Re: Clive Carter
ORB File No: 8721
Hearing held on: Tuesday, August 12, 2025
Place of hearing: Centre for Addiction and Mental Health 1001 Queen Street West, Toronto
Pursuant to: Section 672.47(1) of the Criminal Code
Before:
Alternate Chairperson: Ms. C. Finley
Members: Dr. P.E. Cook Dr. A. Park Ms. J. Ferguson Ms. B. Little
Parties Appearing:
Accused: Clive Carter Counsel: Mr. M. Zaffina
The person in charge of hospital: Counsel: Ms. M. Warner
Attorney General of Ontario: Counsel: Mr. M. Feindel
REASONS FOR DISPOSITION
(Dated September 18, 2025)
Introduction
On February 7, 2025, Clive Carter was found not criminally responsible on account of mental disorder (NCR) on charges of assault with a weapon (x 3), Failure to comply with a release order (x 2), criminal harassment, possession of a weapon for dangerous purposes, contrary to the Criminal Code of Canada. Mr. Carter was interviewed at CAMH on the basis of a Form 6 Order for Examination on 11 April 2024. Mr. Carter was also interviewed at CAMH on 22 August 2024 and 17 October 2024 on the basis of a Form 48 Assessment Order for criminal responsibility He was found to be Not Criminally Responsible by way or court order dated February 7, 2025 and referred to the Ontario Review Board for a disposition and was released on conditions. Mr. Carter was seen at CAMH through the Brief Assessment Unit (BAU) on 17 April 2025, pursuant to an Assessment Order of the Ontario Review Board (ORB), dated 7 March 2025. which order follows the February 7, 2025 finding of Not Criminally Responsible on account of Mental Disability. He is currently residing in the community.
On August 12, 2025, the Board convened to conduct Mr. Carter’s hearing pursuant to s. 672.47 (1) of the Criminal Code. Mr. Carter was present and represented by Mr. Zaffina.
At the outset of the proceedings, all parties were canvassed as to their positions on the two issues to be determined by the Board: whether Mr. Carter continues to represent a significant threat to the safety of the public, and if so, the necessary and appropriate disposition having regard to the criteria set out in s. 672.54 of the Criminal Code.
Dr. Jones, on behalf of the hospital, submitted that Mr. Carter continues to represent a significant threat to the safety of the public and the necessary and appropriate disposition is a detention order with conditions, including the requirement that he abstain from consuming alcohol or non-prescribed substances and submit samples of his urine and/or breath for testing purposes and not to attend at the place of work, residence, school or other place where certain individuals who were victims of the index offences are likely to be.
Mr. Feindel, on behalf of the Ministry of the Attorney General, concurred in the hospital’s position.
Mr. Carter’s counsel, Mr. Zaffina took the position that Mr. Carter no longer poses a significant threat to the safety of the public and should be given an absolute discharge. Mr. Zaffina pointed out the following factors that favour such an order:
Mr. Carter has shown his strengths in the last several months despite the presence of significant stressors in his life during that time including the death of his mother and financial debt; and
It has been quite a long period of time since the index offences occurred; and
Mr. Carter has been compliant in taking his medications and attending his appointments with Dr. Owen, his psychiatrist in the community; and
His urine screenings for substance use have all come back negative for some time;; and
Mr. Carter has not suffered any psychotic incidents in some time; and
Restrictions on Mr. Carter are stressful; and
His supporting team including Dr. Owen are sufficient to keep him on track while he continues to work on his addiction and other issues.
Findings
- For the reasons that follow, the Board finds that Mr. Carter continues to represent a significant threat to the safety of the public and the necessary and appropriate disposition is a detention order with the terms and conditions recommended by the hospital.
