Re: Adam Sean Palmer, 2025 CanLII 94999

Ontario Review Board

Re: Adam Sean Palmer

ORB File No: 4242

Hearing held on: Tuesday, July 22, 2025

Place of hearing: Ontario Review Board, 151 Bloor Street West, Toronto

Via Zoom Video Conference

Pursuant to: Sections 672.69 and 672.81(1) of the Criminal Code

Before:

Alternate Chairperson: Ms. L. Banks

Members: Dr. T. Verny

Dr. M. Mamak

Ms. K. Tomaszewski

Mr. A. Mete

Parties:

Accused: Adam Sean Palmer

Counsel: Mr. J. Kopman

The person in charge of Waypoint

Centre for Mental Health Care: Counsel: Ms. J. Lefebvre

Attorney-General of Ontario: Counsel: Ms. S. Curry

Correctional Services Canada

Representatives: Dr. A. Allman (CSC Liaison to ORB)

Mr. N. Smith (Parole Officer, Matsqui Institution)

Ms. N. Shaw (Parole Officer RTC Pacific Institution)

REASONS FOR DISPOSITION

(Dated September 16, 2025)

Introduction

1. On July 8, 2005, Mr. Adam S. Palmer was found not criminally responsible on account of mental disorder (“NCR”) on a charge of second-degree murder, contrary to the Criminal Code of Canada (the “Criminal Code”). This charge relates to an incident which occurred on July 29, 2002, when Mr. Palmer was 18 years old. As a result of the NCR verdict, Mr. Palmer came under the jurisdiction of the Ontario Review Board (the “ORB” or the “Board”). Over the years, he has been ordered detained in various designated forensic hospitals, most recently at Waypoint Centre for Mental Health Care - High Secure Provincial Forensic Programs Division (“Waypoint”) in Penetanguishene, Ontario.

2. On July 26, 2021, while subject to the jurisdiction of the ORB, Mr. Palmer was convicted on two counts of aggravated assault and one count of assault. While detained at the medium secure forensic hospital of Providence Centre for Mental Health Care in Kingston, in May 2015, Mr. Palmer attacked a female nurse, a co-patient and two security staff members with a makeshift weapon. As a result, he was transferred to Waypoint. A second incident of significant violence occurred on April 5, 2016, when Mr. Palmer attacked three staff members at Waypoint with a screwdriver.

3. On July 26, 2021, the court designated Mr. Palmer as a Dangerous Offender and imposed an indeterminate penitentiary sentence. His appeal of this Dangerous Offender designation and sentence was dismissed by a decision of the Court of Appeal in 2024.

4. As a result of the criminal conviction and sentencing and his pre-existing status as a NCR accused, Mr. Palmer became a “dual status offender” as defined in s. 672.1 of the Criminal Code. Since the Dangerous Offender finding and sentencing to an indeterminate sentence in a federal penitentiary, he has remained incarcerated in the penitentiary system pursuant to s. 672.67(1) of the Criminal Code.

5. Mr. Palmer has not resided in a forensic hospital since April of 2016, when he committed the criminal offences at Waypoint that resulted in the finding that he is a Dangerous Offender. After being charged for those offences, he resided in pre-trial custody in several correctional and detention centres.

6. As at the hearing date, Mr. Palmer was incarcerated in a medium security facility of the Correctional Services Canada (“CSC”), at the Regional Treatment Centre (“RTC”) at the Pacific Institution, in Abbotsford, British Columbia. He had been recently transferred there on July 8, 2025.

7. Mr. Palmer is currently subject to a Disposition of the Board dated July 31, 2023, which orders him detained at Waypoint, on cessation of his term of incarceration.

8. On July 22, 2025, the Board convened a hearing by Zoom video conference for the purpose of conducting an annual review of Mr. Palmer’ ORB Disposition pursuant to s. 672.81(1) of the Criminal Code.

9. The issues before the Board at the hearing were: (i) whether Mr. Palmer poses a significant threat to the safety of the public as defined in s. 672.5401 of the Criminal Code and, if so,

(ii) what is the necessary and appropriate Disposition which is also the least onerous and least restrictive taking into account the factors set out in s. 672.54 of the Criminal Code.

10. For the reasons set out below, the Board finds that Mr. Palmer remains a significant threat to the safety of the public and that he should remain subject to his existing Disposition which orders that he be detained at Waypoint in the event that he is no longer subject to a term of imprisonment. The Board declined to order a placement hearing.

Positions of the Parties

11. All parties advised the Board of their joint recommendation that Mr. Palmer continues to constitute a significant threat to the safety of the public.

