Kipusi again that he was at high risk of acute psychosis because of the combination of use of cannabis together with noncompliance with his antipsychotic medication. She explained to him that in order for him to be able to drive again, he had to both adhere to recommended treatment and abstain from the use of cannabis.

16Mr. Kipusi did engage in psychotherapy, attending 27 of 30 sessions. He showed motivation to learn and practice coping skills for stress management, balancing his thoughts and for regulating his emotions. He was able to describe current stressors and to indicate when he felt “unsafe” at certain locations at the Hospital. He did not voice anger or aggression over the course of his sessions. He diligently pursued exercises associated with self-reflection and experienced a decrease of the unsafe feelings. According to his self-report, his overall paranoia, hypervigilance, and distress decreased significantly. He was open with the psychotherapist and indicated that while he still experienced paranoia at times, it was under control. He indicated that his engagement with psychotherapy helped him feel more relaxed when participating in weekly forensic outpatient programming.

17The Hospital maintained concerns associated with Mr. Kipusi’s level of compliance with prescribed antipsychotic medications. Mr. Kipusi insisted meanwhile that the absence of his antipsychotic medications in his urine drug screenings was the product of his high metabolism. He continued to show motivation to attend weekly therapy, was tidy, attentive, reflective, appropriate, and respectful. He demonstrated self-reflection and journaled regularly. His therapeutic alliance with the treatment team improved and expressed paranoia and hypervigilance were usually well-contained. Mr. Kipusi particularly appreciated a holistic approach to his recovery that included both the psychotherapy and spirituality and faith. He showed increased appreciation for boundaries compared to what had been exhibited by him prior to psychotherapy as he properly engaged in sessions without raising or discussing details associated with his outstanding criminal charges. Mr. Kipusi’s mood and motivation improved further as he attended in the weight room and basketball groups consistently each week.

18Mr. Kipusi is currently diagnosed with schizophrenia, multiple episodes. The Hospital Report includes an “Updated Violence Risk Assessment”, the contents and methodology of which were not challenged at this hearing. It concludes that Mr. Kipusi presents a high risk of future violence and describes his reoffence scenario in the following terms:

His likely reoffence scenario is aggressive acts such as those he has demonstrated previously while psychotic – e.g., criminal harassment, mischief, utter threats, carry concealed weapon, obstruct peace officer – which would occur in the context of an acute exacerbation of his schizophrenia. Such an exacerbation could be triggered from partial or full non-adherence to antipsychotic medication or treatment at a suboptimal dose. Psychosocial stressors related to relationships, housing, finances, school, criminal charges, and can also trigger psychosis. The use of cannabis with THC, present in his urine in the fall of 2024, is another potential destabilizer for his schizophrenia. Antisocial behaviours, particularly as they relate to driving or to interpersonal relationships with women, present a separate violence risk scenario, even in the absence of psychotic symptoms.

It cites five current or clinical risk factors – recent problems with insight, with violent ideation or intent (a factor driven by his outstanding criminal charges), recent problems with positive psychotic symptoms, recent problems with instability of mood and recent problems with treatment or supervision response. It also indicates that Mr. Kipusi, notwithstanding the progress made as a result of his physical fitness, spirituality and faith and engagement with psychotherapy, was subject to all five risk management factors for violence as of February 2025, foreseeing problems with professional services, with his living situation, with personal support, with treatment supervision and response, and with stress and coping.

19In her evidence, Dr. Strike gave a valuable update that was important for the panel in light of the dated nature of the Hospital Report. Dr. Strike testified of several positives associated with Mr. Kipusi’s progress. He is managing stresses associated with the outstanding criminal charges well. He has not experienced any major decompensation or resurgence of symptoms of schizophrenia. He reports abstaining from cannabis and his urine drug screenings have been negative for all substances. He has completed several programs including the Emotional Regulation group, Emotions 101, the Risk Recovery Group, and the WRAP group with an outpatient peer supporter. He continues to engage in recreational therapeutic programming associated with his physical fitness and athleticism. He continued until recently to engage with individual psychotherapy and with an occupational therapist and has acknowledged that financial stress is a risk factor for him. He feels positive about his progress and wants certain challenges – such as his past use of cannabis – to be framed in their context, namely that he did not use cannabis-products recreationally or intentionally but was using cannabis oil for muscular pain without awareness that it contained compromising THC.

