Re: Sindiso Nyoni
ORB File No: 7966
Hearing held on: Tuesday, July 8, 2025
Place of hearing: Brockville Mental Health Centre Via Zoom Video Conference
Pursuant to: Section 672.81(2.1) of the Criminal Code
Before:
Alternate Chairperson: Ms. C. Finley Members: Dr. R. Wood Hill Dr. S. Wiseman Ms. N. Nathanson Ms. B. Little
Parties Appearing:
Accused: Sindiso Nyoni Counsel: Mr. A. Sheivari
The person in charge of hospital: Counsel: Ms. P. Miltenburg
Attorney General of Ontario: Counsel: Mr. K. Schultz
REASONS FOR DECISION
(Dated August 5, 2025)
Introduction
On November 5, 2021, Sindiso Nyoni was found not criminally responsible on account of mental disorder on a charge of aggravated assault contrary to the Criminal Code of Canada. He is currently subject to a disposition of the Ontario Review Board (ORB/the Board), dated September 4, 2024, detaining him at the Secure Forensic Unit of the Brockville Mental Health Centre – Member of the Royal Ottawa Health Care Group (BMHC/the hospital), with discretionary privileges including the ability to reside in the community in accommodation approved by the person in charge.
By way of letter dated June 2, 2025, the hospital notified the Board of a significant increase in the restriction of Mr. Nyoni’s liberty that exceeded seven days. As a result, the Board convened a hearing using zoom technology on July 8, 2025, pursuant to s. 672.81(2.1), to review the restriction. Mr. Nyoni was present and represented by Mr. Sheivari.
All parties confirmed that the only issue to be determined was whether the decision by the hospital to admit Mr. Nyoni to hospital on May 27, 2025, and his continued detention as of the day of the hearing, was warranted.
Ms. Miltenburg, counsel for the hospital, submitted that the initial decision to readmit Mr. Nyoni was necessary and appropriate to manage his risk to the safety of the public and continued to be so. Mr. Schultz, on behalf of the Ministry of the Attorney General, concurred in the hospital’s positions. Mr. Sheivari indicated that he was inclined to agree that the restriction was necessary and appropriate but deferred taking a firm position until the conclusion of the evidence. He ultimately joined the hospital and agreed that both the initial and ongoing restriction on Mr. Nyoni’s liberty were necessary and appropriate.
Findings
- For the reasons that follow, the Board finds that the hospital’s decision to readmit Mr. Nyoni to hospital on May 27, 2025 was necessary and appropriate and represented the least restrictive and least onerous measure available to the hospital in the circumstances. Further, the continued detention in hospital up to the day of the hearing also was necessary and appropriate.
The Evidence
- The evidence at the hearing consisted of the Hospital Report, dated June 24, 2025 (ex. 1), and the viva voce evidence of Dr. Carefoot, Mr. Nyoni’s treating psychiatrist.
The Index Offence
- On September 8, 2021, Mr. Nyoni was observed walking around the Salvation Army shelter with a knife in his hand. Staff contacted police. Mr. Nyoni left the shelter and soon approached the victim, who was panhandling with his back turned to Mr. Nyoni. Mr. Nyoni proceeded to stab the victim in the head and then walked away. The victim sustained injuries to his upper cheek and required stitches. The incident was captured on video surveillance. When arrested, Mr. Nyoni was found to be in possession of a set of 10 brand new serrated knives.
Background Information
Given the limited focus of this hearing, it is not necessary to review Mr. Nyoni’s background and psychiatric history. That information is included in the Hospital Report which was made an exhibit.
Mr. Nyoni is a 33-year-old man who was born in Zimbabwe. He moved to Canada at the age of ten with his mother and sister and settled in Ottawa. He dropped out of high school when he began to experience symptoms of his mental illness. He was diagnosed with schizophrenia at the age of eighteen. Drug use, in particular amphetamines, was noted to cause a deterioration in his mental stability.
