Re: Gusseto Greenland, 2025 CanLII 78511

Ontario Review Board

Re: Gusseto Greenland

ORB File No: 8526

Hearing held on: Thursday, June 26, 2025

Place of hearing: Centre for Addiction and Mental Health 1001 Queen Street West, Toronto

Pursuant to: Sections 672.81(1) and 672.81(2.1) of the Criminal Code

Before:

Alternate Chairperson: Mr. J. Weinstein Members: Dr. L.E. Cappe Dr. L.O. Lightfoot Ms. M. den Haan Mr. A. Mete

Parties Appearing:

Accused: Gusseto Greenland Counsel: Ms. M. Perez

The person in charge of hospital: Counsel: Mr. K. Dow

Attorney General of Ontario: Counsel: Mr. D. Brandes

REASONS FOR DECISION AND DISPOSITION

(Dated August 6, 2025)

Introduction

1. On March 25, 2024, Ms. Gusseto Greenland was found not criminally responsible on account of mental disorder, on charge of assault with a weapon (x2), weapons dangerous, and mischief over $5000, all contrary to the Criminal Code of Canada (“Criminal Code”).

2. Ms. Greenland is subject to the terms of a Disposition of the Ontario Review Board (the “Board”), dated August 16, 2024, which orders that she be detained at the Forensic Service of the Centre for Addiction and Mental Health, Toronto (“CAMH”).

3. Pursuant to s. 672.56(2) of the Criminal Code, CAMH notified the Board, by letter dated May 23, 2025, that Ms. Greenland’s liberty had been restricted; Ms. Greenland had been living in the community, in accommodation approved by the hospital, and she was readmitted to CAMH on an inpatient basis, on May 15, 2025.

4. On June 26, 2025, the Board convened a hearing at CAMH to conduct the annual review of the current Disposition and to conduct a restriction of liberty hearing (“ROL”).

5. Ms. Greenland was present at the hearing and was represented by her counsel, Ms. Perez.

6. When a hospital significantly restricts the liberty of an accused for more than seven days, it has an obligation, under s. 672.56(2)(b) of the Criminal Code, to provide notice to the Board, as soon as practicable. Under s. 672.81(2.1), the Board is then required to convene an ROL hearing to review the hospital’s decision, also as soon as practicable. Since Ms. Greenland’s annual hearing was scheduled for June 26, 2025, it was agreed that her annual review and the ROL would happen concurrently.

7. A Hospital Report and Restriction of Liberty Report (the “Hospital Report”), dated May 28, 2025, was entered as Exhibit 1.

8. For the ROL, the issues at this hearing are:

a) Was the decision made by the person in charge, to significantly increase the restrictions of liberty on Mr. Elliott, warranted and necessary, as well as the least onerous, and least restrictive, option in the circumstances, at the time of its onset on May 15, 2025?

b) Does it continue to be so?

9. For Ms. Greenland’s annual review, the issue is whether Ms. Greenland continues to be a significant threat to public safety, as defined in s. 672.5401 of the Criminal Code. If so, the necessary and appropriate Disposition in the circumstances must be determined, bearing in mind the factors enunciated in s. 672.54 of the Criminal Code.

10. For the reasons set out below and based on the expert evidence and opinions before it, the Board concluded that the initial restriction of liberty was warranted, necessary and appropriate, as is the ongoing restriction of liberty. The Board found that these restrictions were necessary for public safety, and they represented the least onerous, and least restrictive, interventions available.

11. For the reasons set out below and based on the expert evidence and opinions before it, the Board also concluded that Ms. Greenland continues to present a significant threat to the safety of the public. The Board ordered the continuation of the existing Detention Order, with the deletion of paragraph 3(b) requiring Ms. Greenland to submit samples of urine and/or breath.

Current Psychiatric Diagnosis

12. Delusional Disorder

Index Offences

13. The circumstances giving rise to the Index Offences are extracted from last year’s Board Reasons, as follows:

“On the morning of May 20, 2022, in Mississauga Ontario, Ms. Greenland got into an altercation in the underground parking lot of her apartment building, with two other residents there, Ms. J. and Ms. J.'s cousin Mr. T.