20Dr. Strike did maintain concerns associated with Mr. Kipusi’s insight into his mental illness, his need for recommended antipsychotic medications, and the threat his lack of insight and treatment compliance pose to the public. She explained that Mr. Kipusi openly expresses the opinion that he does not have schizophrenia and that he believes he can control psychotic symptoms by taking oral medications as needed. He continues to express the belief that a long-acting injectable antipsychotic medication harmed his body and that he continues to experience physical harm from previous injections received years ago. He still insists that he experienced unfairness in being found not criminally responsible on the index offences and wants that finding overturned. He continues to drive, and the Hospital’s occupational therapist is still working with him to confirm that financial stressors are addressed.

21Dr. Strike expressed some concern that Mr. Kipusi seems now to be regressing from his level of engagement in personal and group therapy. After missing several sessions of individual psychotherapy, Mr. Kipusi has asked to take a break from it. His group attendance has decreased. He takes his antipsychotic medication intermittently. He continues to show motivation to live independently and attend school and to obtain employment, but appropriate housing remains a concern. While the Hospital is exploring an application to the Grove program and a Grove satellite apartment, there are barriers to Mr. Kipusi’s eligibility for the same. He needs to show insight into his illness and the risk it and treatment noncompliance pose to the safety of the public. Honesty, prolonged and persistent program participation, and cooperation will need to be shown if Mr. Kipusi is to be accepted into the Grove’s programming.

22Dr. Strike expressed appreciation for the period of progress Mr. Kipusi showed from the fall of 2024 through to February 2025, but noted that Mr. Kipusi’s risk was still significant, referencing the index offences, his past absolute discharge, his current outstanding criminal charges and his difficulties with insight and compliance with treatment and recommendations (including her direction that he does not drive). Dr. Strike testified twice that Mr. Kipusi was effective in intimidating her to dissuade her from reporting her concerns to the Ministry of Transportation. Such manipulation would be a barrier to any progress towards the Grove programming and reintegration of Mr. Kipusi into the community. Dr. Strike confirmed that while Mr. Kipusi’s criminal charges are still outstanding, they are only awaiting sentencing and that he was convicted of 5 of 6 charges. The victim of these charges is one of the same victims noted in the Index Offences and described some similarity between these charges and those that informed the Index Offences.

23Dr. Strike indicated some need to confirm the sufficiency of Mr. Kipusi’s diagnosis. She explained that she does not question a past diagnosis of anti-social personality disorder but does not yet have a reliable history sufficient to verify that diagnosis.

24In response to questions from counsel for Mr. Kipusi, Dr. Strike testified that while the Hospital had not issued any Form 49’s bringing Mr. Kipusi back to the Hospital over this period of review, this would not have been the case had she been aware of the details of the most recent offences Mr. Kipusi has now been convicted of, or had she been in contact with the victim of those offences. She testified that though Mr. Kipusi had not experienced any major decompensations over the course of this past year, even after four months of not taking medications, this did not decrease his risk potential, particularly in light of what appears to be personality factors and in a context where he has committed further offences that are similar in nature to the index offences and, as mentioned, shares a victim to the index offences. She also explained that, while Mr. Kipusi improved when participating meaningfully with individual psychotherapy and group therapy, that period was relatively brief when considering the overall length of the period of review, which has, because of adjournments, extended to the date of this hearing. And, as noted, Mr. Kipusi has now regressed from his level of participation with both of those sources of support.