12. Counsel for Waypoint recommended that Mr. Palmer’s existing Disposition remained necessary and appropriate.

13. Counsel for the Attorney General supported Waypoint’s recommendations.

14. Mr. Kopman asserted that the necessary and appropriate Disposition was a transfer of his client’s care from the penitentiary system to detention in a medium secure forensic hospital in Ontario. Mr. Kopman also affirmed his position as articulated at several pre-hearing conferences that he would attempt to lay a foundation for a future placement hearing at this hearing. Mr. Kopman asserted that there has been a significant change in circumstances such to trigger a s. 672.69(2) review of placement hearing.

15. Both counsel for Waypoint and the Attorney General endorsed the position that there was no evidentiary basis for the Board to direct the holding of a placement hearing pursuant to s. 672.68(2) of the Criminal Code as his current place of custody is appropriate to meet Mr. Palmer’s mental health needs and to safeguard the well-being of other persons. Further, counsel for Waypoint and for the Attorney General stated that there was no evidentiary basis to find that there was a significant change in circumstances requiring that a placement review be conducted pursuant to s. 672.69(2) of the Criminal Code.

16. The parties all maintained their respective recommendations to the Board in closing submissions.

Index Offences

17. The circumstances of the index offences resulting in Mr. Palmer’s NCR finding are extracted from the Board’s most recent Reasons for Disposition dated September 7, 2023 (“Board’s 2023 Reasons”), as follows:

“Mr. Palmer and his friend Michael McGuinty were in a park in the City of Brampton, when he stabbed his friend multiple times in the face, neck and back area, resulting in his friend’s death. Mr. Palmer left the park, went to another friend’s place, and told this friend and then his mother what had happened.

Initially, Mr. Palmer gave police a made-up story involving Mr. McGuinty and himself having attempted to rob two men when one pulled out a knife and Mr. Palmer fled. Shortly after giving that story, however, Mr. Palmer was arrested, confessed what had happened, and was charged with murder.

Mr. Palmer explained that he had stabbed Mr. McGuinty in self-defence because he had become convinced Mr. McGuinty was poisoning him. He explained that when they were in the park Mr. McGuinty began to sing a song with lyrics related to poisoning, which Mr. Palmer believed indicated Mr. McGuinty was poisoning him. He then stabbed him with a knife he had taken to carrying ‘for protection – just in case’.”

18. In later interviews, Mr. Palmer and his mother elaborated upon the circumstances surrounding the index offences. This information is summarized as follows in the Board’s 2023 Reasons:

“Mr. Palmer stated that their friendship had become strained when he no longer wanted to participate in robberies and Mr. McGuinty began ridiculing him for this. Around the same time, he became increasingly suspicious that Mr. McGuinty was trying to poison him by doping his drinks; this suspicion was connected to unusual physical sensations he was experiencing. He nonetheless continued to spend time with Mr. McGuinty because he wanted to ‘know what [Mr. McGuinty] was up to’ at all times.

At the time of the index offence, Mr. Palmer stated, he felt ‘high, extra buzzed out.’ He had had a few beers and a couple joints of marijuana. He thought he was going to die as a result of a swollen vein in his heart he was feeling. He held the same suspicion, of his friend poisoning him, whether or not he was under the influence of alcohol or marijuana. Mr. Palmer’s mother corroborated that he had been complaining to his family and had visited his family physician about heart problems, breathing problems, and dizzy spells. All test results had been normal. In the weeks prior to the index offence, his belief had surfaced that his friend Michael was trying to kill him by poisoning him. Mrs. Palmer had tried to dissuade her son of these beliefs, but they persisted.”

Background and Personal History

19. There is considerable information contained in the documentary evidence before the Board regarding Mr. Palmer, his personal history, his mental health history, his criminal history, and his course subsequent to the date of the NCR finding. As these documents were entered as exhibits in this hearing, it is not necessary to repeat all of that information. In addition,

the panel had the Board’s 2023 Reasons which provide a useful summary of Mr. Palmer’s background and personal history, and we have relied heavily on those Reasons herein.

20. Mr. Palmer’s childhood reveals conduct-disordered, aggressive, and violent behaviours, documented from a very young age. The Board’s 2023 Reasons indicate:

“He kicked a pregnant teacher in the abdomen while in Grade 2, at seven (7) years of age, resulting in a school suspension. At age eight (8), he engaged in cruelty to animals by throwing kittens. His parents were separated, and by the time he was 12 years old his mother reported that she could not control his behaviour. He was aggressive at home and damaging property. He started using alcohol and cannabis at age 12 or 13 and reported to Dr. Klassen that between ages 12 and 18 he drank as much alcohol as he could. By Mr. Palmer’s self-report recorded above, the circumstances of the index offence included his consumption of both alcohol and cannabis.

Repeated psychological testing of Mr. Palmer between the ages of six and twelve revealed concerns that included his sensitivity, substantial anger, retaliatory attitude (using retaliation as a way of making things “fair” as he perceived himself being treated unjustly), lack of empathy, and lack of remorse for misbehaviour. He was repeatedly suspended from school, starting in the primary grades, mainly for fighting, and was expelled from high school at fifteen, having earned no credits, after assaulting a peer with a knife.”