When Ms. Greenland saw them in the parking lot, she grabbed a machete from her car, got out, and went over to their car. She stood at the window by the driver's seat, where Ms. J. was sitting, and made accusations against her, including: "I've had enough with you. You're breaking my house and violating me. And you mess up my life with your witchcraft." She shook the machete at her and then struck the car with it several times, smashing the window and causing an estimated $500 damage.

Apparently, Ms. J. got out of her car, and Ms. Greenland chased her with the machete. In a physical altercation shortly after that, Ms. Greenland struck Ms. J. in the right leg, causing two minor lacerations. Mr. T. pinned Ms. Greenland on the parking lot floor, and she struck him, causing no injuries.

Police arrived and Ms. Greenland was arrested, charged, and taken to the police station, where she was read her rights, gave a statement, and was held for a bail hearing the following day. Police also advised her that she would be referred for a psychological assessment and for assistance in finding new housing.

In her statement and in subsequent psychiatric interviews, when unwell, Ms. Greenland reported that for years Ms. J. and her daughter had been harassing and tormenting her, destroying her life spiritually, and demonically attacking her."

Prior History and Course Following the Index Offences

14. Ms. Greenland’s prior history and course following the Index Offences are set out in detail in the Hospital Report. The relevant portions are accurately set out in last year’s Reasons for Disposition:

“Ms. Greenland began grade 10 high school in Canada. She made friends, and graduated despite difficulties adjusting to the language, culture, and education system. She completed a course at Seneca College in Office Administration. She worked as a department store cashier from age 17 to 25. She worked other jobs as well. In 2003, at about age 27, she completed a Yorkdale Adult Education course to become a Personal Support Worker ('PSW'). In 2011, she enrolled in a Nursing Degree program at Centennial College, but did not complete the course, which she attributed to people in her apartment building launching a "spiritual attack" on her. She then trained to be an insurance broker, but apparently was not certified.

Ms. Greenland married her teenage boyfriend of many years, after he moved to Canada in 1997. Her daughter was born, and she described problems including his infidelity and his new romantic partner "witch-crafting" her. She divorced him in 2000. In 2003 she began a 14-year on-and-off relationship with her second partner, her second daughter was born, and this relationship ended in 2017, due to what she described as arguments and "witchcraft" performed by an upstairs neighbour to cause them to separate.

From 2018 to 2020, Ms. Greenland was employed as a PSW. She reported she lost the job due to "management bullying", and that "everything started then", with "witchcraft work" preventing her from finding a new job. Her ability to work was noted to have been impeded by Covid-19 pandemic restrictions, her mental health difficulties, and other stresses.

In February 2022, Ms. Greenland contacted police to report her concerns about her neighbour. The police wanted to take her to hospital, but she refused, instead agreeing to see her family doctor the next day. She did that, and her family doctor, Dr. Sulaiman, told her to go to hospital. She did that, and attended at the Credit Valley Hospital emergency department, with a reported worsening of her longstanding psychotic symptoms, including auditory hallucinations and delusions involving paranoid beliefs that her neighbour was performing witchcraft against her and intending to harm her. It was thought this worsening was due to a new low mood she was experiencing secondary to stressors, with her financial worries, workplace bullying, and the deaths of multiple close family members, including her two former husbands and a brother.

The assessing psychiatrist diagnosed schizoaffective disorder, with three differential or other primary diagnoses to consider, of schizophrenia versus bipolar disorder with psychotic features versus a delusional disorder. Ms. Greenland's eldest daughter reported that she had no concerns and no violent acts had occurred. Ms. Greenland was not found certifiable, and was discharged with a recommendation to increase her already-prescribed quetiapine antipsychotic medication. Outpatient follow-up was arranged for her, with referrals made to the hospital's Mental Health Urgent Response Services ('MHURS') and to ReLink, a community-based case management service offered through Trillium Health Partners. A letter was also provided to expedite her move to a new accommodation.

Ms. Greenland did not respond to several contacts from ReLink to book an appointment, and did not attend a scheduled MHURS appointment in March 2022; her file was eventually closed. Her family doctor saw her next on a one-week follow-up in February and again in June 2022; Dr. Sulaiman recommended Ms. Greenland continue taking the medication and made no note of any mental health concern at those times.

