Ontario Review Board
Re: Adrian Gbenle
ORB File No: 7406
Hearing held on: Tuesday, July 8, 2025
Place of hearing: Ontario Shores Centre for Mental Health Sciences 700 Gordon Street, Whitby
Pursuant to: Sections 672.81(2) and 672.81(2.1) of the Criminal Code
Before:
Alternate Chairperson: Mr. M.D. Segal Members: Dr. B. Sheppard Dr. M. Kalia Hon. E. Kruzick Mr. A. Bouvier
Parties Appearing:
Accused: Adrian Gbenle Counsel: Mr. T. Whillier
The person in charge of hospital: Counsel: Ms. J. Szabo
Attorney General of Ontario: Counsel: Ms. N. MacDonald
REASONS FOR DECISION AND DISPOSITION
(Dated August 8, 2025)
Introduction
Adrian Gbenle, age 38, on August 28, 2018, was found not criminally responsible on account of mental disorder in relation to charges of assault and assault peace officer, contrary to the Criminal Code. Mr. Gbenle is on a Conditional Discharge Disposition dated February 5, 2025.
On July 8, 2025, Mr. Gbenle appeared before the Ontario Review Board (the “Board”) from the Ontario Shores Centre for Mental Health Sciences (the “hospital”). The hospital had requested an early hearing, and the Board was also presented with a Restriction of Liberty.
Mr. Gbenle had been found in Quebec. He was in a hospital there with no money, food or fuel. He was apprehended and was admitted to the hospital’s Forensic Assessment Unit on May 7, 2025, presenting with significant clinical decompensation. unauthorized visit
Exhibit 1 was a Hospital Report dated July 3, 2025. Exhibit 2 was a Hospital Report dated October 3, 2024. Exhibit 3 was correspondence dated May 12, 2025, outlining the hospital’s position. Mr. Gbenle’s mother and grandmother attended the hearing.
In preliminary positions the hospital requested a Detention Order and a finding that the Restriction of Liberty was justified. Crown counsel supported the hospital. Mr. Gbenle’s counsel urged that the current Disposition be maintained. In the alternative, it was urged that a Conditional Discharge could include a Young clause (Young (Re) 2011 ONCA 432) relating to attendance at hospital, a consent to treatment clause, along with other appropriate conditions such as abstention from substances, and a submit to samples clause. While Mr. Whillier, for the patient agreed that the initial Restriction of Liberty was necessary, he urged that the continued restriction was unnecessary and not warranted.
Index Offences
- The circumstances of the index offences are taken from last year’s Reasons are as follows:
“Assault
On Wednesday, June 7, 2017, at approximately 9:05 p.m., the complainant, [female complainant’s name], left her residence, located at [street address] in Thorold, with the victim, [male victim’s name], and was followed by a vehicle driven by the accused. [The male victim] turned south onto Sunset Way in [an] attempt to flee the following vehicle; however, the accused followed [the male victim] and [the female complainant] into the dead end of [a] housing complex. At this time, the accused parked his vehicle; then exited and approached [the male victim], who was outside of his vehicle. The accused proceeded to yell at [the male victim] and call him a paedophile. [The male victim] had no idea what the accused was referring to and attempted to deescalate the situation. The accused then punched [the male victim] in the face with his right hand. [The male victim] was able to defend himself, while [the female complainant] dialed 9-1-1, and pinned the male on the ground until police arrived. As a result of the accused punching [the male victim] in the face, he was charged with Assault, contrary to Section 266 of the Criminal Code.
Assault Peace Officer
On Wednesday, June 7, 2017, at approximately 9:18 p.m., police responded to an assault in the area of Barker Parkway and Sunset Way in Thorold. Upon arrival, they observed the accused being physically held by the victim, [male victim’s name]. As police investigated and split the two up, the accused immediately got to his feet and continued to try assaulting [the male victim], yelling, “You’re a paedophile”. Police attempted to communicate with the accused but were met with negative results and had to restrain him in order to prevent a continuation of the offence. As attempts were made to gain control of the accused, he elbowed Constable Critelli [in] the shoulder and continued to be combative. Many efforts were made to control the accused; however, none of them were successful. As a result of this, a conductive energy weapon was used and assisted in physically controlling the accused. As a result of the accused elbowing Constable Critelli on the right shoulder, he was further charged with Assaulting a Peace Officer, contrary to Section 267(1)(a) of the Criminal Code.
The accused was subsequently transported to Niagara Health System at 2147 hours to be medically assessed. The accused [was] advised he was under arrest at 10:35 p.m. for Assault and Assault Police. The accused was read his rights to counsel and caution, which he demonstrated he understood, and requested to speak with [counsel]. The accused was medically assessed and later taken to central cells to await a bail hearing.”
