Ontario Review Board
Re: Devon Ambrose
ORB File No: 7891
Hearing held on: Wednesday, August 6, 2025
Place of hearing: St. Joseph's Healthcare Hamilton West 5th Campus, 100 West 5th Street
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Ms. J. Mills Members: Dr. S. Swaminath Dr. J. Kis Mr. E. Siebenmorgen Mr. A. Mete
Parties Appearing:
Accused: Devon Ambrose Counsel: Ms. B. Bromberg
The person in charge of hospital: Counsel: Ms. L. Barney
Attorney General of Ontario: Counsel: Ms. K. Malkovich
REASONS FOR DISPOSITION
(Dated September 10, 2025)
Reasons of the Majority
(Ms. J. Mills, Dr. J. Kiss, Mr. E. Siebenmorgen and Mr. A. Mete)
Introduction
[1]. On April 30, 2021, Devon Ambrose was found not criminally responsible on account of mental disorder (“NCR”) on charges of second-degree murder, aggravated assault, assault police with a weapon (x2), and assault resist arrest, contrary to the Criminal Code of Canada (the “Criminal Code”). Mr. Ambrose is currently subject to a disposition of the Ontario Review Board (the “Board”) dated May 21, 2024, discharging him with conditions.
[2]. On August 6, 2025, a panel of the Board convened to hold a hearing to review Mr. Ambrose’s disposition pursuant to s. 672.81(1) of the Criminal Code. Mr. Ambrose was present for his hearing and was represented by counsel throughout the proceedings.
[3]. The issues to be determined are whether Mr. Ambrose poses a significant threat to the safety of the public and, if so, the necessary and appropriate disposition to manage that risk having regard to the criteria set out in s. 672.54 of the Criminal Code.
[4]. At the commencement of the hearing counsel for St. Jospeh’s Healthcare Hamilton (the Hospital), submitted that Mr. Ambrose continues to represent a significant threat to the safety of the public and there should be no change to his current disposition, except that consent to provide treatment and alcohol abstention clauses be removed and that reporting should be changed to not less than once each month. Counsel for the Attorney General reserved her position. Counsel for Mr. Ambrose submitted that Mr. Ambrose no longer represents a significant threat to the safety of the public and should be discharged absolutely.
[5]. In closing submissions, the Hospital maintained its initial position; counsel for the Attorney General submitted that Mr. Ambrose should be required to report not less than twice each month and was in agreement that consent to treatment and abstention from alcohol clauses should be removed but that Mr. Ambrose should continue to be required to abstain from cannabis use. Counsel for Mr. Ambrose maintained her initial position.
[6]. For the reasons set out below, the majority of the Board concludes that it cannot positively find that Mr. Ambrose represents a significant threat to the safety of the public. Absent such a positive finding, he must be discharged absolutely.
Evidence at the Hearing
[7]. The Board received documentary evidence in the form of a Hospital Report dated July 17, 2025, and a letter from Dr. S. Menon, Neurologist, dated July 17, 2025, marked as Exhibits 1 and 2 respectively. The Board also heard viva voce testimony from Dr. Shariati, Mr. Ambrose’s treating psychiatrist.
Index Offences
[8]. The circumstances of the index offences are contained in the Hospital Report. The circumstances of the homicide and aggravated assault are excerpted from last year’s Reasons for Disposition, as follows:
"On November 13, 2020, Mr. Ambrose (Devon in this paragraph) was residing with his parents in Hamilton. His parents had noticed that over the previous few weeks he had been acting differently and in the preceding few days acting noticeably stranger. He had been pacing, mumbling to himself, and making statements such as “Kobe Bryant raped me”. On the date in question, Devon’s mother was on the phone discussing his concerning behaviour. Overhearing his mother, Devon became enraged. He yelled, slammed doors, and threw a chair. He then attacked his father, punching him in the face and body. He next turned to his mother and punched her in the face. She called 911. When Devon and his father proceeded to fight on the floor, Mrs. Ambrose went to the kitchen and grabbed a knife block. Devon was able to grab the block out of her hands and used a knife to stab his father. Because Devon had a history of aggression towards his father, Mrs. Ambrose yelled for her husband to leave the house in the hopes that Devon’s aggression would stop. Devon pushed his father out of the house and locked the door. Within 15 seconds his father could hear his wife calling for help. When he unlocked the door, he found Devon with his arm around his mother’s neck and the other arm with a knife pointing at her neck or chest. She had sustained several stab wounds in the torso, which would lead to her death. His father suffered injuries to his hand, arms and torso and a punctured kidney.”