Ms. Greenland has no past history of any recreational substance use concerns. She has reported drinking alcohol very infrequently, less than one drink per month. Ms. Greenland has no record of any criminal charges prior the index offence. Ms. Greenland has no history of medical concerns apart from her major mental illness; while she suffered a concussion from several head injuries at the time of the index offence, she had no loss of consciousness and has apparently had no further concerns arising from that.

At the time of the index offence, Ms. Greenland was living in her three-bedroom apartment in Mississauga with her daughters, the eldest about twenty years old and the youngest in her late teens. She was not employed, and was financially supported by the Ontario Disability support Program, and a rent-geared-to-income subsidy. She was taking quetiapine antipsychotic medication at a dose of 25 to 50 mg daily, as needed. She had a family doctor for medical care, and had no mental health care supports.

On May 21, 2022, the day after the index offence, Ms. Greenland returned to live in the community, in her Mississauga apartment with her daughters, under the terms of a Judicial Interim Release order.

On May 23rd, she went to Credit Valley Hospital emergency department, complaining of a head injury incurred in the index offence. On May 27th, she was admitted involuntarily, found incapable to consent to treatment, and her eldest daughter served as her substitute-decisionmaker ('SDM') for treatment. On that day, she was transferred to Trillium Health Partners Mississauga ('Trillium Mississauga') Hospital. No abnormalities were found on a CT scan. She exhibited significant chronic paranoid delusions (such as believing her neighbour broke into her home, and set traps to kill her), but did not regularly take her prescribed medication, quetiapine 25 mg twice daily as needed. She reported being "quite surprised" that police arrested her rather than her neighbours. On May 28th, she was transferred to the hospital's Mental Health ICU, due to significant verbal agitation and overt paranoia.

In early June 2022, the Consent and Capacity Board ('CCB') upheld the incapacity finding, while overturning the involuntary committal. Ms. Greenland did not wish to remain in hospital and was therefore discharged. The discharge diagnosis was delusional disorder versus schizoaffective disorder, with psychiatrist noting that her risk of harming others "would not be sufficiently mitigated without further pharmacological intervention", and recommending, due to the family's view of Ms. Greenland's circumstances and risks, that their ability to act as her SDM be re-assessed in any future readmission. Ms. Greenland declined outpatient follow-up.

A year later, in June 2023, Ms. Greenland went on her own to Trillium Mississauga hospital's Emergency Department, reporting passive suicidal ideation, depression for about a year, and rare alcohol use. When referred to the mental health team, she asked to leave, and was discharged against medical advice, with a quetiapine prescription, referral to a psychiatrist, and advice to follow up with her family doctor.

In September 2023, Ms. Greenland reported only taking her medication intermittently, and having increased her alcohol intake slightly (to one or two drinks per month), to help her sleep and cope with stress and isolation, with no negative effects. In November, she apparently saw a psychiatrist for a consultation. She reported feeling more depressed and hearing voices at night that put self-critical and other thoughts into her head when she was sleeping; the psychiatrist identified the voices to be vivid dreams rather than frank hallucinations. It was also noted that she was "clinically intoxicated", but when reassessed she was not seen to be suffering from withdrawal symptoms. In December, Ms. Greenland reported that one of the voices told her that her neighbour was the one putting these thoughts in her head. In 2023, Ms. Greenland attended occasionally (about once per month) at the Peel Family Counselling Centre, for drop-in therapeutic support when she was feeling overwhelmed.

In January 2024, her family physician prescribed Aripiprazole antipsychotic medication. Ms. Greenland later explained that she only took the oral medication intermittently because she found it was worsening her symptoms.

On February 6, 2024, Ms. Greenland went to Trillium Mississauga hospital's Emergency Department again, reporting insomnia and disturbing hallucinations at night. At that time, she reported that she had been doubling the dose of her prescribed Quetiapine (from 25mg to 50mg) when she felt her symptoms were worsening, and that the medication had a sedative effect.

At some point before June 13, 2024, Ms. Greenland reported having "lots" of suicidal thoughts, and frequently hearing the voice of a demon telling her to kill herself. During an assessment on that date, she said she had attempted to "overdose on alcohol", while also saying she had been trying to cope, not to commit suicide, and had no suicide plan. She also reported thinking about drinking bleach sometime in the past year, but her daughter took the bleach away before she could drink it. She reported that maternal aunt had a diagnosis of schizophrenia, but otherwise no family history of mental illness, suicide, or substance use.