The Index Offences
- The circumstances of the index offences are excerpted from the Risk Assessment Report dated July 30, 2025 (Exhibit 1) as follows:
On January 24th, 2022, the accused, Clive CARTER, stood before the Honourable H. KRELING, a Justice of the Peace in the Ontario Court of Justice, to answer to the charges of assault with a weapon, uttering threats, assault level 1, two counts of possess weapon for committing an offence and two counts of fail to comply with release order. The accused was released on a Release Order with several conditions, including to not possess weapons as defined by the criminal code or any imitation weapons. At 4:00 am, on the 31st of March 2023 the accused was within his residence, apartment 809 of 415 Maclaren Street in the City of Ottawa. The victim, Julie COUSINEAU, was on the 8th floor walking back to her unit which directly neighboured that of the accused. The accused opened his door, and brandished two meat cleavers, smashing them together while yelling at the victim. The victim was fearful for her safety and fled to her unit, locking the door immediately. She called police. At 7:30 am the accused left his unit and went to the door of the victim. The accused yelled the victim's name and swore at her. He demanded that she open her door. The accused smashed at her door with the meat cleavers damaging the door. The victim was fearful for her safety and called police at 7:46 am police arrived on scene and discovered the accused was inside of his unit. Police contained the accused in their unit until tactical officers arrived on scene. At this time, at 8:44 am, the accused exited his unit on his own volition and was placed under arrest. The accused was read their right to counsel, caution, secondary caution, and section 524 warning. The accused was transported to central cellblock at 474 Elgin Street to be held for bail. The accused was charged with Mischief to Property, Harassment by Threatening Conduct, Possession of a Dangerous Weapon and Breach of Release Order. Self Report When asked about this incident, Mr. Carter said, "They say that there was some incident with a neighbour when I was already in Toronto. She is a person who smokes a lot of crack cocaine, and she could be hallucinating."
“On February 6, 2022 in the City of Ottawa, victim Martin ROULEAU and his 15year old son Brandon ROULEAU where visiting Ottawa and attended the Tim Horton location at 263 Bank St at approximately 0757 hours. While inside the restaurant staff employees including the victim heard a male yelling and screaming toward patrons. The accused was later identified by patrol officers 6 as Clive CARTER 1980/09/09. The victim approached CARTER confronting him and telling him to shut up. CARTER responds by assaulting the victim. Video evidence seized by police show CARTER assaulting the victim by using his left hand striking him in the face and proceeded to grab onto the victim. CARTER then proceeds to assault the victim with a weapon by using a pen and stabbing the victim in the neck and on the back. CARTER then proceeds to bite the victim on the back of the neck. Further video evidence taken by the son of the victim shows CARTER being the aggressor chasing after the victim inside the store with a silver knife in his left hand. The blade is clearly visible on video. The accused then threatened the victim by yelling "I'm going to shoot you. I'm going to shoot your child". Cst. BELL arrived on scene and observed the accused with a Swiss army knife in his left hand. Search incident to arrest also revealed a lighter on the accused person which is a breach of his conditions.
“On or about the 4th day of November in the year 2022 at the City of Ottawa in the East/De L'Est Region did, having appeared before a court, fail, without lawful excuse, to subsequently attend court, contrary to Section 145, subsection (2), clause (b) of the Criminal Code of Canada.”
Background Information
The Risk Assessment Report contains detailed information about Mr. Carter’s background, substance use history, legal history and psychiatric history, the salient points of which are reproduced below.
Mr. Carter is a 44-year-old male who is a Canadian citizen and a qualified Registered Practical Nurse (RPN). He is currently unemployed and supported by Ontario Disability Support Plan (ODSP).
The following is extracted from the NCR report dated 18 November 2024. Mr. Carter was born in Saint Vincent and Grenadines. He had no problems during his birth or early development as far as he is aware. He described himself as a “small child” that was “easily blown away by the wind.” Mr. Carter is the third of four children born to his mother. His parents separated when he was very young and he was raised by his mother. He described his mother as “a strong woman.” He said that she “raised herself from a state of poverty to being able to afford things.” (Note: Mr. Carter’s mother passed away in 2025.)
Mr. Carter stated that his father was a fisherman. They had only sporadic contact when he was a child. He died last year at the age of 79. With regard to his childhood, Mr. Carter stated that he had “nurturing that was necessary to survive,” but he did not feel loved or wanted. He said that he always struggled to fit in because of his homosexuality. He also stated that because of his mother's work and being her third child, he was left to fend for himself. Mr. Carter described frequent physical punishment by his mother. He said that he was beaten with sticks, broom handles, belts and anything that was close to hand. He said that his brother did not suffer the same form of punishment. Mr. Carter said that he felt sad and lonely as a child. He said that he rarely had friends. He reported that he was told he was “very effeminate” and was “cast out” by other children and by his own family. He said it was “hard to find a space to fit in.” Mr. Carter reported that he had experienced sexual abuse by his neighbours from the age of five to fifteen. He stated that it occurred on a weekly basis by people that were close to his family. He did not report it to anyone at the time. He said that his parents “might have had an inkling it was happening” but did not do anything about it. He said that abuse affected him greatly, stating that he had always struggled to fit in and had been “searching for acceptance and belonging” for most of his life.