Mr. Ambrose left the home and was promptly confronted by police officers who demanded that he drop the knife. He initially complied but then picked up the knife and charged at the officers. An attempt to stop him with a conducted energy weapon was ineffective. He started to flee on foot by eventually complied with demands to get on the ground. He resisted officers’ attempts to place him under arrest and was eventually subdued by another deployment of the conducted energy weapon.
[9]. The Hospital Report outlines Mr. Ambrose’s history and background and need not be repeated here in detail. In brief, Mr. Ambrose is 34 years old. He has an older brother and a younger sister. Another brother tragically died in a car accident in 2014. Mr. Ambrose dropped out of high school in Grade 11, due to difficulties coping with school. Mr. Ambrose has a limited employment history. He is single with no dependants.
[10]. According to collateral sources, Mr. Ambrose started using cannabis and alcohol when he was 13 years old. He started to drink heavily in 2013, after finding out that his mother had lymphoma. In 2014, after the death of his brother, his alcohol consumption escalated (he developed a routine of drinking up to 34 beers and as much as 26 ounces of liquor per night). In 2014, he was admitted to hospital twice for alcohol withdrawal and related seizures. In 2014 and 2019, the police were called to the family home for heated arguments between Mr. Ambrose and his father after bouts of drinking. Mr. Ambrose reports having stopped drinking in 2019. At the time of the index offences, he was consuming cannabis daily.
[11]. Prior to the index offences, Mr. Ambrose had no criminal record and no formal psychiatric history. However, his family noticed that he began experiencing difficulties after the death of Kobe Bryant in January 2020. In September 2020, a few months prior to the index offences, Mr. Ambrose had an MRI, which identified areas of abnormality, and he was referred for investigation for possible multiple sclerosis. By November 2020, his mother advised the family physician that he had a “significant decline in his cognitive ability” and was saying strange things.
[12]. On the day of the index offences, Mr. Ambrose was escorted by police to the emergency department of the Hospital pursuant to a Form 1 (Mr. Ambrose required prongs from a conductive energy weapon be removed from his skin). He was discharged later the same day after a psychiatric assessment. In January 2021, Mr. Ambrose was referred to Dr. Ferencz for an NCR assessment. As part of that process, Dr. Ferencz requested a neurological consultation that resulted in a finding that Mr. Ambrose was suffering with “highly active” demyelinating disease, which meets the criteria for multiple sclerosis (MS). An immediate course of high dose intravenous steroidal medication was recommended. Mr. Ambrose has been consistently treated for his MS since that time.
[13]. His current diagnoses are psychotic disorder due to another medical condition (multiple sclerosis), cannabis use disorder, moderate, in sustained remission, and alcohol use disorder, severe, in sustained remission. Mr. Ambrose is capable of consenting to psychiatric treatment.
Evidence of Dr. Shariati
[14]. Dr. Shariati testified that Mr. Ambrose has been clinically stable since March 2024 and there have been no signs of psychosis since starting treatment for his MS in 2021. Mr. Ambrose has good insight into his major mental illness and has engaged well with the treatment team. He follows his treatment plan closely. Mr. Ambrose fully understands his illness and recognizes the potential for substance use to cause a deterioration in his mental state. Mr. Ambrose has a neurologist whom he sees twice each year. There was a new ‘focus” on his MRI this year, but it is not thought to be significant.
[15]. Due to his lack of personal supports in the community Mr. Ambrose is seen twice weekly by the Forensic Outpatient team (FOPS). Mr. Ambrose appreciates the follow up with FOPS and this is why it has been maintained. Mr. Ambrose does not view the Board as onerous and appreciates the support. Mr. Ambrose lives in CMHA housing in a residence that he shares with two others. He is on a waitlist for independent housing.
[16]. Stress could precipitate a deterioration in his mental health which could lead to a falling away from treatment. However, at his core, given the way he feels about the index offences, Mr. Ambrose would be very unlikely to fall away from treatment. Any relapse, should it occur, would be subtle at first and then over time his symptoms would become more apparent. Subtle changes may be missed but any disease progression would be caught by an MRI. Alcohol use could increase his risk but with cannabis use the risk of psychosis would be attenuated if his MS is managed. Alcohol was not a factor at the time of the index offences and had not been for approximately a year prior to it. Cannabis was a factor but there has been no use of cannabis since the index offences. Mr. Ambrose had a positive substance use screen (oxycodone) this reporting year that was subsequently determined to be a false positive. It is unlikely that he would return to substance use.