In that assessment, Ms. Greenland advised she was on a waiting list for a psychiatrist, and was no longer attending counselling. She was seeing her family doctor for medical and psychiatric follow-up once every one-to-three months, who prescribed quetiapine (at a dose then of 50 to 75 mg. nightly, as needed). She said she took this medication on most days, for sleep and anxiety. She had no other prescribed medication. Ms. Greenland also said she regretted her actions in the index offence, and she no longer had a car and no longer carried any weapons for protection. She said she has psychosis and the medication helped with this, that she would follow any conditions asked of her, and that she would continue treatment if asked to do so. However, she did not view her difficulties with her neighbours as part of her psychosis. She was assessed at that time as having partial insight into her illness and risk.

Ms. Greenland's daughters apparently both live with her. Her elder daughter, Breanna, is now 23 years old and a full-time university student; her younger is 19 and a college student.

Her daughter Breanna, in helpful information given in a July 2024 interview with Ms. M. Beron (MSW, RSW), described their mother as someone always pleasant, who since 2019 became less cheerful, less energetic, more irritable, easily agitated and overwhelmed, and less able to cope. Breanna described the changes as coinciding with the onset of her mother's depression, financial stressors, a lawsuit with a bank over her late uncle's estate, and the family deaths in the years from 2016 to 2020.

Breanna recognized her mother's diagnosis of depression with psychotic features, which she could see, for example, in her mother talking to people who were not there. She reflected that her mother always believed in witchcraft, which was a cultural belief abundant in Jamaica, but the intensity of her mother's beliefs went beyond what is considered culturally normative, and her mother now relied on witchcraft as the default explanation for most events. In the year before the interview, Breanna had had no concerns about her mother becoming physically aggressive at home or with others.

With respect to her mother's medication and daily life, Breanna reported her own concern that the current medication was too sedating and negatively impacting her mother's functioning, but could not say whether her mother took it as prescribed. Breanna thought her mother would benefit both from medication, and being compliant with it, and from therapy that increased her coping skills. She had no concerns about her mother's use of alcohol, noting that it was "occasional", perhaps one glass of wine or beer every 3-4 weeks, and that she has never seen her mother inebriated. She had no concerns about her mother's ability to look after her own daily care, and described her mother's daily life as waking between noon and 1 p.m., and for the rest of the day watching TV or YouTube videos.

Breanna was not aware of any issues with the landlord or any risks to their tenancy in their subsidized family apartment. She reported having a good relationship with her mother and talking with her regularly, and described her mother's supports as including her children, her grandmother in Jamaica, and the pastor of her church. In June 2024, Ms. Greenland said that she no longer went very often to church, but that it was still a community support for her.”

Reason for Restriction of Liberty

15. The Hospital Report sets out the reason for Ms. Greenland’s readmission to CAMH:

“Ms. Greenland was reviewed May 15 2025 following concerns we had over her mental state and risk since Tuesday 13 May 2025. We subsequently requested her admission using a Form 49. When she attended her weekly OT outing group we explained the reasons for admission and escorted her to ER.

Ms. Greenland was upset and angry with the writer and responded ' Is it because I told you I will strip naked...they provoke me and then I am the crazy one? That’s why I don't want to talk to you people...you are part of this'. We explained that we wanted her to walk with staff to ER for assessment and admission. She stayed in ER until May 16, 2025 when she moved to CCC Unit 7 where she remained at the time this report was written.

Dr. Stephen Sokolov, May 15 2025, saw her in ER and documented: ‘On assessment she reports that people are trying to kill her. She is unable to say why. She is irritable when these beliefs are challenged. She does not appear to be responding to hallucinations in any modality. She denies thoughts of harming herself. She does not espouse specific thoughts about harming other people.”

Position of the Parties

16. At the conclusion of the hearing, the parties were canvassed for their positions on both the annual review and the restriction of liberty. Counsel for the hospital, the Attorney General and Ms. Greenland agreed that the initial restriction of liberty was warranted, necessary and appropriate.

17. Counsel for the hospital and the Attorney General also agreed that the ongoing restriction of liberty was warranted, necessary and appropriate.

18. Counsel for Ms. Greenland took the position that the ongoing restriction of liberty is not warranted, necessary and appropriate and that her client should be discharged back to her approved accommodation.

