Ontario Review Board
Re: Jacqueline Davies
ORB File No: 4832
Hearing held on: Monday March 2, 2026
Place of Hearing: St. Joseph’s Healthcare Hamilton
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Mr. R. Bigelow
Members: Dr. K. Hand Dr. T. Stirpe Mr. K. McKenna Ms. M. McKinnon
Parties Appearing:
Accused: Jacqueline Davies Amicus: Ms. C. Francis
The Person in charge of Hospital: Counsel: Ms. L. Barney
Attorney General of Ontario: Counsel: Ms. A. Lepchuk
REASONS FOR DISPOSITION
(Dated March 27, 2026)
Introduction
On July 3, 2007, Ms. Davies was found not criminally responsible on account of mental disorder on charges of assault with a weapon and aggravated assault, all contrary to the Criminal Code. Ms. Davies’ is currently subject to a disposition of the Ontario Review Board (the Board) dated April 3, 2025 ordering her detention at the Forensic Psychiatry Program of St. Joseph’s Healthcare Hamilton (the Hospital or SJHH) with privileges up to and including residence in the community in accommodation approved by the person in charge.
On Monday, March 2, 2026, the Board convened a hearing to review Mr. Davies’ disposition pursuant to section 672.81(1) of the Criminal Code. Ms. Davies was present at the hearing and represented herself. Board appointed Amicus Ms. Francis, was also present virtually, attending by Zoom.
The issues to be determined at the hearing were whether Ms. Davies continued to represent a significant threat to the safety of the public as defined in section 672.5401 of the Criminal Code and, if so, what was the necessary and appropriate disposition that was also the least onerous and least restrictive, taking into account the factors set out in 672.54 of the Criminal Code.
Initial Positions of the Parties
At the commencement of the hearing the parties were requested to provide their initial without prejudice positions with respect to the issues before the Board. Counsel for the Hospital submitted that Ms. Davies continued to represent a significant threat to the safety of the public, that a therapeutic impasse has been reached and that the necessary and appropriate disposition would be a transfer to the Southwest Centre for Forensic Mental Health Care (the Southwest) on a detention order with the terms as set out at pages 136 and 137 of the Hospital Report. Pending her transfer, the necessary and appropriate disposition is a continuation of the current detention order on the terms as set out at those pages. The major changes in terms from the current disposition was the removal of the privilege of community living and the imposition of a prohibition from the use of cannabis.
Counsel for the Attorney General supported the Hospital’s position.
Amicus advised that Ms. Davies had informed her that she agreed to the reintroduction of the prohibition on use of cannabis, would like to have community living in her disposition but was not requesting it and that she was requesting passes into the community totaling 16 hours with 12 of those hours with an approved person and 4 of those hours indirectly supervised.
Evidence at the Hearing
- The evidence at the hearing consisted of the Hospital Report dated February 6, 2026, correspondence from SJHH to Southwest dated February 9, 2026 notifying of intent to seek transfer of Ms. Davies and response from the Southwest dated February 26, 2026, the oral evidence of Dr. Duboff, Ms. Davies’ most responsible physician, and the oral evidence of Ms. Davies.
Findings:
For the Reasons that follow, the Board finds that Ms. Davies continues to represent a significant threat to the safety of the public, and that the necessary and appropriate disposition is a continuation of the current detention order with the changes in the terms and conditions as recommended by the Hospital.
The Board also finds that a treatment impasse has been reached and that an independent assessment of Ms. Davies’ diagnosis and treatment consideration of whether another hospital may be better able to assist in her treatment is indicated. The Board found that a transfer to Southwest is not supported by the evidence at this time.
Index Offences:
- The following is a synopsis of the index offences which occurred on February 16, 2007, taken from last years Reasons for disposition:
On February 16, 2007, at approximately 2130 hrs the accused had been standing alone in the front lobby at 85 1st Avenue holding a folding tree saw. Eleven year (11) old [N.P.] and [J.P.] walked past the accused on their way out to the parking lot through a rear door. The accused approached [N.P.] from behind and without provocation struck the girl in the back of the head with the blade of the saw. [N.P.]’s crying alerted her [J.P.] who then rushed to protect [N.P.] from further attack. [N.P.] sustained a superficial cut, measuring approximately six inches long, on the right side of her head, behind the ear, and cut with some swelling to her right thumb. [N.P.] attended the Welland County General Hospital Emergency for treatment of her injuries.
