Ontario Review Board
Re: Alexander G. Coaker
ORB File No: 7414
Hearing held on: Monday, January 12, 2026
Place of Hearing: Brockville Mental Health Centre
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Mr. P Capelle
Members: Dr. Y. Alatishe Dr. P. Wright Mr. K. McKenna Ms. R. MacIntyre
Parties Appearing:
Accused: Alexander G. Coaker Counsel: Ms. M. Munsterman
The person in charge of hospital: Representative: Dr. A. Adiele
Attorney General of Ontario: Counsel: Ms. J. Masse
REASONS FOR DISPOSITION
(Dated February 25, 2026)
On August 31, 2018, Alexander Coaker was found not criminally responsible on account of mental disorder on a charge of assault causing bodily harm, contrary to the Criminal Code of Canada (“the Criminal Code”). Mr. Coaker is currently subject to a Disposition of the Ontario Review Board dated February 4th, 2025, detaining him within the Forensic Program of the Brockville Mental Health Centre (“BMHC”) with privileges up to and including to live in the community in supervised accommodation approved by the person in charge.
On January 12, 2026, a panel of the Ontario Review Board (“the ORB” or “the Board”) convened a hearing at the BMHC pursuant to s. 672.81(1) of the Criminal Code. The annual review for Mr. Coaker was held in person. The hospital was represented by Dr. A. Adiele, the Attorney General by Ms. J. Masse and Mr. Coaker by counsel, Ms. M. Munsterman.
Without Prejudice Position of the Parties
At the outset of the hearing, the Board was advised that the Hospital was recommending a continuation of the current disposition as indicated at page 100 of the Hospital Report, absent any changes.
Counsel for the Attorney General and Patient’s Counsel both indicated their agreement with that recommendation and the hearing proceeded on the basis of a joint position.
After considering the evidence and deliberating, the Board accepted the joint recommendation of the parties that Mr. Coaker continues to represent a significant risk to the safety of the public and determined that the necessary and appropriate disposition in the circumstances is a renewal of his detention order, without any change.
Index Offences
- The circumstances giving rise to the charges on the index offences can be summarized as follows:
“On Wednesday, August 1, 2018, the accused and the victim got into an altercation for unknown reasons. At some point, the accused punched the victim causing a laceration to the left side of his head. The police officer was on a general patrol in a marked police cruiser in the City of Ottawa. At 2159, he was dispatched to a call for service regarding a disturbance at the Presland Residence, that there had been a fight between the victim, Mr. So and the assailant, Mr. Coaker. When the police officers arrived, he noticed the victim, Mr. So, was seated on the front steps. Mr. So stood up and walked toward him. His forehead was covered in blood with a laceration that appeared to be on the top left portion of his head. Mr. So advised “Alex and I got into a fight. He kicked the shit out of me”. As Mr. So spoke to me, he pointed back towards the step where Mr. Coaker was walking towards the officer with a cigarette in his mouth. When questioned by the police, the accused stated “I didn’t do anything wrong. We just got into a tussle”. When asked how the victim sustained his injuries, the accused responded “I punched him”. Paramedics provided first aid to Mr. So and advised the police officers that Mr. So had sustained a 2-inch laceration on the top left portion of his head. They also advised that the laceration was deep enough that fatty tissues were visible and Mr. So would need sutures. The victim was taken to the General Hospital to receive sutures. There were no witnesses or no video of the incident. The accused was arrested by the Ottawa Police and charged with assault causing bodily harm. He was held for a show cause hearing and recommended for mental health court.”
Current Psychiatric Diagnoses
Schizoaffective Disorder, Bipolar Type
Amphetamine-type substance use disorder
Cocaine use disorder
Other or unspecified stimulant use disorder
Evidence at the Hearing
As a result of the joint position the oral evidence focused on the events of the past clinical year and risk management issues relevant to a necessary and appropriate Disposition.