21. Mr. Palmer has a long and significant history of violence and criminal offending. He accumulated a youth court record including three robbery convictions and one for assault with a weapon (involving a knife) related to an incident of stabbing a peer at his school. He spent time in youth assessment and correctional centres in the two years prior to the index offence and was on a probation order at the time of its commission.

22. Mr. Palmer also described having engaged in other incidents of violence or vandalism that did not result in the laying of criminal charges.

23. Mr. Palmer’s overall legal history, including criminal charges that did not result in findings of guilt, as well as institutional charges within detention/correctional centres, is

summarized at Appendix “C” to Dr. Bunker’s 2021 report, included as Exhibit 8 at the hearing.

24. Following the index offence of second-degree murder when Mr. Palmer stabbed a friend multiple times as he believed the victim had been poisoning him, Mr. Palmer spent almost three years in pre-trial custody prior to coming under the Board’s jurisdiction in 2005.

25. After committing violent assaults at Providence Care Mental Health Centre in 2015, he spent further time in pre-trial custody until he was convicted and sentenced for those offences.

26. After committing further assaults (the predicate offences resulting in the dangerous offender designation) at Waypoint on April 5, 2016, Mr. Palmer has remained in continuous custody in detention and/or correctional centres.

27. We note that the considerable documentary evidence before the Board is also indicative of significant institutional violence while Mr. Palmer has been incarcerated. Examples noted (but not intended to be a comprehensive record), include:

• while at Maplehurst Correctional Centre in 2004, it was alleged that Mr. Palmer stabbed another inmate with a shank however, the charge was either stayed or withdrawn;

• in January 2005, Mr. Palmer was charged with assault causing bodily harm. He was alleged to have kicked another prisoner in the face while in a transport van. That charge was later stayed;

• in November 2010, Mr. Palmer was alleged to have committed a sexual assault on an 18-year-old female co-patient. Mr. Palmer was charged with sexual assault and transferred to jail. Mr. Palmer was acquitted at trial in 2012;

• in November 2019, Mr. Palmer made multiple attempts to assault a corrections officer with a broom handle as a weapon;

• in October 2021, at Millhaven Institution, Mr. Palmer was involved in an incident where he was threatening and chasing another inmate and was wielding a knife;

• in September 2022, Mr. Palmer concealed pieces of what appeared to be razorblades on his body;

• in February 2023, at RTC (Pacific Institution), Mr. Palmer was found with a homemade shank and debt lists;

• in October 2023, Mr. Palmer was directed to lock up in his cell and he refused. He stated he wanted to go to Kent Institution. When speaking with a Correctional Manager, he stated he wished he still had his shanks as he would have shanked the correctional officers;

• in January 2024, during a routine search, staff found a 7-inch homemade stabbing weapon in a plastic bag in Mr. Palmer’s possession; and

• in May 2024, Mr. Palmer approached a correctional officer and handed over a homemade weapon he said he had found in the yard.

28. The record also indicates that Mr. Palmer is not always in compliance with institutional rules, specifically rules related to being in possession of weapons and other contraband items (including amphetamine on one occasion) and inter-cell visiting.

Current Diagnoses

29. Mr. Palmer’s current diagnoses are:

Unspecified Schizophrenia Spectrum and other Psychotic Disorders;

Antisocial Personality Disorder (“ASPD”); and

Alcohol and Cannabis Use Disorders, in sustained remission in a controlled environment.

Evidence Before the Board

30. The evidence at the hearing consisted of the documentary evidence recorded in the Record and Exhibit List as set forth below together with the oral evidence of Dr. P. Klassen, Mr. N. Smith, Mr. Palmer’s parole officer at Matsqui Institution and Ms. N. Shaw, Mr. Palmer’s parole officer at RTC, Pacific Institution.

Record:

Notice of Hearing

PHC Report (x10)

Reasons for Adjournment- December 19, 2024

Transcript – Reasons for Sentence Ontario Court of Justice – July 26, 2021

ORB Order & Amended ORB Disposition – July 31, 2023

ORB Reasons for Disposition – September 7, 2023

Psychiatric Assessment Report – December 29, 2017- Dr. P. Klassen

Exhibits:

1. CSC Psychological Risk Assessment- June 1, 2023 - Regional Treatment Centre (Pacific)- Dr. T. Willoughby

2. CSC Psychiatric Risk Assessment- January 30, 2024 - Registered Psychiatric Dr. A. Kolchak

3. Independent Psychiatric Assessment dated July 14, 2025 - Dr. P. Klassen (“2025 Independent Assessment”)

4. CSC Transfer Letter – November 20, 2024 - Mountain Institution to Matsqui Institution in BC

5. CSC Transfer Letter – December 13, 2024 - Matsqui Institution to RTC at Pacific Institution

6. Correctional Plan- October 10, 2024 - authored by Ms. Marshall-Sehra

7. Waypoint Hospital Report – December 23, 2016

8. Assessment Report – March 23, 2021- Dr. A. Bunker (Waypoint)

9. Encounter Notes – July 9, 2025- RTC

10. Mental Health Clinical Notes- June 30, 2025-2 pages

11. Patient Drug Profile

Evidence of Dr. Klassen

31. Dr. Klassen endorsed the contents of his 2025 Independent Assessment and his finding that Mr. Palmer remains a significant threat to public safety. He then opened himself up to questions from the parties and panel members.