On Friday, February 16, 2007, at approximately 2130 hrs the victim, [J.P.], was walking in front of her daughter as they made their way out to the rear parking lot of the building when they passed the accused standing alone in the front lobby of their apartment. [J.P.] came to [N.P.]’s rescue after hearing her screams and seeing her being attacked with a tree saw by the accused. [J.P.] tackled the accused into a corner and yelled for [N.P.] to get away. The accused continued fighting and struck [J.P.]’s face with the saw. The accused was disarmed and fled on foot through the parking lot. [J.P.] attended the Welland County General Hospital with [N.P.] to have the large gash repaired and sore hand examined.
Background Information Regarding the Accused:
As of the date of the hearing, Ms. Davies was 38 years of age. She was born in the Port Colborne area and was initially raised by both of her biological parents. However, they separated when Ms. Davies was approximately 7 years old. Both her parents continued to be supportive of Ms. Davies although they were unable to have her reside with them due to her history of aggressive behaviour within the home.
Ms. Davies was reported as being an average student until grade 10 when things began to deteriorate rapidly. She became very argumentative, irritable, and stopped attending classes.
Substance Use History
- Ms. Davies began using substances once she was in grade 10 and has a long history of cannabis, cocaine, and alcohol use.
Legal History:
- Ms. Davies was charged with assaulting her grandmother when she was 17 but the charge was eventually withdrawn. It was noted that, at the time of that charge, she had been becoming increasingly aggressive towards family members.
Psychiatric History
Ms. Davies’ first admission to hospital with respect to mental health related issues was in September 2003 when her parents obtained a Form 2 under the Mental Health Act and she was brought to hospital for psychiatric assessment. She had become increasingly agitated, suspicious, paranoid, and difficult to manage at home and at school. She was admitted to hospital and t
ried ontreated with antipsychotic medication but was discharged from hospital before any improvement could be observed after her parents arranged for a bed at a residential treatment facility for drug rehabilitation counselling. Her discharge diagnoses were obsessive-compulsive disorder, rule out simple schizophrenia, substance abuse disorder, and oppositional defiant disorder.Ms. Davies entered the Portage Residential Treatment Program, a six month private treatment program for substance abuse and initially did well. However, staff at the program discontinued her antipsychotic medication and she quickly decompensated. She left the program after six weeks.
Subsequently she had numerous hospitalizations with respect to mental health related issues and extensive involvement with psychiatric professionals in the community due to aggressive behaviour with paranoid delusions.
Current Diagnosis
- Ms. Davies current diagnoses are:
Schizophrenia
Cannabis Use Disorder
Alcohol Use Disorder
Borderline Personality Disorder
Autism Spectrum Disorder
Course Subsequent to NCR Finding
On admission to hospital after the NCR finding, Ms. Davies was ordered detained on a minimum-security unit at the Hospital. She remained in Hospital until February 2012 when she was placed on a leave of absence and then discharged to her own apartment supported by the Good Shepherd Homes Program. In August 2013 Ms. Davies was readmitted to Hospital at her own request reporting that she was feeling overwhelmed. She remained in the Hospital until May 2015 when she was discharged to Mathias Place a supervised residential care facility. In October 2016 Ms. Davies was granted a conditional discharge with a term requiring her to reside at Mathias Place where she resided until July 2018 when she did not return to the residence for a curfew. She was finally found at a shelter in Toronto six days later largely as a result of efforts by her family to find her; she was returned to SJHH and admitted to the inpatient forensic unit on July 9, 2018.
Ms. Davies’ room at Mathias Place was searched after her failure to return and 19 bottles of liquor, drug paraphernalia with marijuana residue and some white powder residue were found. Upon readmission to Hospital Ms. Davies admitted to using alcohol and marijuana throughout the year as well as cocaine and hydromorphone.
Ms. Davies has continued to reside in the Hospital since her return from the AWOL.
Evidence of Dr. Duboff
- Dr. Duboff indicated that:
He had been Ms. Davies’ attending physician since September 2024. He had reviewed and adopted the contents of the Hospital Report. In terms of update he indicated there had been a medication adjustment, with Wellbutrin being discontinued.
The reporting year had been similar to previous years. Over the year there had been numerous incidents of property damage, verbal, and physical aggression as well as incidents of self-harm. Those incidents resulted in multiple seclusions.