Diagnosis
- Mr. Gbenle’s current diagnoses are Schizoaffective Disorder, Bipolar Type and Cannabis Use Disorder, moderate.
Background
- A good survey of the patient’s background is found at paragraphs 10 to 18 of the most recent Reasons, which are reproduced below:
Mr. Gbenle’s personal background and psychiatric history are reviewed in the Hospital Report filed as an exhibit at the hearing.
Briefly, Mr. Gbenle was born in Toronto and at the age of two, he moved with his mother to the Niagara Region, following his parents’ divorce. Mr. Gbenle’s mother reported that her son was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) when he was eight years old. He responded well to medication, until 16 years of age, when he chose to discontinue it. At that time, he got involved with the wrong friends and began using illicit substances. He reported using marijuana on a casual basis, approximately one to three times a month. Mr. Gbenle has worked in such fields as landscaping, welding, auto mechanics, and general labour. He quit various jobs as he did not get along with co-workers.
About four years prior to the index offences, Mr. Gbenle lived in his own apartment in Niagara Falls, Ontario. His mother reported that during this time, her son expressed paranoid thoughts about his neighbours, including that they could “hear his thoughts”, “see him typing on the computer”, and that they had “superpower hearing”. He lived at this residence for about three weeks before he decided to move back in with his mother. His paranoid beliefs and bizarre behaviour became more apparent when he came to live with her.
In late 2016, Mr. Gbenle began to demonstrate behaviours consistent with signs of mania. He was persistently irritable and dismissive with his mother and others when they did not agree with his conspiratorial beliefs or adopt his lifestyle. He began sleeping on the floor in the laundry room and covering electronic devices with foil at night. He became suspicious of people entering the home, and his social interest and interpersonal functioning declined.
By Easter 2017, his mother observed that her son was increasingly vocal about his beliefs concerning pedophile networks and told her that their neighbours were pedophiles. She recalled her son’s constant rants about the neighbours and pedophilic activity. On several occasions, Mr. Gbenle either warned or accused different neighbours of activity related to child molestation.
Two months before the index offences, Mr. Gbenle’s “ranting” increased from about 45 minutes to four hours daily, and the level of intensity, anger and agitation increased dramatically. He claimed to hear voices of children telling him about various pedophiles in the neighbourhood. His mother grew increasingly fearful of her son’s behaviour and the consequences of his outbursts.
In May 2017, Mr. Gbenle started keeping a journal of his activities. The journal entries detailed times and dates that he would patrol his neighbourhood, in search of those he believed were hosting deviant activities, such as ritual sacrifices, child prostitution or slavery. Mr. Gbenle’s behaviour escalated sufficiently for his mother to notify the police and mental health crisis services. On June 7, 2017, Mr. Gbenle was arrested for index offences.
Mr. Gbenle had no psychiatric admissions prior to the index offences. He has no criminal record. Following his arrest on the index offences, Mr. Gbenle was released on a court recognizance. He breached the terms of his recognizance on three separate occasions when he failed to report as required. On June 8, 2018, he was charged with failure to comply with recognizance, which was withdrawn on August 28, 2018.
On August 28, 2018, Mr. Gbenle was found NCR on the index offences. On November 7, 2018, he was transferred to the Waypoint Centre for Mental Health Care (Waypoint) pursuant to an ORB Disposition, dated October 19, 2018. He was subsequently transferred to Ontario Shores by the ORB on November 8, 2019. At the time of this hearing, Mr. Gbenle was living in the community pursuant to a Conditional Discharge Disposition.
Evidence at Hearing
Dr. D. Pallandi, the patient’s psychiatrist, testified. He has been treating the patient for two years but had prior contact with him some time ago at Waypoint.
Dr. Pallandi reported that until relatively recently, Mr. Gbenle had been capable to consent to treatment. Once capable, he reduced his oral antipsychotic medication, became detached from his forensic team and stopped engagement with them. Mr. Gbenle exhibited antagonism toward his team. Eventually, Mr. Gbenle ceased all medication.
Because of a desire to have Mr. Gbenle reconnect with his forensic team, a meeting was set up for Mr. Gbenle on May 5 with a different psychiatrist. Mr. Gbenle did not show up for the appointment. The hospital sought a Form 2. A police search ensued. On May 6, Mr. Gbenle’s mother informed the hospital that Mr. Gbenle had been admitted to hospital in Quebec without money, food or fuel. With the help of Durham Regional Police, Mr. Gbenle was transferred back to Ontario Shores and admitted. He had significantly decompensated. He was certifiable.