32. Dr. Klassen stated his understanding is that presently Mr. Palmer is being treated daily with two oral antipsychotic medications, Olanzapine and Brexpiprazole. As well, he receives daily treatment with the antidepressant, Cipralex.

33. Dr. Klassen stated that his understanding is that Mr. Palmer’s long-acting injection (“LAI”) of an antipsychotic medication was recently discontinued on around the beginning of July 2025, at Mr. Palmer’s request because he was experiencing priapism (i.e., involuntary erection). Dr. Klassen stated that in his opinion Mr. Palmer is currently sub-optimally treated. He testified that since 2017, even when Mr. Palmer was compliant with his prescribed treatment, he experienced breakthrough psychotic symptoms. The doctor acknowledged that it is often difficult to differentiate Mr. Palmer’s stress-related reality-based anxieties/paranoia from his psychotic symptoms of paranoia. Dr. Klassen heavily endorsed the need for treatment with Clozapine to better control Mr. Palmer’s psychotic symptom load. Dr. Klassen commented that Mr. Palmer would need to consent to treatment with Clozapine in order for it to be administered, in part, due to the related bloodwork protocols necessary for treatment with this medication.

34. Dr. Klassen stated that during the course of his recent Zoom meeting with Mr. Palmer, they discussed treatment with Clozapine and Mr. Palmer advised that it was not something that his psychiatrist recommended, and he personally expressed his concern that Clozapine treatment might cause him to experience hyper-salivation. The doctor confirmed that this was a possible side effect. In the final analysis, in Dr. Klassen’s opinion, absent treatment with Clozapine, there is no real possibility that Mr. Palmer will be ready for transfer to a forensic hospital, whether Waypoint or elsewhere.

35. Dr. Klassen was asked by Ms. Lefebvre whether he thought there had been any change in Mr. Palmer’s risk profile since his last ORB hearing in 2023. Dr. Klassen responded by stating that he does not think there have been any significant changes in either Mr. Palmer’s presentation or level of risk to the safety of the public.

36. In response to a question posed by Waypoint’s counsel, Dr. Klassen commented that he would not characterize Mr. Palmer as being “treatment-resistant” at the present time. He elaborated by stating that there have been increasing challenges in obtaining a good response to antipsychotic medications over time. The doctor commented that Mr. Palmer might be experiencing a progressively poor response to his current medications, re-iterated

the recommendation for a trial of Clozapine, considered the gold-standard for treatment resistant psychotic illnesses.

37. Dr. Klassen’s 2025 Independent Assessment confirms Mr. Palmer’s diagnoses as Schizophrenia and Antisocial Personality Disorder (“ASPD”) and indicates that his Schizophrenia “…is likely the more salient diagnosis, in terms of his institutional and community risk, at this juncture.”

38. Dr. Klassen commented that Mr. Palmer’s psychotic symptoms (i.e., primarily anxiety, paranoia, and somatic concerns) can present very subtlety, and that historically, Mr. Palmer is prone to react to those subtle symptoms with an unpredictable level of severe violence. Dr. Klassen referenced his December 29, 2017, Report (“Klassen 2017 Assessment”) and commented that it remained applicable. The doctor highlighted his observations from his 2017 Assessment and reiterated that although Mr. Palmer can present as quite stable, in the past, emerging psychotic symptoms have initially been quite subtle, at times, “…manifested by social withdrawal, affective constriction, and irritability”, and these symptoms can unpredictably and without apparent provocation, drive significant aggressive behaviour.

39. Dr. Klassen commented that Mr. Palmer’s illness is fragile and prone to breakthrough symptoms and as noted in the 2025 Independent Assessment “In 2019, there was paranoia about his food, and correctional officers, and an attempt to strike officers. In 2020, there was paranoia about his food, and there were threats. In 2021, Mr. Palmer discontinued medication, and there was an incident with another inmate, with knives. In 2022, Mr. Palmer armed himself with razorblades, and there was paranoia and somatic concerns. In 2023, Mr. Palmer was found with a shank and debt lists, and there were threats. In 2024, Mr. Palmer was twice found with a weapon.”