However, recently she has begun working with the treatment team although her engagement varies from moment to moment. She frequently expresses her frustration with not progressing through the system despite her lengthy hospitalization. The unpredictable nature of her reactions has created ongoing tension on the unit and has contributed to heightened vigilance among staff. This combined with frequent verbal assaults and continual need to manage behavioural escalation has resulted in significant staff burnout.
The treatment team is recommending a transfer to Southwest as it is the most proximate to her community supports. The treatment team had considered requesting a transfer to Hummingbird Lodge, an all-female unit at North Bay Regional Health Centre, but Ms. Davies was strongly opposed and indicated she felt that an all female unit would have a negative impact on her stability.
Her behaviour over the reporting year has clearly established a direct link between the use of cannabis, decompensation of her mental state and aggressive behaviour. In particular he noted the incidents from September 2025 summarized in the Hospital Report at page 126.
Evidence of Ms. Davies
Ms. Davies stated that she wanted to move forward and that when she stopped using cannabis she would be able to move forward because it was causing all her problems. Her current goals were to get well and get a job. She believed that some of her anger related to her not receiving sufficient food.
Although she was ambivalent with respect to transferring to another hospital, she felt that it might be bad because she would have to adjust to a new group of co-patients. She also did not want to be transferred to an all female unit as she felt that she would be disruptive there because she did not get along with women with mental health issues.
Analysis and Conclusion, Significant Threat:
While the issue of significant threat was not contested at the hearing, the Board nevertheless makes an independent finding that Ms. Davies continues to represent a significant threat to the safety of the public. The Board notes that Ms. Davies was unrepresented at the hearing and that therefore, any concession she made must be carefully considered. However, the evidence clearly establishes that Ms. Davies continues to constitute a significant threat.
Ms. Davies suffers from a major mental illness, schizophrenia, as well as alcohol and cannabis use disorders, borderline personality disorder, and autism spectrum disorder. The Board accepts and relies on the statement in the Hospital Report that:
Ms. Davies’ risk for violent offending continues to be impacted by the nature of her psychotic illness, comorbid substance use disorder, cognitive deficits, and personality traits. Her mental state is fragile with rapid decompensation that further increases her risk of re-offending.
- The Hospital Report also notes that there has been an increase in aggressive outbursts over the reporting year:
During this reporting period, Ms. Davies exhibited 27 instances of mild verbal aggression (AIS 1 or 2), 17 instances of threatening behaviour (AIS 3), 10 instances of property destruction, and 3 instances of physical aggression. Several of these incidents arose from frustrations or conflicts with co-patients.1
The Hospital Report documents and Dr. Duboff reported that staff have observed that her mental state deteriorates further when she uses cannabis, that she has acknowledged this deterioration and has voiced intention to not use cannabis again but later is ambivalent about continued abstinence. This reporting year she has had multiple urine drug screens positive for cannabis.
- Absent the significant supervision provided by a Board disposition, there is little doubt that Ms. Davies would increase her use of substances and fall away from treatment increasing her risk to the safety of the community.
Necessary and Appropriate Disposition
Treatment Impasse and Transfer
Ms. Davies has been under the jurisdiction of the Board for almost 19 years. She was first discharged from the Hospital in 2012 but was readmitted to Hospital one and a half years later at her own request after she advised the treatment team that she was feeling overwhelmed. She was next discharged to community living at Mathias Place May 20, 2015. She achieved a conditional discharge disposition in October 2016. July 3, 2018 she did not return to her residence for curfew and was located in Toronto six days later. She was readmitted and has remained in hospital since July 9, 2018. She has been on a Detention Order since 2018.
The Hospital Report summarizes Ms. Davies’ progress since her readmittance to Hospital and the rationale for the recommendation for a transfer as follows:
Overall, Ms. Davies' treatment course reflects the chronic and complex nature of her difficulties, along with the considerable efforts made by multiple clinical teams over many years. Despite periods of engagement and some earlier progress, sustained improvement has been challenging to achieve, and her risk related behaviours continue to require intensive management. Recent years have shown limited gains despite comprehensive interventions and ongoing support.