19. Counsel for all parties agreed with the recommendation of a continuation of a Detention Order Disposition. Counsel for Ms. Greenland requested that paragraph 3(b) of the current Disposition, which requires her to submit samples on a random basis, is no longer necessary and appropriate, and it should be deleted . Counsel for the Attorney General and for the hospital took no position with respect to the deletion of the paragraph.

20. Counsel for Ms. Greenland advised that she would not be contesting the issue of significant threat at this hearing.

Course Since Last Disposition

21. Ms. Greenland’s course since her last Disposition is set out in detail in the Hospital Report. The following extracted paragraphs are relevant to this hearing:

“Ms. Greenland was admitted to CAMH FOPS on September 12, 2025, under the care of psychiatrist Dr. Meng. She was seen weekly by the FOPS team and had regular UDS, all of which were negative for substances.

There have been no incidents of violence in the reporting period.

On May 27, 2025 Dr. Igoumenou and members of her FOPS team reviewed Ms. Greenland on CCC Unit 7. She was irritable and angry for ‘bringing’ her to hospital. Her mental state was unchangeable. She declined the offer to increase further her medications or change to a different antipsychotic such as paliperidone. Later that day she agreed on a trial of paliperidone, so she was started on 3mg paliperidone at night, with a slight decrease of her quetiapine (to 150mg).”

Evidence at the Hearing

22. The Board had available to it the evidence and documents forming the Record, the Exhibits, and oral evidence from Dr. Artemis Igoumenou. Dr. Igoumenou co-authored the Hospital Report and testified as follows:

a) She has been Ms. Greenland’s attending psychiatrist in the community since May 2025.

b) She has reviewed the Hospital Report and adopts its contents.

c) Ms. Greenland was initially admitted to General Unit CCC7. She has since been transferred to the psychosis treatment ward on the non-forensic side of CAMH, awaiting the availability of a forensic bed.

d) While in hospital, Ms. Greenland has been undergoing a change in her medication regimen. She received a loading dose of a long-acting injectable medication, paliperidone, on June 11th and a full dose on June 18th. It is likely that Ms. Greenland’s medication regimen was not optimal, and that she was being under treated for her mental illness, while living in the community. The treatment team noticed that, while under her previous medication regimen, Ms. Greenland was suffering from ongoing symptoms of her mental illness, including delusions of both a paranoid, and persecutory, nature, as well as ideas of reference.

e) She was initially readmitted to hospital on May 15, 2025, as two weeks prior to that readmission the clinical team noticed that she was becoming more preoccupied and distressed by her delusional beliefs. Prior to her readmission to CAMH, the treatment team asked her to return to hospital voluntarily, to optimize her medication regimen, but Ms. Greenland declined. The treatment team felt it was necessary to readmit Ms. Greenland to hospital; to optimize her medication and to reduce the risk she represented to public safety. The treatment team also wished to assess Ms. Greenland’s capacity to make decisions about her treatment. Ms. Greenland was experiencing an increase in her delusional beliefs, involving witchcraft and persecution from her neighbours and the building superintendent. This increase was quite concerning, as these are the same delusional beliefs that occurred at the time of the Index Offences.

f) The treatment team has reported a continuing fluctuation in Ms. Greenland’s mental state. For example, on June 20,she was presenting as not being perseverative as to her beliefs, but on June 24, she was less engaging and more perseverative and thought disorganized.

g) The treatment team has noticed some improvement after the most recent dose of Ms. Greenland’s antipsychotic medication; however, she is not ready, or close to ready, to be discharged from the hospital. The hospital still needs to monitor the effectiveness of her new medication regimen and optimize it, as required. The hospital also wishes to continue to assess her capacity, with the hope that the new medication regimen will improve her capacity to consent to treatment. Ms. Greenland is currently only marginally capable of consent for treatment.

h) The treatment team also needed to readmit her to hospital to update her risk assessment and to determine what risk management would be required, upon discharge into the community.

i) If Ms. Greenland were to be discharged into the community at this point in time, there would be likely be a risk of harm to others .

j) For the reasons set out in the Hospital Report, Ms. Greenland remains a significant threat to the safety of the public. She still suffers from her delusional beliefs.

k) The treatment team believes that the current Disposition is responsible for maintaining Ms. Greenland’s stability in the community and for preventing harm to the public.

l) The treatment team is also hoping that Ms. Greenland will soon start psychological therapy in hospital, and continue when she is in the community, to give her additional coping strategies when she is experiencing her delusional beliefs.