[17]. Mr. Ambrose is unlikely to experience psychosis because he is well treated. The only context within which this might happen is in the face of stressors or substance use relapse or if he became too unwell to recognize the symptoms of a relapse. However, the risk is very low. Mr. Ambrose was aware that something was wrong with him prior to the index offence. Mr. Ambrose knows the signs of his illness and has insight to get help. While losing insight is part of the illness, Mr. Ambrose knows the subtle signs of his illness. There is a very small chance that the treatment for MS may not work and a very small chance of Mr. Ambrose returning to substance use.
[18]. Mr. Ambrose has worked at stress management and has been very involved with programming. Mr. Ambrose would not be a candidate for a civil mental health team as he does not require ongoing psychiatric care. Mr. Ambrose can continue to reside in his CMHA residence, and his medication can be prescribed by his family doctor. Mr. Ambrose’s family doctor is retiring but he is in the process of being transferred to another family physician. The treatment team are considering recommending Mr. Ambrose for a CMHA case manager. Mr. Ambrose is employed with a landscaping company and is looking into training to be a peer support worker. If Mr. Ambrose is discharged absolutely the treatment team will work with him to develop a critical care plan for him.
Analysis
[19]. The relevant legal principles to be applied to the evidence with respect to the issue of significant threat are summarized in the decision of the Ontario Court of Appeal in Marmolejo (Re), 2021 ONCA 130 at paras 34-37:
…the role of the Board is first to determine whether an NCR accused represents a significant threat to public safety. If the answer to that question is "no" or uncertain then the NCR accused must be discharged absolutely: Winko v. British Columbia (Forensic Psychiatric Institute), 1999 CanLII 694 (SCC), [1999] 2 S.C.R. 625, [1999] S.C.J. No 31, at pp. 659-61, 669 S.C.R. If the NCR accused does present a significant threat, the Board must either conditionally discharge or detain the individual: Winko, pp. 662, 669 S.C.R.
It is important to bear in mind that the Board's responsibility to grant an absolute discharge is non-discretionary in the event that it harbours any doubt about whether the NCR accused represents a significant threat: Carrick (Re), [2018] O.J. No. 4878, 2018 ONCA 752, at para. 16. As the majority of the Supreme Court emphasized in Winko, at pp. 652-53 S.C.R.: "Once an NCR accused is no longer a significant threat to public safety, the criminal justice system has no further application."
Individuals with mental disorders are not inherently dangerous: Winko, at p. 653 S.C.R. There is no presumption of dangerousness and no burden on the NCR accused to prove a lack of dangerousness: Winko, at pp. 660-61, 662 S.C.R. Rather, the legal and evidentiary burden of establishing significant threat rests on the Board or the court: Winko, at p. 663 S.C.R.
The threshold for significant risk is "onerous": Carrick (Re) (2015), 128 O.R. (3d) 209, [2015] O.J. No. 6524, 2015 ONCA 866, at para. 17. A significant threat to the safety of the public means a foreseeable and substantial risk of physical or psychological harm to members of the public: R. v. Ferguson, [2010] O.J. No. 5138, 2010 ONCA 810, at para. 8. The conduct must be of a serious criminal nature: Ferguson, at para. 8. A very small risk of grave harm will not suffice, nor will a high risk of trivial harm: Ferguson, at para. 8. The threat must be more than speculative in nature; it must be supported by evidence: Winko, at p. 665 S.C.R.; Pellett (Re) (2017), 139 O.R. (3d) 651, [2017] O.J. No. 5025, 2017 ONCA 753, at para. 21.
[20]. Further, in Marmelejo at para. 47, the court held that, “the risk of substance abuse does not justify the denial of an absolute discharge unless that substance abuse would pose a significant threat to the public.”
Position of the Majority
[21]. Mr. Ambrose’s risk is rooted in the potential for another psychotic episode driven by the progression of his MS. It is undisputed that Mr. Ambrose’s MS will continue to progress. Whether that progression will manifest itself in another psychotic episode and whether that psychotic episode would result in conduct of a serious criminal nature is unknown.
[22]. Mr. Ambrose stopped taking antipsychotic medication in February 2021 with no re-emergence of psychotic symptoms. Mr. Ambrose is noted to show insight into his mental illness; he adheres to his prescribed medication regimen (for MS) and has engaged meaningfully with the forensic outpatient team. Mr. Ambrose has also successfully participated in rehabilitative and vocational programming.