25Dr. Strike confirmed concerns associated with Mr. Kipusi’s level of consistent transparency with the treatment team. Counsel for Mr. Kipusi elicited what turned out to be frail excuses for Mr. Kipusi’s non-attendance for urine drug-screenings, including that “it was raining” or he had a “sore ankle”. Twice Mr. Kipusi simply did not respond to requests. This was particularly concerning given that on at least two occasions, Mr. Kipusi’s anti-psychotic medications did not appear in his screening at all. Dr. Strike testified that, even if Mr. Kipusi did have the high metabolism he offered as an excuse, the fact that there was no indication of treatment compliance over the course of these urine drug screenings would strongly suggest that Mr. Kipusi had in fact not been taking his prescribed medication for several days. This factor, together with his non-attendances and lack of responsiveness to requests that he attend for screenings raises the spectre of purposeful efforts on his part to avoid drug screenings when aware that he would not test as expected under the disposition that ordered urine drug screenings so as to ensure the safety of the public.

26Dr. Strike confirmed again that Mr. Kipusi “strongly and incessantly advocated” against her reporting him to the Ministry of Transportation. She confirmed that Mr. Kipusi “intimidated her”. This is most concerning when coming from a primary treatment provider charged with ensuring the safety of the public of which Dr. Strike is one. It is also concerning when one considers the evidence received by the Board that Mr. Kipusi still does not believe that he has ever caused harm to anyone and that he blames the victim of the index offences for the Board’s jurisdiction over him, and the victim of the most recent charges for his conviction. These factors do not support the suggestion put to Dr. Strike by counsel for Mr. Kipusi that her client does not have violent ideations or attitudes.

27The panel asked Dr. Strike if Mr. Kipusi continued to miss appointments. The answer was that yes, he attends for psychiatric appointments but has missed and paused the psychotherapy appointments that had produced the most progress in him over the course of this review period. He continues to miss urine drug screenings.

28The panel asked Dr. Strike if there had been concerns with regard to medication compliance. Her answer was “repeatedly, yes.”

29The panel asked if the concerns with alleged reoffending had now resulted in convictions. Dr. Strike answered “yes”, highlighting that Mr. Kipusi presented to the Hospital wanting admission to Montfort or the Royal Ottawa Hospital but not to the Royal Ottawa Mental Health Centre, and then made his way to Toronto without permission on January 25, 2025, where he was admitted. Dr. Strike explained that this avoidance with the Hospital coincided with the offences for which Mr. Kipusi has now been convicted.

30The panel asked if Mr. Kipusi took the stand during the trial on the new charges and disclosed psychotic symptoms including that he felt that someone had placed their “hand on him” and was giving him command prompts over the course of the commission of those offences. The panel asked Dr. Strike if Mr. Kipusi had disclosed those command prompts to her. She answered that Mr. Kipusi had not disclosed those command prompts to her, but that she learned the afternoon of the hearing that he had in fact taken the stand in the course of the trial on the most recent charges and had described those symptoms. She indicated that, had this been disclosed or discovered, she would have issued a Form 49 to return Mr. Kipusi to the Hospital, even if there was a concern that he could be malingering.

31The panel asked Dr. Strike if she continued to see personality factors such as antisocial and borderline traits that present a risk of aggression in the absence of acute psychosis, and whether this has been fully assessed as of yet. She confirmed that Mr. Kipusi satisfies the full criteria for narcissistic personality disorder with borderline anti-social personality traits. She explained that further assessment has been undertaken, but that it is difficult to fully assess Mr. Kipusi at this time given challenges associated with his lack of medication compliance, his lack of transparency in the reporting of symptoms, and his efforts with impression management.

32The panel asked whether it could be said, in light of the personality factors, that Mr. Kipusi is optimally treated. Dr. Strike testified that he is not optimally treated. She explained that optimal treatment would likely include a higher does of antipsychotic medication, consistent engagement with psychotherapy, and consistency on Mr. Kipusi’s part in taking his medications as prescribed or returning to a long-acting injectable anti-psychotic medication.

33The panel asked whether it was correct that Mr. Kipusi continued to show lack of insight with regard to his major mental illness and need for medications and treatment. Dr. Strike answered simply – “correct.”