40. The recent 2025 Independent Assessment also notes that “…while Mr. Palmer does not present as overtly paranoid, nor is he expressing somatic concerns, he is reporting high levels of anxiety about his environment, to the extent that this affects his concentration. This may be the product of what has become a partially treatment-resistant illness. This may also result in part from the environment in which he is living, and, at least at points in time, his facing considerable debt.”

41. With regard to Mr. Palmer’s diagnosis of ASPD, Dr. Klassen commented that this diagnosis remains an active risk factor. Dr. Klassen stated that, to his knowledge, Mr. Palmer has not engaged in any physical violence for several years and there have been no reports of him being in possession of weapons since 2024; however, the doctor commented that Mr. Palmer has a significant history of instrumental violence, sometimes driven by psychosis, sometimes not.

42. Dr. Klassen pointed out that according to a July 2, 2025, clinical note authored by Dr. Kolchak, Mr. Palmer had, on that date, expressed that that he was under stress at Matsqui Institution and was “… starting to feel paranoid, that everyone on range was against him, even people who had no reason to be. He had brief thoughts of protecting himself with a weapon if attacked but did not acquire a weapon because he said "it was not worth it" because of potential consequences for him. He was transferred to RTC on July 8, 2025.

43. In response to a question posed by Mr. Kopman, Dr. Klassen confirmed that his 2025 Independent Assessment involved a single Zoom interview with Mr. Palmer and a file review of the documents noted therein. The doctor confirmed that no psychological retesting was conducted for the purposes of his report.

44. On further questioning from Mr. Kopman, Dr. Klassen testified that it is likely that in a forensic hospital setting there might be more surveillance of a patient and potentially more responsiveness from hospital staff than would be the case in a CSC institution; however, the doctor noted that Mr. Palmer’s current placement at RTC, Pacific Institution, is akin to a hospital setting so in his opinion, there would likely be no substantive difference between the two environments in terms of mental health care.

45. Mr. Kopman referred Dr. Klassen to Dr. Willoughby’s 2023 CSC Psychological Risk Assessment wherein it is noted (on page 13 of that report), when refencing a transfer of Mr. Palmer’s care to RTC, that “… it is clear that Mr. Palmer requires the structure and supervision afforded by a Treatment Centre. There is sufficient evidence that Mr. Palmer requires medical assistance and intervention in the management of his case.” Dr. Klassen commented that in his opinion the most critical factor in the management of Mr. Palmer’s risk is getting his medications optimized by treatment with Clozapine. Dr. Klassen stated that the optimization of Mr. Palmers treatment of his Schizophrenia is more important to his risk management than the institutional setting (i.e., CSC placement versus forensic hospital) within which he is detained.

46. In terms of Mr. Palmer’s level of insight, Dr. Klassen stated that Mr. Palmer has an awareness that he requires treatment with medication as he suffers from Schizophrenia. Yet the doctor commented that several health care professionals who have closely and consistently treated Mr. Palmer indicate that absent direct and ongoing supervision, Mr. Palmer would be likely to become medication noncompliant.

47. In response to a question posed by the legal member of the panel relating to whether Dr. Klassen believed there was any significant change in Mr.’s Palmer circumstance from that of his 2023 ORB annual hearing, the doctor responded that Mr. Palmer’s illness appears to be somewhat more fragile at this time. He noted that there was an increase in Mr. Palmer’s level of distress and anxiety, but the doctor was not clear whether this distress was related to situational stressors, including his debts to other inmates, as opposed to psychotic symptoms of his illness. In Dr. Klassen’s opinion, in light of Mr. Palmer’s history of fashioning weapons and using weapons to perpetrate extreme violence on others, his experience of anxiety must be actively managed. The doctor noted that Mr. Palmer’s pattern of unprovoked and unpredictable aggression, even within secure settings, is such that CSC would be better suited to manage Mr. Palmer’s risk of harm to others than a forensic hospital.

Evidence of Mr. Neil Smith:

48. Mr. Neil Smith, Mr. Palmer’s parole officer while he was incarcerated at Matsqui Institution from January to July 8, 2025, testified at the hearing. He advised that Mr. Palmer was transferred to Matsqui Institution, a medium security CSC institution, in January 2025 from RTC. He remained detained there until July 8, 2025, when he was transferred back to RTC.

49. Mr. Smith advised that Mr. Palmer was incarcerated on unit 7 at Matsqui Institution which housed approximately 96 offenders with a minimum of three correctional officers supervising at all times. He commented that among the inmate population of that unit, there were mental health offenders as well as sex offenders.

50. Mr. Smith testified that Mr. Palmer participates in the Journey to Health Program (“JTH”) program. He described the JTH program as a mental health program offering intensive supports for mental health inmates. The JTH program is delivered by group sessions from Monday through Friday as well as one to one counselling sessions with an inmates assigned mental health worker. Individual counselling supports also include social workers and psychiatric nurses. Mr. Smith advised that Mr. Palmer had missed several sessions of the JTH modules, which Mr. Palmer explained was due to morning sedation side effects of his medication. staff member. He is in the process of completing this program.