The Board admitted into evidence the Hospital Report dated December 17th, 2026, as Exhibit No. 1. That document provides a great deal of information concerning Mr. Coaker’s personal history, mental health history as well as his course in hospital and in the community both prior to and subsequent to the index offences. As the Hospital Report was made an Exhibit, it’s unnecessary to reproduce the information contained therein in these Reasons.
In addition to the documentary evidence the Board heard from Dr. Anthony Adiele. Dr. Adiele advised that there were no updates to the December 17th, 2025, Hospital Report and invited questions.
Ms. Masse inquired vis-à-vis the intention to discharge Mr. Coaker to the FITT House. Dr. Adiele responded that the referral has been made, and it is realistic that Mr. Coaker may be discharged there within the next 12 months. Mr. Coaker currently requires 24-hour supervised accommodation. Davidson House is therefore also an option in the Brockville area. A discharge plan is ready to be initiated for either placement which typically begin with a 30-day temporary discharge. It was noted that a kitchen assessment has been completed and there are no concerns in that regard.
Reference was made to page 16 of last year’s Reasons for Disposition. Dr. Adiele noted that Mr. Coaker has not yet been seen by the hospital’s psychologist due to that professional’s heavy workload. Mr. Coaker has also been referred to an addictions’ counsellor.
In responding to questions from Ms. Munsterman, Dr. Adiele confirmed that Mr. Coaker’s parents remain an excellent community support for their son; both are approved persons. Mr. Coaker has enjoyed visits to his parents’ Ottawa home which have gone well. He has shown himself able to go back and forth from hospital to the Brockville train station without issue.
Mr. Coaker remains treatment incapable as well as financially incapable. Currently, for treatment, it remains the PG&T as substitute decision-maker, with no current plans to change. There are no issues with medication compliance. His parents have requested to be his substitute decision-makers for finances.
Mr. Coaker’s current Clinical Risk Factors, described at pages 97-98 of the Hospital Report have improved. He is not currently endorsing grandiose residual beliefs as frequently/fervently as in the past. His engagement in vocational activities continues to improve as does his hygiene. Mr. Coaker gets on well with co-patients on the unit. He currently has the highest level of privileges which include overnight visits home.
Dr. Adiele was asked by a panel member if past aggression towards Mr. Coaker’s parents may impact on them being his SDM for finances. Dr. Adiele responded that this will be monitored adding that Mr. Coaker’s father advised him during the Christmas break that his son was not fixated on having extra money as has been the case in the past.
Dr. Adiele was questioned vis-à-vis Mr. Coaker’s attempted discharge in 2023 which, due to substance use, was short lived. Dr. Adiele responded that this was prior to Mr. Coaker’s admission to the BMHC. Dr. Adiele advised that Mr. Coaker has not had a positive urine screen since his admission to the BMHC. Further, Mr. Coaker has made it clear that he is no longer interested in street drugs.
No significant changes have been noted subsequent to the reduction of Mr. Coaker’s clozapine levels, titrated down from a high of 1400mgs.
Dr. Adiele was questioned with regard to an aggressive incident in March of 2025 referenced at page 86 of the Hospital Report. Dr. Adiele responded that this incident featured some verbal escalation but did not involve a physical element.
Ms. Munsterman inquired if the rationale for Mr. Coaker’s parents becoming his SDM for finances would be so that funds could be released faster as required. Dr. Adiele agreed.
Closing Observations
- Both Dr. Adiele and Ms. Masse indicated they had nothing to add. Ms. Munsterman submitted that she was in favour of the hospital’s approach whereby the transition to a 24-hour supervised accommodation would be accompanied by a 30-day transition period so that a bed could be kept for him in hospital as required.
Analysis and Decision
(a) Significant Threat
Ongoing significant threat to the safety of the public cannot be speculative. It must entail a real risk of serious physical or psychological harm arising from conduct that is both serious and criminal in nature.