34Mr. Kipusi testified himself. He highlighted his self-reflection and confirmed that he does not believe that he suffers from any clinical mental health issues. He minimized his role in the index offences and said that his communications were to “get his property back” and receive payment on a debt owing to him by the victim. His testimony did not correspond with the objective evidence, including text messages and other communications, and interactions with persons other than his ex-girlfriend as detailed in the very lengthy summary of the index offences found in the Hospital Report and set out above.

35Mr. Kipusi did say that he wished his ex-girlfriend no ill-intent and wanted to move on. He testified that she had asked him specifically to communicate with her back in 2022 as she was in therapy and wanted his support. He said, “learning that she did not appreciate the communications now, I have remorse and empathy for if I was annoying to her or made her feel unsafe or harassed, but previously she had expressed clearly she wanted me to contact her weekly to support her.” The fact that Mr. Kipusi suggested that he has only come to this realization over the course of this hearing is concerning.

36Mr. Kipusi testified that he is “currently on Abilify” and said, “I take it.” He said that it prevents his emotional range from being “too wide” and that he sees a benefit to it as a “precautionary kind of thing, but in terms of it being for psychotic symptoms like me not being in touch with reality or having delusions, it’s not doing that for me. For me specifically, personally, that’s not what I am getting from it.” He said that his previous long-acting injectable left him heavily sedated. He described experiencing rapid eye movement, handshaking, constriction in his throat and associated difficulties eating. He said that his oral medications produced less side effects. He said that he would continue to take his medication if granted an absolute discharge. This testimony causes some concerns given that the objective evidence coming from the urine drug screens inconsistently complied with showed periods of noncompliance. It is also concerning given the consistency between Dr. Strike’s evidence and that offered by Mr. Kipusi that he believes that he suffers from no major mental health issue and could take his medications “as needed” as opposed to “as has been required.”

37Mr. Kipusi indicated that, if he was granted a conditional discharge, he would consent to a treatment condition and that, in that situation he would take his medication as prescribed. He again emphasized that he did not want to be placed on a long-acting injectable and indicated that he would not consent to a treatment condition if placed on that form of antipsychotic medication. He confirmed “there were times in the past year when I did not take the oral meds as prescribed” but added that these were “minimal.” He said that his mood and energy level was being affected, as was his functioning. He attributed this to the antipsychotic medications, not to his major mental illness.

38Mr. Kipusi asserted that he would recognize any signs of mental decompensation, which was an odd assertion when contrasted with his statement that he does not suffer from a major mental illness. It is noted that, in response to questions from the representative of the Attorney General he asserted again that he does “not suffer from schizophrenia” and that he knows this from “reflection on my own self and my own life.” He added “I don’t believe that I have another diagnosis.”

39Mr. Kipusi said that, if in that state, he would then take his medications as prescribed, would take care of his mental health and speak with Dr. Strike and his treatment team. He said “they have shown they are able to work with me. I would work with them.” He said that, if granted an absolute discharge he would continue to work with the team. This was interesting given that he has not cooperated when under the external motivation of a Board disposition to attend as requested for urine drug screenings. He has not shown consistent treatment compliance over the course of this review period. He was not transparent with the treatment team when allegedly experiencing symptoms of acute psychosis that he testified of experiencing over the course of the most recent criminal charges. He has not cooperated with Dr. Strike’s direction that he not drive, but rather proceeded to intimidate her from calling the Ministry of Transportation though she ostensibly was under an obligation to do so.

40Mr. Kipusi said that since being permitted to drive again, he has not had any issues. It seems that this was in reference to “driving issues” given the convictions on the most recent charges.

41Mr. Kipusi testified that he should not have ever been found to be not criminally responsible on account of mental disorder. He said that while his lawyer asked for the NCR assessment in the context of the criminal process on the index offences, that Dr. Gojer “did not get it right.”