51. Mr. Smith testified that Mr. Palmer is also participated in the moderate intensity, Integrated Correctional Program Module (“ICPM”) of CSC from March 5 to July 4, 2025. This program is designed to provide offenders with both the skills and tools to better manage their individual criminogenic risk factors. The overall goal of this program is to decrease an offender’s risk profile.

52. Mr. Smith advised that Mr. Palmer missed approximately 16 sessions of the ICPM and risked suspension from the program due to his late arrival and early departure from group sessions. Mr. Palmer attributed his inconsistent attendance at this program to medication side effects, challenges with his concentration, and stressors related to his debts to other inmates. Given his absence from many of the ICPM sessions, Mr. Smith opined that it is unlikely that Mr. Palmer absorbed much of the materials presented. Eventually with considerable 1:1 support from his facilitator, Mr. Palmer was able to complete this program at the end of June 2025.

53. In terms of Mr. Palmer’s medications, Mr. Smith testified that Mr. Palmer unilaterally decided sometime in spring 2025, without prior consultation with his general physician or his psychiatrist, Dr. Rai, to either lower the dose of his antidepressant medication or stop taking same. The result has been an increase in Mr. Palmer’s anxiety together with other side effects.

54. Mr. Smith provided an update to the documentary materials before the Board and advised that on or around June 3, 2025, when staff were assisting Mr. Palmer in packing up his belongings to prepare him for his transfer to RTC, a white powder was found in his cell. The substance has been identified as an amphetamine. Mr. Smith indicated that he was not aware if any testing for substances had been conducted on Mr. Palmer’s blood or urine at that time. Mr. Smith was not able to opine as to whether or not Mr. Palmer had ingested the amphetamine. Mr. Smith testified that on a review of CSC records, he could advise that no institutional charges were laid against Mr. Palmer in respect of this incident.

55. Mr. Smith was asked what prompted Mr. Palmer’s transfer to RTC on July 8, 2025. He responded that Mr. Palmer had requested the transfer due to his experience of increased symptoms of paranoia and his fear that he was at risk of harm from other inmates. Overall, he stated that there had been a deterioration in Mr. Palmer’s mental state. Mr. Smith commented that Mr. Palmer was able to meet with Dr. Rai, his psychiatrist at Matsqui Institution, on an as-needed basis and Mr. Palmer met with his psychiatrist on several occasions, including a consultation with Dr. Rai prior to Mr. Palmer’s transfer to RTC. Mr. Smith stated that Mr. Palmer’s assigned mental health practitioners at Matsqui had also consulted with Dr. Rai and all were in favour of his transfer to RTC given his experience of heightened paranoia and the ability of the treatment team at RTC to more closely monitor his presentation. Mr. Smith stated that Mr. Palmer’s symptoms of his mental illness can present in a subtle manner, and, in the past, unpredictable significant violence has followed the onset of his symptoms.

56. Mr. Smith advised that RTC is located on Pacific Institution’s grounds, and it is a facility that manages offenders with “acute” mental health needs. He anticipated that Mr. Palmer’s placement there would be temporary and would allow him to avail himself of more intensive mental health resources and supports available at that facility. As well, his placement at RTC would allow CSC to more closely monitor his presentation. Mr. Smith anticipated that after Mr. Palmer had re-stabilized, he would likely be transferred back to Pacific institution.

57. Mr. Kopman asked Mr. Smith if he had prepared an updated Correctional Plan and Mr. Smith advised that one was currently being prepared and would be finalized prior to Mr. Palmer’s October 2025 Parole Board Hearing.

58. When asked a series of questions by a panel member regarding whether there were any material changes in Mr. Palmer’s current level of risk from that outlined in the 2024 Correctional Plan prepared by Ms. Marshall-Sehra (Mr. Palmer’s previous parole officer), Mr. Smith advised as follows:

• Mr. Palmer’s current security classification is still “medium”

• Mr. Palmer risk to public safety is still assessed as being “high”

• Static and dynamic risk factors identified in Ms. Marshall-Sehra’s Correctional Plan remain relevant and are each assessed as “high.

59. Overall, Mr. Smith stated that the updated Correction Plan when issued will not result in any change in any of Mr. Palmer’s risk assessments or ratings. He did however refer to additional institutional incidents of note and referenced an incident on February 14, 2025, when Mr. Palmer was observed smoking in a cell and the incident referred to above, when on July 3, 2025, staff seized a powder from his cell that was later identified as amphetamine.

Evidence of Ms. N. Shaw:

60. Ms. N. Shaw, Mr. Palmer’s parole officer at RTC, Pacific Institution, since July 8, 2025, also testified at the hearing. She concurred with Mr. Smith’s evidence that Mr. Palmer’s transfer to RTC had been on a voluntary basis, as a result of his deteriorating mental health and his corresponding mental health needs.