23. In response to questions from counsel for the Attorney General, Dr. Igoumenou testified:

a) Ms. Greenland presents as superficially composed and presents no management problems; however, a challenge of her belief system triggers her. Ms. Greenland does not believe that her beliefs are delusional; to her, they are real. The treatment team’s goal is not to eliminate these delusions, but to manage the distress that they cause her.

b) There is currently a rupture in the therapeutic relationship with Ms. Greenland, as Ms. Greenland considers the doctor responsible for readmitting her into hospital.

24. In response to questions from counsel for Ms. Greenland, Dr. Igoumenou testified:

a) Although the team is still waiting for a forensic bed, the delay would not stop the hospital from discharging Ms. Greenland back into the community, once she no longer represented a risk to public safety.

b) Dr. Meng’s reports indicate that Ms. Greenland had ongoing delusional beliefs, which would fluctuate in intensity throughout much of last year. However, Ms. Greenland was able to remain in the community, despite this fluctuation. Ms. Greenland had been living in the community with her two daughters, in the same apartment building, with no incidents since the time of the Index Offence and for several years before the it.

c) Ms. Greenland has adhered to all the terms of her Disposition, including not communicating, directly or indirectly, with the victims of the Index Offence.

d) Ms. Greenland is a person who abides by rules, which is a protective factor.

e) It would be appropriate to delete paragraph 3(b), from her current Disposition, as Ms. Greenland has had no positive urine drug screens nor a history of abusing substances or alcohol.

f) Ms. Greenland has been adherent to the recommendations of the treatment team regarding her medication regimen, both while in the community and in the hospital.

g) Ms. Greenland agrees to take quetiapine, as it helps her with sleep and stress levels.

h) Ms. Greenland has seen two psychiatrists since her admission to hospital: Dr. Khan and Dr. Rohani. Based on discussions with both doctors, she would describe Ms. Greenland as currently being marginally capable. The treatment team is hoping that Ms. Greenland’s insight will improve with her new medication regimen.

i) Ms. Greenland consents to treatment, as she believes it helps her with stress and sleep, but she does not believe that her medication regimen helps with delusional beliefs and psychotic symptoms.

j) It was Dr. Kahn’s opinion that Ms. Greenland did not need to stay in hospital, as of June 11, before she was transferred out of his care, It is Dr. Rohani’s opinion that Ms. Greenland still needs to remain in hospital and is not ready to be discharged.

k) Ms. Greenland had not engaged in any acts of violence.

l) Ms. Greenland has attended groups on the unit and has been described by all as very pleasant. While she cannot predict when Ms. Greenland will be ready for discharge, it is her intention to keep her in hospital for as short a period as possible. However, she does not wish to provide Ms. Greenland with any false hope, by specifying a timeline, as this would further damage their therapeutic relationship.

m) Ms. Greenland has been very compliant in reporting to, and in keeping her appointments with, the treatment team.

25. In response to questions from the panel, Dr. Igoumenou testified:

a) There is no benefit in retaining paragraph 3(b) in the current Disposition, as Ms. Greenland has no history of abusing drugs or alcohol. She believes that deleting the paragraph 3(b) would give Ms. Greenland more freedom and would improve her therapeutic relationship with the treatment team.

b) Ms. Greenland can present as very high functioning in every aspect of her life, apart from when her delusional beliefs become overwhelming and cause her distress.

Her attention was then drawn to the following paragraph on page 24 of the Hospital Report:

c) “Ms. Greenland denied any risks to self or to/from others. ‘No…I am good …I am not planning on doing anything…I will stay in my home…I take my medications …I am good…but they provoke me.’ She could not guarantee no risk to others apart from her intention not to harm, but she was not sure how long she could resist a perceived provocation.”