Substance Use History:
- Mr. Carter stated that he started using methamphetamine in 2019, which was given to him by a romantic partner. He said that he believed that his drink was spiked, after which he started using it regularly. (Note that in his health records he had reported starting to use methamphetamine after he had surgery in 2016). In the interview on 22 August 2024, Mr. Carter said that he had been “unknowingly introduced” to a substance that affected his ability to concentrate or to feel like his normal self. He said the effect lasted several months. He said that at the time he was a drag entertainer, and was “hanging out with people who had a colourful disposition.” He said, “Anyone could have given it to me.” After being introduced to methamphetamine he reported that he started using it “consciously” between 2019 and 2021 stating he was “liberally open to taking it from anyone.” He reported being dependent on methamphetamine during this time, smoking it around ten times per day at that time. He said that he recognised it was problematic and tried to cut down in 2021 but was not abstinent other than when in custody. Mr. Carter reported that he continues to use methamphetamine daily, and last used the day prior to the interview (21 August 2024). Mr. Carter reported that he also “unknowingly” took GHB, heroin and fentanyl in 2018 and 2019. Mr. Carter stated that he had used cannabis a few times when others have passed it to him, but he does not really like using cannabis. With regard to alcohol, he stated that he drinks socially, once or twice per year but otherwise does not drink. He has never consumed alcohol heavily and has never been alcohol dependent.
Legal History:
- Mr. Carter has a significant history of conflict with the law and numerous legal charges in addition to the index offences.
Psychiatric History:
The Risk Assessment Report indicates that Mr. Carter has been diagnosed with schizoaffective disorder – bipolar type, stimulant use disorder and polysubstance use disorder in remission.
Mr. Carter reported that he had a mental breakdown in 2003 at the age of 23. He said he was going to drive off the wharf in Cobourg but was stopped and was taken to hospital and was admitted for a few days. He reported that he had been newly diagnosed with HIV and was trying to cope with the stigma. He said he was experiencing hallucinations and had suicidal ideation. He said he was diagnosed as having bipolar disorder and was prescribed quetiapine.
After his discharge from hospital, Mr. Carter was given outpatient follow up and he said that his mental health improved. Mr. Carter stated that he was living in Cobourg from 2009 until 2011. He was at that time working in several facilities including at the hospital, at a long-term care facility and at two nursing homes. He stated that his mental health was “a bit strained” during this time. In 2011 he and his partner moved to Ottawa where he stayed until 2022. During that time, he stated he was not getting much mental health support, but attended therapy groups at Sandy Hill community centre.
From 2022 until the present, Mr. Carter has been living in Toronto. He stated he has had only sporadic mental health follow-up, mainly from his family doctor. He said he has attended hospital emergency rooms a few times but does not have any regular psychiatric follow-up. Mr. Carter reported that his mental health has fluctuated ever since this hospitalization in 2003. He reported that he had subsequently been diagnosed as having schizophrenia, and estimated that he had had more than ten hospitalizations.
Physical Health
- Mr. Carter is HIV positive and has acknowledged this condition and has been receiving treatment and support. Mr. Carter also suffers from diabetes and is taking medication for it. Mr. Carter takes numerous medications to treat various medical conditions.
Concerning Behaviours
The Risk Assessment Report includes a concerning incident In March of 2024 at Mr. Carter’s sister’s home. Mr. Carter and his sister began to argue and his sister reported that he was wielding a knife and told her he was hearing the voice of God. She became very frightened and fearful. Mr. Carter indicated that he happened to be holding a knife when the incident broke out. Mr. Carter has previously reported to have heard the voice of God, including during the occurrence of the index offences at Tim Hortons.
There have been no episodes of concerning behaviour since March of 2024.