61. Ms. Shawn advised that Mr. Palmer will be seen by his psychiatrist Dr. Rai, at RTC on at least a monthly basis, or more frequently, as may be needed. She advised that in addition to Dr. Rai’s services, other mental health supports available to Mr. Palmer at RTC include a team of psychiatric nurses who are available 24/7 and a dedicated clinical case coordinator with whom he meets regularly. He will also have a clinical occupational therapist and a social worker as part of his integrated mental health team.

62. Ms. Shaw stated that she has already met with Mr. Palmer approximately two to three times a week since he has been transferred to RTC. She indicated that during those meetings, Mr. Palmer has been keen to ask questions about his upcoming ORB hearing, his interest in possibly being transferred to other federal CSC institutions (specifically, he has made inquiries about Mission Institution, Bath Institution and more recently, a possible return to Matsqui Institution). Ms. Shaw also reported that Mr. Palmer has recently requested a transfer of his care from Dr. Rai to Dr. Wiehan.

63. In terms of programming, Ms. Shaw stated that these are early days in Mr. Palmer’s detention at RTC, but she expected that he would be encouraged to engage in appropriate programming while detained at RTC. She advised that the Correctional Interventions Board will structure a program for Mr. Palmer in the upcoming weeks but at the present time they are awaiting the ICPM final report from Matsqui Institution.

64. In response to a question posed by a panel member, Ms. Shaw advised that she anticipated Mr. Palmer would remain detained at RTC for several months for close observation. She stated that at RTC, there is more intensive supervision, and mental health supports than would be available at Matsqui Institution.

65. No further evidence was called by the parties.

Analysis and Conclusions

66. The Board finds merit in the joint recommendation of the parties and finds that Mr. Palmer remains a significant threat to the safety of the public. This issue was not contested at the hearing. The panel finds that there is ample evidence in the documentation before us as augmented by the oral testimony of Dr. Klassen to support our decision that Mr. Palmer continues to represent a significant threat to public safety.

67. In addition to the index offence of second-degree murder, while subject to the Board’s jurisdiction and detained in secure forensic hospitals, Mr. Palmer acted out in two separate unprovoked and unpredictable incidents in 2015 and 2016 causing serious harm to the many victims. On both occasions, he used a weapon. Both were premeditated attacks on a targeted individual which then expanded to include assaults on the intervenors. In 2021, the court designated Mr. Palmer as a Dangerous Offender and imposed an indeterminate penitentiary sentence. In its reasons for sentencing, the court commented, “It is impossible to know what might provoke Mr. Palmer; what minor slight may become a grievance that spurs a violent retaliation.” This remains the case.

68. Mr. Palmer’s diagnoses of Schizophrenia and ASPD have continued to drive his aggressive behaviours within the correctional setting as set out at paragraph 27 of these Reasons. Further, Mr. Palmer remains sub-optimally treated and he continues to experience, albeit subtle, symptoms of his illness. In addition, his insight into his illness remains underdeveloped and he minimizes the risk of harm he poses to others.

69. The Board also accepts the joint recommendation of Waypoint and the Attorney General that there should be no change to Mr. Palmer’s current Disposition. Mr. Palmer is currently serving an indeterminate sentence in a medium security CSC institution. Should his sentence end, this panel finds that the necessary and appropriate Disposition is that he be detained in the High Secure Provincial Forensic Programs Division at Waypoint in accordance with the terms of his existing Disposition. In this panel’s assessment, Waypoint is the only forensic hospital in this province that could potentially manage Mr. Palmer’s risk upon cessation of his incarceration. Any less secure forensic hospital would not be an appropriate or realistic option in terms of public safety.

70. With regard to the issue of the placement of a dual status offender, s. 672.67(1) of the Criminal Code states that a penitentiary sentence imposed by a court takes precedence over the ORB’s custodial disposition, pending any placement decision of the Board.

71. We note in Palmer (Re), 2022 ONCA 899, the court indicated that “In the absence of a placement hearing warranted by a significant change of circumstances, the only relevant basis to alter the appellant’s placement is under s. 672.68(2) – if the Board finds that incarceration is inappropriate to meet his mental health needs or to safeguard the well-being of other persons.

72. In the circumstances of this case, the panel declined to order a placement hearing as we find that Mr. Palmer’s placement in CSC’s penitentiary system is “not inappropriate to meet his mental health needs or to safeguard the well-being of others.” Further, this panel finds there is no evidentiary basis to find that there was a “significant change in circumstances” requiring that a placement review be conducted pursuant to s. 672.69(2) of the Criminal Code. In Mr. Embry’s closing submissions, he asserted that Mr. Palmer’s engagement and participation in programming, specifically the JTH program and the ICPM. In our assessment, his more recent, albeit at times, inconsistent, engagement in therapeutic programming, has not significantly altered the risk that he poses as a dangerous offender. With regard to Mr. Embry’s assertions that Mr. Palmer’s risk to public safety has been reduced to a point that he can now be managed within the forensic mental health system, we note that the 2024 Correctional Plan together with the testimony of Mr. Smith, indicates that Mr. Palmer’s risk to public safety continues to be assessed as “high”.