She confirmed that Ms. Greenland has no intention of hurting anybody. Unfortunately, the nature of her major mental illness makes it difficult to predict how she would react if she felt “provoked by people,” as a result of her delusional beliefs, including other’s use of witchcraft.

d) Ms. Greenland’s current coping mechanisms are believing in God and listening to gospel music with headphones. It is clear that she needs additional mechanisms to cope with her delusional beliefs and the impact they have on her mental status. This is another reason it is still necessary to keep Ms. Greenland in the hospital.

e) She confirmed the rational for keeping Ms. Greenland in the hospital is to further improve her ability to cope with her delusional beliefs, with both the increase in her medication and psychotherapy. The treatment team needs to maintain her in hospital to monitor her mental status, until they feel that she is optimally treated. It usually takes several weeks after the initiation of an adjustment in medication to see improvement. As soon as the team observes sufficient improvement, they will discharge her back to the community.

f) Ms. Greenland can start working with a therapist in the hospital and continue the treatment once she is discharged back to the community.

g) The nature of Ms. Greenland’s diagnosis makes it very difficult for her to ever gain insight into the cause of the Index Offences, as when she experiences these delusional beliefs, they are very real to her.

h) The following paragraphs from last Reasons for Disposition are still true today:

“A Detention Order is recommended for a number of reasons. Ms. Greenland is being treated as capable of making decisions respecting her psychiatric medications, but she was found incapable at one point, and there is still a lot to understand about her. In the past, the Mental Health Act was not sufficient for her to be kept in hospital; the CCB did not uphold her involuntary status and found her not-certifiable.

Dr. Ali thought her likely trajectory, if she were not under the Board, would be: She would continue to have symptoms of psychosis, her compliance with medication would not be sure, ongoing stressors would likely exacerbate her symptoms, her insight would be limited due to her illness, and the escalating psychosis would likely lead to violence in the community if it remained untreated. She may also seek to leave the hospital once having arrived.”

i) Neither Dr. Khan nor Dr. Rohini is a forensic psychiatrist.

j) Dr. Khan would not use the same criteria for discharging a patient into the community as the forensic system requires, i.e., that she no longer represents a significant threat to the safety of the public.

Analysis and Conclusions

A. Annual Review

26. Having heard and considered the entirety of the evidence, as well as the submissions from the parties, the Board finds that Ms. Greenland remains a significant threat to the safety of the public.

27. In Winko, the Supreme Court outlined that, in coming to the conclusion on the issue of significant risk, a Review Board should closely examine a range of evidence, including: the circumstances of the original offence; the past and expected course of the accused’s treatment; the present state of the NCR accused’s medical condition; the NCR accused’s own plans for the future; the support existing for the NCR accused in the community; and most importantly, the recommendations provided by experts who examined the NCR accused. In coming to our conclusion in this matter, the Board relies on the uncontroverted expert evidence of Dr. Igoumenou, in addition to the documentary evidence before us.

28. Ms. Greenland has exhibited problems with insight, symptoms of her major mental illness, and instability over the past 12 months. The Hospital Report also indicates that the following risk management items are present and highly relevant: “professional services and plans, living situation, treatment or supervision response and stress or coping.”

29. The Board agrees that the evidence before us does not require including a clause in her current Disposition requiring Ms. Greenland to submit samples for analysis. She has no history of abusing alcohol or substances. The treatment team does not need this clause to determine whether any decompensation in Ms. Greenland’s mental state is a result of substances. Accordingly, the Board agrees that paragraph 3(b) should be deleted.

30. In particular, the Board relies on the Criminogenic Risk Factors and Re-Offence Scenario set out in the Hospital Report:

“CRIMINOGENIC RISK FACTOR

a. Major Mental Illness

Ms. Greenland’s most pertinent criminogenic risk factor is her illness. Ms. Greenland has been clearly found to have a history of psychosis, namely Delusional Disorder. Ms. Greenland has ongoing paranoid delusions about her neighbours, and some of her relatives. It is unclear whether her previous depressive symptoms were due to her delusions or occurred prior to her psychosis.

b. Insight and Compliance with Medication

Ms. Greenland has limited insight into her symptoms. She agrees that medication has been helpful to manage ‘stress and sleep,’ however, does not identify her ongoing symptoms. Her compliance is unclear and further collateral information from her provider would be beneficial to clarify treatment. If Ms. Greenland were to be non-compliant with medication, her risk of relapse would increase.