[23]. Mr. Ambrose is committed to his treatment. He understands his illness and manages it well. Mr. Ambrose’s MS can be exacerbated by stress and or substance use (specifically alcohol). Mr. Ambrose has not consumed alcohol since 2019 and has not consumed cannabis since the index offences in 2020.
[24]. Mr. Ambrose has not been living in the community for long and does not have a large social circle; however, he enjoys a good relationship with his maternal uncle, with whom he speaks almost daily. He has a residence where he can remain, with a CMHA housing manager and has the option of applying for a CMHA case manager who can further assist him. Mr. Ambrose is employed part-time and supported by ODSP. He also has realistic goals for future employment. In addition, in the event of a discharge absolutely, the treatment team will work with him to develop a critical care plan.
[25]. Mr. Ambrose’s likelihood of violence with or without professional supports was assessed on the eHARM as low in the short term (i.e., days to weeks). The long-term risk (i.e., weeks to months) was assessed as low-moderate in the absence of ongoing professional support. Notably, Mr. Ambrose is connected to a neurologist with whom he meets twice each year and has historically had a family physician. Although his family physician is about to retire, Mr. Ambrose is in the process of being referred to another family doctor.
[26]. Dr. Shariati testified that, given Mr. Ambrose’s treatment for MS, his risk of another psychotic episode is low and even were he to experience another psychotic episode, his risk for serious harm is attenuated by the medication (for MS) and it too would be low. Dr. Shariati further testified that Mr. Ambrose is very capable of identifying any subtle changes in his mental state and that his annual MRI’s will identify bigger changes. Mr. Ambrose has now been taking the same medication for his MS since July 2021 and with the exception of the new “focus” referred to in Dr. Menon’s letter, dated July 17, 2025 (Exhibit 2), there have been no difficulties.
[27]. Dr. Menon addressed the likelihood of a clinical MS relapse, as follows:
“…he recently had an MRI done in April 2025. This was compared to the previous scan which was available form July 2022. Direct comparison was difficult because of motion artefact, however there was a single new focus noted in the juxtacortical white matter in the right parental lobe. There was no DWI changes. He can have repeat MRIs over the next year, at this time he is clinically stable. Plan will be to continue ocrelizumab at this time. Ocrelizumab is a highly effective treatment option for multiple sclerosis with evidence for significant reduction of disease activity, both clinically and radiologically in the range of 90 percent. The risk of clinical relapse is very low on this agent.”
Mr. Ambrose is committed to his wellness and the likelihood of his falling away from treatment is low.
[28]. Mr. Ambrose suffered an unusual and tragic consequence of his then undiagnosed MS which has impacted both Mr. Ambrose and his family immeasurably. The tragic nature of the index offence cannot be overstated. Both the Attorney General and Hospital believe that a cautious approach is warranted, that more time is needed to observe Mr. Ambrose’s progress in the community and that this would be the best way to ensure that there would be no relapse. This is understandable; however, such an approach is not consistent with the established legal test. The evidence is unequivocal that the risk of relapse is low and that even were Mr. Ambrose to relapse, the risk for serious harm is attenuated by Mr. Ambrose’s medication, which he is committed to taking. The Board finds no positive evidence of significant threat. Given the evidence, the test for significant threat as outlined in Winko has not been met and Mr. Ambrose must be discharged absolutely.
Reasons of the Minority
(Dr. S. Swaminath)
[29]. I agree with the facts as outline above. Mr. Ambrose’s risk to the safety of the public is driven by his MS which resulted in the index offences. MS is a progressive disease. It is inevitable that Mr. Ambrose will continue to suffer a deterioration in his health, which may include his mental health. Despite the progress that he has made with the assistance of medication, there remains a possibility that the medication (which is relatively new) may not continue to work effectively to prevent a further psychotic episode. In my view, given the serious nature of the index offences, the more prudent course is a longer period of observation to ensure that Mr. Ambrose does not relapse into psychosis and represent a significant threat to the safety of the public.
Conclusion
[30]. In making a disposition, the Board must take into consideration s. 672.54 of the Criminal Code, including the safety of the public which is the paramount consideration and the mental condition of the accused, the reintegration of the accused into society and the other needs of the accused.
[31]. For the above reasons, the majority of the Board finds that Mr. Ambrose can no longer be said to positively represent a significant threat to the safety of the public and must be discharged absolutely.
DATED this 10th day of September 2025, at the City of Toronto, in the Region of Toronto.
Ms. J. Mills Alternate Chairperson
Office of the Registrar Ontario Review Board