Evidence at Hearing:
Dr. Jones provided oral testimony at the hearing, endorsing the contents of the Risk Assessment Report dated July 30, 2025.
Dr. Jones testified that Mr. Carter has being doing quite well over the last several months, that he has found housing in the community, has been taking his medications as prescribed, has been seeing Dr. Owen, a psychiatrist in the community and has enjoyed the support of family and friends. Dr. Jones indicated that he has indirectly liaised with Dr. Owen but has not yet had the opportunity to review Dr. Owens’ notes on Mr. Carter’s care although he has requested them. Dr. Jones gave evidence that Dr. Owens has confirmed that Mr. Carter is compliant with going to his appointments with Dr. Owens and with taking his medications. However, Dr. Jones testified that Dr. Owen has no ability to mandate that Mr. Carter take his medications or attend his appointments or mandate abstinence from substance use.
Dr. Jones testified that, as of his assessment in April, 2025, Mr. Carter had not ruled out further substance use and that the Mental Health Act is inadequate to require an individual to mandate abstinence. Dr. Jones also testified that consumption of methamphetamines by Mr. Carter, as he has done in the past, would pose a serious risk factor for reoffending. Dr. Jones indicated that Mr. Carter continues to use methamphetamines though on a less frequent basis. In response to questions from Mr. Feindel, Dr. Jones agreed that Mr. Carter is currently at a pre-contemplative stage with respect to abstaining from substances. He does not recognize the impact of substance use on his mental state.
Dr. Jones testified that the treatment team would have concerns about compliance if Mr. Carter was not taking injectable medications. If Mr. Carter were to become non-compliant there would undoubtedly be a deterioration in his mental status leading to more erratic behaviour, an inability to control emotions and manage anger and that his judgment would become impaired, he would become more paranoid, suspect others of doing things to or against him or speaking about him or interfering with him, and that Mr. Carter could then react in a violent or aggressive fashion.
Dr. Jones gave evidence that Mr. Carter is vulnerable to stressors and has faced some challenging stressors over the last year, including the death of his mother which Mr. Carter described as causing him overwhelming grief and that he was “just holding it together.” Mr. Carter’s father also died last year. Mr. Carter does enjoy significant support from his sister which Dr. Jones expects will continue going forward. Mr. Carter is also facing significant financial debt which is an added stressor and must still be resolved.
Dr. Jones testified that Mr. Carter’s medications have not been optimized as evidenced by the fact that Mr. Carter continues to suffer from some symptoms such as delusions/psychosis. Mr. Carter continues to experience auditory hallucinations and delusional grandiose beliefs. He believes that he has special powers and is able to change water to medication, perform telekinesis, and travel through time and space. The symptoms are present but are not evident unless Mr. Carter is directly asked about them. Dr. Jones testified that in order to optimize his medications, a step-by-step process would be tried which might include changing doses or trying alternative medications. Dr. Jones added that Mr. Carter would also greatly benefit from substance abuse programs.
When asked about a notation in an assessment from Northumberland Hospital indicating a possible personality dysfunction, Dr. Jones confirmed that early presentations were around depression and trauma from childhood interfering with functioning but that with respect to a personality component, it would be difficult to assess because of Mr. Carter’s ongoing psychosis. As a result, Dr. Jones has been unable to form an opinion about personality traits although he did add that previous psychiatrists who have treated Mr. Carter have commented on personality dysfunction. Further, Dr. Jones has been unable to confirm that Mr. Carter has a dependant personality as he has seen no information that would confirm such a finding. Dr. Jones testified that one of the main features evidenced by Mr. Carter was grandiosity which is a feature of psychosis and not the underlying personality.
With respect to Mr. Carter’s insight into his condition, Dr. Jones testified that he lacks insight into his situation and that he has been charged with quite a few offences and acknowledges some of his offences but not others. With respect to the January, 2022 offences, he doesn’t acknowledge facts as in the synopsis and has a completely different take on them, including taking the position that it was one of the victims who had a knife but not him, notwithstanding video evidence of the assault. Dr. Jones testified that although Mr. Carter is a registered nurse, his insight with respect to his mental health remains partial and that his training as a nurse does not compensate for that.