RE-OFFENCE SCENARIO

In risk assessment, one of the best predictors is a patient’s history of violence. If Ms. Greenland were to reoffend, it would likely transpire in the context of psychotic exacerbation in the context of being under-treated/non-compliance with medications and increased stressors. This would result in increased paranoia and/or other delusions, perceptual disturbances, and potentially violent ideation. As Ms. Greenland has limited insight, she would be unable to appreciate her symptoms and may not seek help appropriately. She would be at increased risk of misinterpreting cues from the environment as threats to her safety, and subsequently acting in a disorganized, impulsive and aggressive manner.”

31. In light of the Board's finding of significant threat, it is charged with shaping a Disposition for the coming year. The Board finds that it would be inappropriate to consider a Conditional Discharge, for the reasons the doctor confirmed in her evidence, and particularly as set out in the team review recommendation as follows:

“The clinical team is of the opinion that Ms. Greenland continues to represent a significant threat to the safety of the public. The least onerous, least restrictive and necessary and appropriate disposition is a Detention Order with a term allowing for community living in approved accommodation and weekly reporting. Given her history, the Mental Health Act of Ontario would likely be insufficient to bring her/keep her in hospital if necessary and, as in the past, she would likely not voluntarily stay in the hospital. For these reasons, a Conditional Discharge would not be sufficient to manage her risk.

Ms. Greenland’s relative stability is predicated on her compliance with psychiatric medication. Her insight into her illness and need for adherence to treatment is partial at best. If she were no longer under the supervision of the ORB, it is likely that she would become non-adherent with recommended dose of medication. When sub-optimally treated, her illness is subject to emergence of increased symptoms, such as irritability, preoccupation and paranoia, which increase her risk of violence towards others.

It is the opinion of the treatment team that Ms. Greenland’s relative stability over the past year has been a direct result of the team’s ability to monitor and manage her under a Detention Order. A continuation of her current disposition will ensure that the team can adequately monitor her clinical status in the community, and intervene rapidly and appropriately if her risk of violence is increasing. It is also imperative that the team be able to assess the suitability of her living situation, provide approval for suitable living arrangements, and intervene if her living environment becomes risk-enhancing.”

B. Analysis of Restriction of Liberty

32. The Board agrees that a restriction of liberty has taken place, pursuant to the decision of the Ontario Court of Appeal, in R vs M.L.C. (2010 ONCA 843) and in Regina v. Campbell (2018 ONCA 140). The Board has also concluded, based on the evidence before us, that the hospital’s decision to significantly restrict Ms. Greenland’s liberty, by readmitting her on May 15, 2025, and her ongoing restriction, were warranted and necessary.

33. At the time of her readmission, Ms. Greenland was presenting with a decompensated mental state and was not optimally treated. Given her mental state, the risk to the public safety and her need for treatment optimization, the hospital needed to readmit her.

34. The evidence before us is that Ms. Greenland is still suffering from an active delusional disorder. Her mental state is still fluctuating, as indicated by the doctor’s evidence: in June, she presented as not being distressed by her major mental illness, but her mental state decompensated only days later.

35. The Board agrees that, while Ms. Greenland’s mental status has improved somewhat, she still needs to be monitored, to determine if she is optimally treated. The nature of Ms. Greenland’s major mental illness does not allow us to rely on how she presents when she is not experiencing delusions. The Board agrees that the treatment team is “not there yet,” and that allowing Ms. Greenland to be discharged back into the community now would represent a significant threat to the public safety. The doctor’s evidence is that she wants to discharge Ms. Greenland back to the community sooner rather than later. However, the team needs to detain her in hospital, to observe her response to her medication regimen, as well as to engage her in psychotherapy and help her acquire additional coping mechanisms.

36. Accordingly, the Board agrees that the treatment team’s decision to readmit Ms. Greenland was warranted at the time, and that her ongoing detention represents the least onerous, and least restrictive, decision.

37. In consideration of all the evidence, submissions of the parties and the criteria set forth in s. 672.54, the paramount consideration being the safety of the public, in addition to the mental condition of Ms. Greenland, her reintegration into society and her other needs, the necessary, and appropriate, Disposition is to continue with a Detention Order.

DATED this 6th day of August, 2025, at the City of Toronto, in the Region of Toronto.

Mr. J. Weinstein Alternate Chairperson

__________________

Office of the Registrar Ontario Review Board