Mr. Nyoni’s current diagnoses are:
Schizophrenia
Post Traumatic Stress Disorder
Amphetamine Type Use Disorder
Cannabis Use Disorder
Following his NCR finding, Mr. Nyoni was admitted to the Royal Ottawa Hospital and then transferred to BMHC in June 2024 under the care of Dr. Carefoot. He has been found incapable of consenting to treatment and his mother is his Substitute Decision Maker. Mr. Nyoni has limited insight into the impact of substance use has on his mental stability and the risk he poses for violence. Ongoing substance use has remained a significant concern.
Mr. Nyoni was discharged to FITT house on March 11, 2025. It is a 24-hour supervised group home located on hospital property. On March 21, 2025, staff were informed that Mr. Nyoni was asking coresidents where to buy drugs. He stated that drugs were good for him and improved his mental health. At the same time, Mr. Nyoni disclosed to his addictions counsellor that he was experiencing an increase in his cravings and endorsed hallucinations that someone was wanting to hurt him. In order to manage his risk, the treatment team increased his dosage of Clozapine and required him to check in with the team on a daily basis.
Notwithstanding this concern, the treatment team discussed transitioning Mr. Nyoni to Murray Street, a residence in the community that provided 8 hours of supervision. Mr. Nyoni reported that although he continued to experience the auditory hallucinations he did not feel unsafe and was looking forward to the transition to Murray Street.
During a meeting with Dr. Carefoot on May 26, 2025, Mr. Nyoni was reminded that substance use would increase his risk and could lead to a readmission to hospital if the treatment team felt that his risk could not be managed in the community. Mr. Nyoni reportedly felt frustrated and told Dr. Carefoot that substance use made the voices go away, at least temporarily. Of added concern, during discussions related to the index offence, Mr. Nyoni justified his actions and indicated that he would act in similar circumstances.
The next day, Dr. Carefoot met with the treatment team and the decision was made to put the transfer to a less supervised residence on hold. Further a decision was made to increase the frequency of Mr. Nyoni’s drug screens and to search his residence to determine whether he was in possession of any weapons as he had a history of hoarding weapons and stabbing. Dr. Carefoot advised Mr. Nyoni of the change in plans and asked him to attend the hospital to meet with her. Upon arrival he was angry and felt that the doctor was overly concerned with his risk of violence in the community.
Dr. Carefoot further told Mr. Nyoni that, after providing a urine sample, he would be accompanied back to the FITT house by members of the outpatient treatment team. As they approached the residence, Mr. Nyoni ran ahead into the residence. He was intercepted coming out of his room and found to be in possession of two knives in his pocket. He was immediately taken back to the hospital for admission and placed in seclusion. When assessed by Dr. Carefoot, he reported that he had been feeling paranoid and unsafe for the previous two weeks. He had purchased the knives two weeks before in order to protect himself.
Mr. Nyoni was moved out of seclusion the following day. He advised staff that he had felt paranoid and unsafe for some time but did not tell the treatment team as he felt that he could manage. All urine drug screens were negative. On May 30, Mr. Nyoni met with Dr. Carefoot. He continued to maintain that his actions during the index offence were justified and that he had had an issue with the victim six months prior to the stabbing.
Dr. Carefoot advised Mr. Nyoni that his discharge back to FITT was being put on hold and he was to remain in hospital due to the increase in his risk for violence. While in hospital he could meet with a therapist to address his historical trauma, a contributing factor in his violent attitude and need for hypervigilance. On June 19, 2025, Mr. Nyoni was transferred to B4N, a unit that would afford him more privileges.
Dr. Carefoot testified before the Board. She described the events outlined above. The FITT residence has four residents with one staff member on site 24 hours a day. In addition, there are various outpatient groups that meet at the residence. In the doctor’s opinion, the level of risk presented by Mr. Nyoni’s increase in paranoia, cravings for substances and possession of knives could not be managed at the FITT residence.
Since Mr. Nyoni has been admitted, there have been adjustments in his medication, and the doctor has noted a significant improvement in his mental status. There has been a decrease in his hallucinations and paranoia, and he has reported feeling safe. In the doctor’s opinion, some of that improvement could be attributed to the inability to smoke. In cases of treatment resistant schizophrenia, the effectiveness of Clozapine can be impacted by smoking. Mr. Nyoni recently has been approved for indirectly supervised passes on hospital grounds, for 30 minute periods up to four times a day. This will provide the team with an opportunity for the team to monitor Mr. Nyoni’s mental status as he exercises these privileges and possibly resume smoking. If an increase in hallucinations and paranoia is observed or reported, consideration will be given to encouraging Mr. Nyoni to quit smoking and/or increasing the dosage of his antipsychotic medication.