The hospitalization was quite problematic. He was incapable of consenting to treatment. A Form 4 was initiated which expires in the first week of August. By the time of the hearing, two injections had been administered of antipsychotic medication. The second injection required a Code White and, because of extreme opposition, necessitated the assistance of over 14 staff and security personnel to administer.
Mr. Gbenle’s insight is poor. His behaviour has now settled somewhat. Mr. Gbenle is in a stabilization phase. In Dr. Pallandi’s view, it generally takes five to seven injections, delivered every 28 days, to assess effectiveness.
Mr. Gbenle’s lease has been vacated. There is no current plan regarding where Mr. Gbenle may live when released. The hospital needs to approve housing. Mr. Gbenle had previously done well in independent living but could not manage that now. It is too early for the hospital to conclude the level of support the patient may require upon release.
The Restriction of Liberty was completely necessary. There were significant issues regarding insight. Engagement with the forensic team was virtually non-existent. There are lots of moving parts at present.
Mr. Gbenle requires stability. The patient is not at baseline. He continues to be in the secure assessment unit.
The Mental Health Act is insufficient to ensure stabilization. If Mr. Gbenle fell below certifiability he would discharge himself. His insight is an obstacle to recovery. There is a history of marked deficiencies in Mr. Gbenle appreciating his illness or the necessity of medication. The hospital's use of Form 2 was too little too late.
If Mr. Gbenle improves, he will be assessed as to whether he could be transferred to a less restrictive hospital unit.
Mr. Gbenle did not inform the hospital he was leaving for Quebec. Elopement is a new phenomenon.
When capable, Mr. Gbenle starts to decrease his medication against hospital advice. He typically says that there are intolerable side effects which the hospital doubts. Mr. Gbenle indicates that he does not need medication and does not suffer from a mental illness.
The forensic team is very sophisticated. They are trained in de-escalation. For them to call a Code White is an indication of how serious the struggle to administer the injection was. The next injection will be in the third or fourth week of July.
One possibility that the hospital will consider is that once Mr. Gbenle becomes better, CMHA supported housing could be examined. That housing is independent but includes supports.
Mr. Gbenle admitted to the team that he was using cannabis a few times per week although none was evident in blood tests upon admission. To ensure recovery, the hospital would want to eliminate possible complicating impacts of cannabis.
The relationship with the forensic team became problematic in March of this year.
It was coincidence that Mr. Gbenle was discovered in Quebec.
A Conditional Discharge would not keep Mr. Gbenle in hospital. There is no housing that could currently be specified. A Young clause would not remedy the need to retain Mr. Gbenle in hospital to ensure stabilization.
The challenge is that Mr. Gbenle becomes psychotic and a danger to the community when he stops his medication. When treated he does well.
Mr. Gbenle’s behaviour demonstrates a cyclical pattern of becoming well, stopping medications, and becoming unwell.
Analysis
Mr. Gbenle’s relationship with the forensic team was poor starting in March of this year. He was antagonistic. When the hospital offered a different psychiatrist, he did not appear and eloped for Quebec. Consistent with his history, when stopping medication, Mr. Gbenle significantly decompensated. He breached his Conditional Discharge by going to Quebec without permission. He was homeless and impecunious. He was living out of his vehicle. Upon his return to Ontario, he was severely decompensated and highly oppositional. A Code White had to be called to administer his second injection.
In summary, the Conditional Discharge he was on did not work. Clearly, a Detention Order is required. The Mental Health Act would not be adequate to respond to the risk to the safety of others. The Act could not ensure Mr. Gbenle would remain in hospital until stabilized. A Conditional Discharge with a Young clause and a consent to treatment clause would not ensure the requisite protection of the public. The cycle of becoming capable, going off medication and becoming unwell must be addressed. The hospital requires the ability to retain Mr. Gbenle in hospital to seek stability and provide the necessary medication. Cannabis, while not contributing to risk, need be avoided to eliminate possible obstacles to recovery.
Mr. Gbenle is on a path toward improving. There is a long way to go. Hopefully, the next injection will be less traumatic for all. Mr. Gbenle is beginning to appreciate the need for treatment. The Board finds that a Detention Order is the least restrictive and least onerous Disposition that can safely manage the risk to the safety of the public.
As Mr. Gbenle’s mental health improves the hospital could look to a possible transfer to a less secure unit and start to consider supervised housing as part of potential discharge planning. Mr. Gbenle has strong support from his mother and grandmother. The Restriction of Liberty was entirely justified and continues to be so. We wish Mr. Gbenle well.
DATED this 8th day of August 2025, at the City of Toronto, in the Region of Toronto.
Mr. M.D. Segal Alternate Chairperson
Office of the Registrar Ontario Review Board