73. The panel also notes that Mr. Palmer recently discontinued his LAI antipsychotic medication in July 2025, and this is likely to render him more vulnerable to experience decompensations in his mental state, particularly given the evidence of Dr. Klassen that Mr. Palmer is presently sub-optimally treated.

74. Mr. Palmer is currently detained at RTC, and he is being followed by an integrated team of mental health team of professionals. He has monthly access to psychiatric care with Dr. Rai and, he can be seen by his psychiatrist on a more frequent basis should his needs mandate same. In addition to the services of his psychiatrist, at RTC, Mr. Palmer has access to a team of psychiatric nurses who are available 24/7 as well as a clinical case coordinator with whom he meets regularly. He is also supported by a clinical occupational therapist, a social worker, and his parole officer.

75. The evidence before us indicates that RTC, much like a forensic hospital, offers its inmate/patients a variety of mental health resources/services. The factor of critical significance, however, is that these mental health services are provided within a penitentiary setting which is better equipped to safely manage the acute safety risk presented by Mr. Palmer. It is clear from Mr. Palmer’s history that the risk of severe re-offence continues to preclude his detention in a psychiatric hospital, which simply does not have a penitentiary’s level of protective security. It is the structural environment, external controls and security resources of a penitentiary that best mitigate the risk of harm Mr. Palmer poses.

76. The Board considers that its paramount responsibility in crafting a Disposition is the protection of members of the public from a risk of significant harm by NCR patients. Our review of this matter indicates that, at the present time, Mr. Palmer continues to suffer from ongoing symptoms of his psychotic illness (likely as a result of sub-optimal treatment). Given Mr. Palmer’s suboptimal response to his treatment and his fluctuating compliance with medications historically, the expert evidence indicates that Mr. Palmer’s mental state remains fragile, and he is likely to experience future exacerbations of his symptoms when exposed to stressors.

77. Although Mr. Palmer currently presents as stable, history has shown that it is exceptionally difficult to predict a deterioration in his mental state, which historically can present rapidly, within days and weeks. It is critically important when Mr. Palmer discloses even mild symptoms of his illness (typically paranoid thoughts, heightened anxiety or somatic preoccupation) that staff respond with extreme caution as these are often indicators that Mr. Palmer poses an immediate risk of harm to others.

78. Exacerbating his risk profile is that fact that Mr. Palmer is also diagnosed with ASPD, which has also been a historical driver of his acts of violence. We agree with the conclusion noted in the Psychiatric Risk Assessment authored by Dr. Kolchak dated January 30, 2024, that “… Mr. Palmer exhibits antisocial personality disorder symptoms and instrumental violence outside of his mental illness. His psychotic illness and antisocial personality disorder are two independent entities which historically combined in the past and manifested in serious violence.”

79. As stated, in our assessment, Mr. Palmer’s risk simply cannot be safely managed outside of a secure penitentiary setting. If Mr. Palmer were to be detained within Waypoint, a maximum secure forensic hospital, that facility would not offer a level of security that is equivalent to a correctional facility, which we consider necessary for public protection.

80. Dr. Klassen opined that there have not been any significant changes in either Mr. Palmer’s presentation or the level of risk he poses to public safety since he last appeared before the Board in 2023. Further, Mr. Smith, who acted as Mr. Palmer’s parole officer at Matsqui Institution, opined that Mr. Palmer risk to public safety is currently assessed as “high” as was the case prior to his last ORB hearing in 2023.

81. This panel is cognizant of the likelihood that the more restrictive and supervised environment of a correctional facility might be less conducive to a mental-health offender’s treatment needs; however, in our assessment, this factor must be weighed against the paramount need of protection of public safety.

82. When Mr. Palmer’s term of penitentiary incarceration is concluded, it is this panel’s finding that Waypoint, being the only high secure forensic hospital in Ontario, is the appropriate forensic hospital for his detention and treatment in Ontario. However, at the current juncture, Mr. Palmer’s risk of severe re-offence continues to preclude his detention in a psychiatric hospital, which simply does not have a penitentiary’s level of protective security. In our assessment, Mr. Palmer’s current detention at RTC at Pacific Institution meets both his mental health needs and the paramount need to safeguard the public.

83. In making this Disposition, the Board has taken into consideration Mr. Palmer’s mental status, his reintegration into society, his other needs and, the paramount need of the safety of the public.

DATED this 16th day of September 2025, at the City of Toronto, in the Toronto Region.

Ms. L. Banks

Alternate Chairperson

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Office of the Registrar

Ontario Review Board