Dr. Carefoot testified that Mr. Nyoni only disclosed his paranoia after he was admitted to hospital. In her opinion, his risk to the safety of the public at that time was very high. The team will carefully monitor Mr. Nyoni’s mental status and begin to slowly increase his privileges with a view to ultimately discharging him back to the community when appropriate.
In response to questions from Mr. Schultz, Dr. Carefoot testified that the first concerning behaviour that she noted was Mr. Nyoni’s change in his attitude towards drugs. This was of particular concern given that drugs would be more accessible to Mr. Nyoni when residing at FITT. Should he be actively using drugs, he would experience a significant decompensation and he would experience an increase in his auditory hallucinations and paranoia. All urine drug screens were negative. However, Dr. Carefoot reported that even the day before the hearing, Mr. Nyoni endorsed that he should be able to use drugs and that “he could handle it”.
Dr. Carefoot testified that Mr. Nyoni has demonstrated an improvement in his attitudes toward the use of violence. He is currently working with a therapist on addressing his Post Traumatic Syndrome Disorder and the underlying belief that he always needs to be prepared to defend himself.
In response to questions by Mr. Sheivari, Dr. Carefoot testified that before a discharge back to FITT is considered appropriate, Mr Nyoni would have to demonstrate substantial improvement in his insight into the use of violence, substance use and the impact on his mental heatlh and a decrease in his auditory hallucinations and paranoia. She noted that the day before his admission to hospital, Mr. Nyoni had reported that the voices, although present, were not bothering him and he denied experiencing any paranoia. It was only after he was admitted to hospital that he admitted being afraid for his safety.
Dr. Carefoot testified that Mr. Nyoni had been in possession of the knives for two weeks and had been experiencing increasing paranoia. Given that and his history, readmission to hospital was the only way to manage his risk. The treatment team had determined on May 6 that a safety plan was to be implemented and notified staff at the residence that vigilance was necessary with respect to Mr. Nyoni’s mental status. Unfortunately, that was not implemented given the events of the following day.
All parties presented a joint submission to the Board.
Analysis and Conclusion
The Board carefully considered the Hospital Report and the evidence of Dr. Carefoot and unanimously finds that the decision to readmit Mr. Nyoni on May 27, 2025 was necessary and appropriate. Mr. Nyoni was experiencing an increase in cravings for substances, including making inquiries where to obtain drugs; an increase in his psychotic symptoms with heightened auditory hallucinations and paranoia; and endorsing the use of violence. When the team discovered that Mr. Nyoni had been in possession of two knives for the previous two weeks, Dr. Carefoot concluded that his risk could no longer be managed in the community, and a readmission was required. The Board finds that that conclusion was reasonable and well-founded.
Further, the Board agrees that the continued detention of Mr. Nyoni in hospital is both necessary and appropriate. It was not until he was admitted to hospital that Mr. Nyoni disclosed his heightened paranoia and his feelings of being unsafe while in the community. Dr. Carefoot is clear that before the team considers a discharge into the community, Mr. Nyoni will have to demonstrate significant improvement in his insight into the impact of substances on his mental health and risk for violence, as well as his attitude towards violence in general. In addition, as Mr. Nyoni obtains increasing privileges, the treatment team will need to continue to monitor his mental status and the impact of smoking and make any necessary adjustments.
In conclusion, the Board finds that the significant increase in the restrictions on Mr. Nyoni’s liberty by his readmission to hospital on May 17, 2025, was necessary and appropriate, and represented the least onerous and least restrictive response available to the hospital. Likewise, his continued admission to the date of the hearing remains necessary and appropriate.
DATED this 5th day of August, 2025, at the City of Toronto, in the Region of Toronto.
Ms. C. Finley Alternate Chairperson
Office of the Registrar Ontario Review Board