42In response to questions from the representative of the Attorney General, Mr. Kipusi testified regarding his last period under the jurisdiction of the Ontario Review Board. He explained that he was under the Board’s jurisdiction from 2019 to 2022 following on two NCR findings – one being made on July 10, 2019, and the other on December 27, 2019. He received an absolute discharge on those findings in January 2022. When he received that absolute discharge, he had indicated, as he did here, that he would continue taking his anti-psychotic medications. He testified that he took these and the minimum dosage that he thought was needed. He believed that, in this way, he would be able to manage his health requirements. He did not testify that he thought the minimum dosage would help him manage his major mental illness which, again, he does not believe he has.

43Mr. Kipusi testified that a few months later, in September 2022 he was found not criminally responsible on the harassment charges that form the index offences. He explained that he was then charged and recently convicted of further harassment charges, as described by Dr. Strike. He framed these convictions in terms similar to what he had indicated with regard to the index offences – that there was a relationship with the victims and that he was just trying to get his personal property back. He agreed that when he was assessed by Dr. Gojer, a psychiatrist with the Hospital that administered an NCR assessment on Mr. Kipusi in the context of the recent charges, he had said that he “felt something on my left shoulder pushing me to the car and a voice in my head compelling me.” In this hearing though, Mr. Kipusi clarified this statement and said “I felt something on my right should and I didn’t mean a voice. I mean I felt compelled and had an intuition my property was in the car.” Mr. Kipusi disagreed that he was trying to be found NCR at the most recent trial and said that he was only attending for the NCR assessment on those charges with Dr. Gojer because he was ordered to go.

44In response to questions from the panel, Mr. Kipusi minimized the number of times and extent to which he drove his car after being directed by Dr. Strike not to drive. He explained that he took a safe driving course to show that he was not a risk. In the meantime, he testified that he understood that Dr. Strike did not want him to drive because of the risk of him being paranoid or impulsive on the road – factors associated with risk of psychotic decompensation that could not be remedied by participation in a safe driving course.

45Mr. Kipusi did testify of his level of caution when in contact with the police. This is understandably driven by both his past experiences with the police and his justifiable apprehensions based on his race. He explained that what he feels when in contact with the police is not a form of paranoia, anxiety, or fear, but rather a heightened caution and vigilance based on experience and systemic factors. This testimony speaks to the fact that contact with the police for a black man with a criminal record and that is subject to conditions both on Board dispositions and on terms of judicial interim release may not be indicative of acute paranoia. It is however an admitted stressor that Mr. Kipusi is living in the context of a major mental illness into which he has a complete lack of insight.

Submissions, Analysis and Conclusion

46At the end of the hearing, the parties renewed their submission as set out at the beginning of the hearing. Dr. Strike, for the Hospital argued that the Winko threshold of significant harm had been satisfied. She argued that the evidence had established that Mr. Kipusi posed primarily a threat of significant psychological harm as set out in section 672.5401 of the Criminal Code and that his main targets appeared to be women and general members of the public that Mr. Kipusi wanted something from. She argued that, in terms of disposition, a detention order was required so that the Hospital could respond quickly to signs of decompensation, non-compliance or inconsistency with urine drug screenings, or discovery of further charges with the issuance of a Form 49 over the next year. She said that there were a variety of risk factors that had not been adequately managed over a period of two years, including this most recent period of review. Adherence to prescribed medication was a concern. She pointed to evidence that clearly established a pattern since 2017 of Mr. Kipusi repeatedly either stopping his oral antipsychotic medications or self-managing it in accordance with his own perceptions – perceptions that denied the existence of a major mental illness or the risk-laden context that has brought Mr. Kipusi under the jurisdiction of the Ontario Review Board or the criminal justice system on 3 occasions since 2017. Dr. Strike pointed to multiple concerns that Mr. Kipusi has not in fact been compliant with medication over the course of the last year, including evidence that Mr. Kipusi has been cheeking his medication in spite of staff observing him at a 24-hour supervised institution.

47Dr. Strike emphasized that Mr. Kipusi does not believe that he has a major mental illness in spite of multiple episodes of psychosis reported by family and in spite of multiple admissions to hospitals. She said that his pattern of blaming others for his situation – something noted over the course of his own testimony – led her to have “major concerns” for illness management. She said that it would be difficult for anyone at the Hospital to approve any community living that did not consist of a 24-hour supervised group home.