Dr. Jones testified that Mr. Carter is capable of consenting to or refusing treatment and that he is free to refuse treatment although Dr. Jones is not aware of any instances in which Mr. Carter has refused treatment, but if there were such instances in future, Mr. Carter would need to be closely monitored and that such refusal would pose a serious challenge for his treatment team.
The Risk Assessment Report included an incident on September 7, 2023 during which Mr. Carter was brought to hospital after experiencing a seizure. Dr. Jones testified that Mr. Carter does not have a diagnosis of epilepsy and that the seizure was likely induced by the use of substances.
Dr. Jones testified that Monica Barren, the social worker involved with Mr. Carter interviewed Mr. Carter’s sister and reported that his sister has seen some improvements in recent months. She remains a positive support for Mr. Carter.
When queried what would happen if Mr. Carter’s drug screening tests came back positive, Dr. Jones testified that the treatment team would be very concerned about that. Dr. Jones indicated that if Mr. Carter was subject to a detention order, the treatment team would consider impact of substance use on Mr. Carter’s mental health, the associated risk to the safety of the public, and whether he needed to be admitted to hospital to manage that risk. Given the seriousness of Mr. Carter’s past substance use and the impact it might have on his mental health, admitting Mr. Carter to hospital would be a real possibility.
Dr. Jones testified that if the detention order the hospital is seeking is made, Mr. Carter’s treatment would be taken over by CAMH from Mr. Carter’s current community psychiatrist. He testified that it is possible that the hospital might make an agreement with a community treatment team but that CAMH would take the lead in treatment decisions.
At the end of the evidence, all parties maintained their initial positions.
Analysis and Conclusion
The Board carefully considered the Risk Assessment Report of July 30, 2025 and the evidence of Dr. Jones and unanimously concluded that Mr. Carter continues to represent a significant threat to the safety of the public. The definition of “significant threat” is guided by the principles set out in Winko v British Columbia (Forensic Psychiatric Institute), [1999] 2 S.C.R. 624, which defines it as a risk of serious physical or psychological harm that is criminal in nature.
Mr. Carter has shown many strengths over the last few months, including taking his medications and seeing his psychiatrist in the community regularly, finding housing in the community and being supported by family and friends. However, the panel is cognizant that there remain salient risk factors present that are a cause for concern and that need to be addressed and that Mr. Carter has faced significant stressors over the past several months including bereavement and financial stresses arising from debt. Mr. Carter has only partially responded to his current medication regime which has not yet been optimized as evidenced by the fact that he still experiences psychotic symptoms which could become problematic. Mr. Carter still lacks insight into his condition and has a long history of substance use and a serious pattern of violence that could reoccur if there is decompensation as a result of a failure to comply with taking medications as prescribed and as a result of using substances, all of which are more likely to occur if his is not under the supervision of the ORB.
Having found that Mr. Carter continues to represent a significant threat to the safety of the public, the panel must consider the necessary and appropriate disposition taking into consideration the criteria set out in s. 672.54 of the Criminal Code, which includes the need to protect the public from dangerous persons, the mental condition of the accused, the integration of the accused into society and the other needs of the accused.
The panel agrees with the submission of the hospital and a detention order with conditions is the necessary and appropriate disposition and least restrictive option available at this time to manage Mr. Carter’s risk to the safety of the public.
The Board has found that Mr. Carter being subject to a detention order would mitigate the risk of non-compliance with treatment and associated decompensation and the resulting risk to the safety of the public. Mr. Carter continues to experience symptoms of his psychotic illness and continues to express and intention to use substances. The hospital requires the ability to readmit Mr. Carter quickly if this becomes necessary. The Board accepts Dr. Jones’ expert opinion that the provisions of the Mental Health Act would not be sufficient.
In addition, the hospital requires the ability to approve Mr. Carter’s accommodation in the community. Although Mr. Carter is to be commended for having found housing, a detention order would enable the hospital to ensure that such housing is stable, appropriate and successful.
In conclusion, the panel wishes to congratulate Mr. Carter on the progress he has made in the last several months and we a re hopeful that he will continue to make progress in the coming year.
DATED this 18th day of September, 2025, at the City of Toronto, in the Region of Toronto.
Ms. J. Ferguson Legal Member
Office of the Registrar Ontario Review Board