In determining whether Alexander Coaker continues to represent a significant threat to the safety of the public the Board carefully analyzed the evidence as it relates to the Supreme Court of Canada decision in Winko, 1999 CanLII 694 (SCC), [1999] 2 S.C.R. 625.
The Board unanimously finds that Alexander Coaker continues to pose a significant threat to the safety of the public. In arriving at this determination, the Board considered the joint position of the parties and accepted the uncontroverted evidence of Dr. Adiele that Mr. Coaker continues to pose a significant threat. The Board also relies on the Hospital Report and the contents of the Violence Risk Scenario and Summary Opinion contained therein at page 99. The following excerpts merit reproduction:
Alexander’s primary violence scenario involves verbal aggression or physical assault, possibly with a weapon of opportunity, driven by acute persecutory delusions that would emerge in the context of stimulant drug use or extended medication non-adherence.
Potential victims include family members who have historically been targets of his delusional accusations, peers in residential settings where proximity and shared resources create friction, and staff who impose limits or consequences he experiences as unjust given his grandiose self-image.
Mr. Coaker suffers from a major mental illness, previously complicated by amphetamine-type substance use disorder and cocaine use disorder. The Board therefore accepts that absent an ORB Disposition, Alexander Coaker would likely become non-compliant with prescribed medications. This would lead to decompensation, the use of substances and the re-emergence of behaviours similar to those seen at the time of the index offences. We are satisfied that absent an ORB Disposition, it is likely that Alexander Coaker will again cause serious physical or psychological harm to members of the public and such conduct will likely be criminal in nature.
(b) Disposition
Flowing from the Board’s finding that Alexander Coaker continues to pose a significant threat to the safety of the public it must shape a Disposition for the year ahead. Its paramount consideration in doing so must be the safety of the public while also considering Mr. Coaker’s needs pursuant to s. 672.54 of the Criminal Code.
The necessary and appropriate disposition for Mr. Coaker provides him as much freedom as possible without subjecting the community to a real risk of dangerous behaviour.
In considering Mr. Coaker’s needs, the Board was attentive to improvements identified over the reporting year. These include:
a reduction in the frequency and intensity of grandiose residual beliefs;
improved engagement in vocational activities;
improved hygiene;
successful overnight visits to his parents’ Ottawa home.
- The above noted improvements must nevertheless be weighed against ongoing clinical risk factors identified at page 96 of the Hospital Report and reproduced below:
The persistence of major mental disorder symptoms remains concerning. While he no longer experiences command auditory hallucinations and reports no active hallucinations currently, his grandiose delusional system remains intact and occasionally drives behavior. Recent incidents include banging on a bus window and claiming "Trump told me" to do so, making inappropriate sexual comments to female staff while discussing space travel, and expressing anger about financial limitations while describing himself as royalty.
As a result, the current terms and conditions of Mr. Coaker’s existing disposition continues to allow sufficient latitude for him to progress in his rehabilitation and community re-integration while managing the risk he poses to the community.
The Board wishes Mr. Coaker success in his upcoming transition to the community, whether that is to the FITT House or to Davidson House. In the interim, it is expected that he will be provided with the opportunity to engage with the hospital psychologist and with an addictions counsellor.
Conclusion
Therefore, the Board unanimously determines that the necessary and appropriate Disposition required to manage the threat Mr. Coaker poses to the safety of the public while still meeting his needs remains a Detention Disposition with privileges as set out at page 100 of the Hospital Report.
In making this Disposition, the Board carefully considered the positions and submissions of the parties and the evidence of Dr. Adiele and is satisfied that this determination is both necessary and appropriate. The Board reviewed the provisions of s. 672.54 of the Criminal Code and carefully considered the need to protect the public from dangerous persons, Mr. Coaker’s mental condition, his reintegration into society and other needs.
DATED this 25th day of February, 2026, at the City of Toronto, in the Toronto Region.
Mr. P. Capelle Alternate Chairperson
Office of the Registrar
Ontario Review Board