48Dr. Strike addressed Mr. Kipusi’s driving and the concerns that she maintained in this regard. She said that those concerns do not relate to cognitive or functional capacity to operate a motor vehicle but to Mr. Kipusi’s response to either paranoia or the stress he feels when in contact with the police. She pointed to his failing to stop for police and to his running into a group home and refusing to come out to provide his ID when he was under both a detention order and under bail conditions that were tantamount to house arrest. She added that her concerns were also the product of the difficulty she had assessing, let alone managing Mr. Kipusi’s cannabis use and medication compliance. She argued that manipulation and deceit is still a serious concern and that it is a factor that gives rise to a risk of recidivism.

49Dr. Strike noted that Mr. Kipusi justifies his behavior, blames his victims, and then asserts he feels “remorse for what the victims feel”. She noted that though Mr. Kipusi, when engaged in psychotherapy that was coupled with his physical fitness regime, faith and spirituality showed strong motivation to progress through the ORB system, he has faltered in his progress. His meals are made for him. He does not shop for himself. He is not engaging in group programming and has paused psychotherapy. He has no insight into his major mental illness and feels, nonetheless, that he can determine what antipsychotic medications are needed and to what extent to manage signs of decompensation for an illness that he says he does not have.

50Dr. Strike argued, compellingly in light of Mr. Kipusi’s own testimony, that his plan for an absolute discharge was entirely inconsistent with reality. Mr. Kipusi presents with all historical, clinical and risk management factors. The index offences are serious and come in a context of previous offending that included violent offences committed against his mother. The victims of the index offences and Mr. Kipusi’s most recent convictions are all women. The Board notes the uncontradicted evidence that Mr. Kipusi intimidated Dr. Strike over the course of this past review period – a factor that dissuaded her from reporting valid concerns to the Ministry of Transportation associated with Mr. Kipusi’s operation of a motor vehicle. She testified that the risk assessed in the Hospital Report would in fact be greater than noted, given that the Hospital has now received evidence that Mr. Kipusi was convicted of these most recent charges and that he had provided evidence of a psychotic episode, denied by him to be indicative of major mental illness, over the course of those charges.

51Dr. Strike confirmed that the Hospital is still attentive to the ultimate objective of Mr. Kipusi’s reintegration into the community. It continues to encourage his engagement with one-on-one psychotherapy, group therapy, physical fitness, spirituality, medication compliance and demonstration of insight by virtue of transparency with the treatment team and compliance with required screenings. She emphasized the need for Mr. Kipusi to engage with the team when looking for appropriate housing – something he has not done over the course of this review period. She noted, validly, that in spite of his self-reflection, there has been no evidence of actual introspection from Mr. Kipusi either over the course of this review period, or this hearing.

52The representative of the Attorney General agreed with Dr. Strike’s submissions. She set out an important timeline that was not noted by Mr. Kipusi’s counsel over the course of her submissions. Though it was asserted by Mr. Kipusi’s counsel that her client had gone a long period of time in a state of noncompliance with antipsychotic medication without any indication of deterioration sufficient to necessitate a Form 49 or call into play the provisions of the Mental Health Act, the established timeline, as summarized by the representative of the Attorney General tells another story. Lack of hospitalization following a Form 49 or application of the provisions of the Mental Health Act is not evidence of absence of decompensation that could or (noting Mr. Kipusi’s recent convictions) should have instigated one of those processes. Mr. Kipusi was brought under the Board’s jurisdiction initially as a result of very serious index offences in, according to his testimony, 2019. He was granted an absolute discharge in 2022 on evidence that he would continue to take antipsychotic medications.

53The undisputed evidence is that his taking of antipsychotic medication was in accordance with his own, nonexistent, insight and that, in fact, he did not take medication as prescribed or as required from the time of the absolute discharge through to the commission of the index offences that began in September 2022 – a few months after the granting of his absolute discharge. He then, in the context of the external pressure of a Board disposition, engaged in non-compliance with recommended treatment under the most recent order. He was then charged and now convicted of further offences that victimized again one of the victims of the index offences in a pattern of conduct that mirrors the index offences both as to substance, excuse offered by Mr. Kipusi, and victim gender. He proceeded in this context to intimidate his female treating psychiatrist from following through with an expression of her concerns to the Ministry of Transportation. These were concerns driven by the objective evidence that she had in her possession at the time and did not include an awareness of Mr. Kipusi’s recent charges or his evidence given over the course of those proceedings that he was experiencing acute psychotic symptoms (of a major mental illness he does not recognize) while committing those offences. It is difficult to square the argument that Mr. Kipusi was “for a long period of time not taking his medications and did not have deterioration necessitating a Form 49 or process under the Mental Health Act.”

54Counsel for Mr. Kipusi argued that her client for the past six months has not tested positive for cannabis and has been “by and large” consistent in taking his medications since December 2024. While this panel cannot speculate, it is certainly a concern nonetheless that Mr. Kipusi does not manifest either externally or internally motivated insight that would be evidenced by compliance with Board ordered urine toxicology screenings. It is a concern that the evidence supports a conclusion that Mr. Kipusi has in fact not been compliant with treatment. In the context of his history of minimizing both his major mental illness, his need for antipsychotic medications as prescribed and not as decided upon by himself, and his minimization of the impact this has all had on the victims of both the index offence and the offences with which he has now been convicted, to say nothing of his own mother and of previous victims of index offences that brought him before the Board in the past, it cannot be said the Mr. Kipusi’s testimony that he has been taking his medication and not using cannabis is reliable. While Mr. Kipusi is under no obligation to show that he does not pose a significant threat to the safety of the public, the Board is persuaded both by his own testimony and that offered by Dr. Strike and through the Hospital Report that Mr. Kipusi does represent that level of threat described by the Supreme Court of Canada in Winko.

55Counsel for Mr. Kipusi suggested that, if the significant threat threshold was established, it would be appropriate, having regard to the provisions of section 672.54 of the Criminal Code and noting the principle of minimal intrusion, Mr. Kipusi be granted a conditional discharge. She pointed to his consent to a treatment clause and suggested that this consent, together with the provisions of the Mental Health Act would be sufficient to ensure the safety of the public.

56The Board disagrees. Firstly, Mr. Kipusi has a compromised therapeutic alliance with the treatment team. He has intimidated his treating psychiatrist over the course of this review period. His victims are primarily women. He has reduced treatments, such as one-on-one psychotherapy that were producing some level of promise of progress, particularly with regard to insight that, on his evidence, is non-existent. According to his own evidence, he experienced psychotic symptoms over the course of this review period that led to convictions on charges that were remarkably similar to those of the index offences. These psychotic symptoms seem to have arisen rapidly. If they were not caught in the context of a detention disposition, it is difficult to conclude that they would be caught in the context of a conditional discharge. Furthermore, Mr. Kipusi, lacking insight into his major mental illness, need for medication as prescribed, and into early signs of decompensation, to say nothing of his apparent personality disorder, cannot exercise any insight as to the type of housing that he requires to attain to the ultimate objective of reintegration into the community while also balancing the need of the primary objective which remains the assurance of the safety of the public – something that apparently lapsed over the course of this past review period. While the Board asked itself whether the threat posed by Mr. Kipusi could be managed by a conditional discharge, it came to the clear conclusion that it could not be.

57Mr. Kipusi’s accommodations must be as approved by the Hospital. The evidence established that he has been cheeking his medication even while under 24/7 supervision. In the Board’s view the evidence further establishes the need for Mr. Kipusi to report more frequently to the Hospital than was provided for in the previous disposition. Mr. Kipusi has been manipulative and intimidating, particularly when not engaged in psychotherapy and when not medication compliant. He has frankly chosen, with weak excuses, when he wants to take his medication and when he wants to come in for urine screenings. There is an apparent need, given the recent convictions and their similarity to the index offences, for Mr. Kipusi to be subject to strict monitoring in order to assure the safety of the public and if Mr. Kipusi’s hopes to progress to full reintegration into the community are to be realized.

58The Board turned its mind to Dr. Strike’s request for a driving prohibition. It respectfully declines to order one. While it is a concern that Mr. Kipusi has not attended for urine drug screenings over the course of a review period where there has been some use of cannabis together with lack of compliance with medications, this all points to lack of insight and continued significant threat to the safety of the public. In our view it is insufficient to rise to the level of a finding of active use of substances. Dr. Strike maintains her ability and obligation to advise the Ministry of Transportation should factors that warrant such a communication to be issued. Those factors may well include Mr. Kipusi’s avoidance of appointments with the treatment team, discovery of further criminal charges, particularly when Mr. Kipusi has not discussed the circumstances or stressors of those charges with the treatment team in advance of their being discovered. They may include evidence of substance use and non-compliance with recommended treatment. They will surely include considerations of lack of insight, minimization of responsibility, and unaddressed feelings of increased stress, fear, anxiety, caution, or paranoia that could prompt lack of predictability while in the control of a motor vehicle. But these are factors that will be determined by Dr. Strike. Intimidating and threatening communications meant to dissuade such reporting should also trigger the reporting, by another reviewing psychiatrist should Dr. Strike find herself in a position of conflict by virtue of the intimidation engaged in by Mr. Kipusi.

59The Board asked itself whether the refusal to grant the driving prohibition would undermine its obligation to ensure the safety of the public. In our view it would not. Mr. Kipusi will be subject to conditions that he does not communicate, directly or indirectly with the victims of the index offences. The police have a range of options that they may rely upon if there is a driving concern or incident of flight from police. Mr. Kipusi is cautious and does not want to breach his conditions to any degree. This caution is externally and internally motivated by a very real apprehension that he feels driven by his experience as a black man with a criminal record and a history with the Ontario Review Board. In our opinion, a driving prohibition does not add to the protections available by virtue of the disposition to be ordered, with its increased frequency of reporting, urine toxicology screening and the obligations maintained by Dr. Strike and the Hospital as mentioned above with regard to reporting to the Ministry of Transportation.

60The Board notes that Mr. Kipusi has the capacity to progress through the ORB system. Psychotherapy, together with his engagement in regular physical fitness and the combination by him of his spirituality and faith together with treatment compliance and the humility required in the process of self-reflection may help with his ultimate recognition of his major mental illness, including a personality disorder, and his ongoing need for medication as prescribed by persons examining professionally his illness from the outside. He has a treatment team and a doctor that, in spite of his efforts to manipulate and to intimidate, hope to build and maintain a meaningful therapeutic alliance with him that balances both the primary and the ultimate objectives set out in section 672.54 of the Criminal Code. His abstinence from substances, full demonstrated compliance with prescribed medications, transparency with the treatment team over periods of time when he feels of his own accord that he should stray from that compliance and then his complete engagement with their recommendations regardless of his personal intentions, and his re-engagement with psychotherapy and groups as noted will hopefully pave the way for him to engage in an assessment relative to a personality disorder – an assessment that may prove very challenging but also very enlightening for him in the context of renewed commitment to medication compliance, psychotherapy and meaningful self-reflection coupled with physical fitness and exercise of spirituality and faith.

61As a result of the foregoing, the Board concludes that Mr. Kipusi continues to represent a significant threat to the safety of the public as defined in section 672.5401 of the Criminal Code. It concludes that a detention disposition is necessary and appropriate to manage that threat, having regard to both the primary objective set out in section 672.54, as well as the other objectives of assuring that Mr. Kipusi’s mental health and other needs are met, including the ultimate objective of reintegration into the community. The Board wishes to encourage Mr. Kipusi to re-commit to the steps set out above, and thanks all who participated in this hearing for their assistances.

62An order will issue accordingly.