At this stage, it appears that treatment has reached a therapeutic impasse. The unpredictable nature of her reactions has created ongoing tension on the unit and has contributed to heightened vigilance among staff. This environment, combined with frequent verbal assaults and the continual need to manage behavioural escalation, has resulted in significant staff burnout. Ms. Davies also appears to be experiencing burnout, reflected in her sense of stagnation, the limited therapeutic progress observed in recent years, and the cumulative impact of long-term institutionalization. Given the above, it is the undersigned's opinion that she may benefit from a transition to a new treatment environment and clinical team. A fresh setting, along with new perspectives and a reset of relational dynamics, may help interrupt entrenched patterns, support more adaptive clinical and behavioural functioning, and enhance her ability to use skills effectively
The Board agrees that a treatment impasse has been reached. Since Ms. Davies readmittance to hospital in 2018 there has been at best limited progress. Both Ms. Davies and the treatment team have reached a level of frustration which clearly is not conducive to progress.
The Supreme Court of Canada has stated with respect to treatment impasses and the responsibility of the Board where one has been reached as follows:
In fulfilling its statutory mandate and role under Part XX.1, it is necessary and essential for a Review Board to form its own independent opinion of an accused's treatment plan and clinical progress, and ultimately of the accused's risk to public safety and prospects for rehabilitation and reintegration. In so doing, a Board must be entitled to order a re-evaluation of current or past treatment approaches, and an exploration of alternatives where necessary -- i.e., where no progress has been made or is likely to be made. Such supervisory powers are an inherent part of a Board's mandate; if there is a treatment "impasse", then a Board's function could not be properly carried out unless it were able to impose conditions to deal with this lack of progress and to seek out more effective treatment opportunities. [page357] The role of a Board is to assess the risk to public safety posed by certain NCR accused persons, to provide opportunities for appropriate and effective medical treatment with a view to controlling and reducing that risk, to work towards the ultimate goal of rehabilitation and reintegration, and to safeguard the liberty interests of the accused in this process. These goals simply cannot be accomplished without accurate, independent, and up-to-date information on an accused's mental condition, treatment plan, clinical progress, and prospects for rehabilitation. This justifies a Board's power to supervise the medical treatment provided thus far, and to suggest or explore alternative approaches where necessary. Review Boards may therefore validly require hospital staff to re-examine a diagnosis or a treatment plan, and to consider alternatives which might be more effective or appropriate, -- thus requiring hospital authorities to justify their position regarding any "treatment impasse".2
All parties, including Ms. Davies, agree that there has been a lack of progress over the last 8 years and in order to fulfill its responsibility the Board is entitled to require a re-examination of the “diagnosis or treatment plan”. Therefore, the Board directs an independent assessment of Ms. Davies’ diagnoses and treatment plan including consideration of whether another hospital may be better able to meet her needs.
The Board has considered the recommendation of the Hospital for a transfer to the Southwest as well as the response from the Southwest. In response to the recommendation for transfer to the Southwest notes that:
Multiple treatment teams at Hamilton have clearly worked hard to provide Ms. Davies with the treatments and support available to help her move forward, but without a great deal success, despite several moves to different units with different treatment teams and attending psychiatrists. While a transfer to another medium secure facility will provide another fresh environment and another new team, the methods and tools (medication, programming, and supports) are the same. It is difficult to envision that there will be a different result at the Southwest Centre, especially given that there are fewer behavioural treatment resources here than are available at St. Joseph’s Hamilton and nothing new to offer in terms of treatment or programming. It seems only a matter of time before resources here are exhausted as well.
- The Board finds that based on the evidence currently before it that a transfer to the Southwest would not likely achieve significant progress for Ms. Davies given the limitedfewer behavioural treatment resources available there.
Cannabis Prohibition
- All parties, including Ms. Davies, supported the re-introduction of a cannabis prohibition. Dr. Dubroff gave evidence of a direct link between cannabis use and serious decompensation and aggression, and Ms. Davies stated that she would only progress when she ceased using cannabis. The Board accepts Dr. Duboff’s evidence and finds that a prohibition on the possession and use of cannabis is necessary and appropriate.
Removal of Community Living Privilege
- Due to the unfortunate lack of progress over the last number of years resulting in a treatment impasse, Ms. Davies is not suitable for discharge into the community and it is unlikely she will become suitable for discharge within the upcoming reporting year. As well given the treatment impasse and the significant possibility that the independent assessment may recommend a transfer to another hospital, where she would have to settle in and establish a relationship with a new treatment team, a discharge into the community is unlikely. The Board is hopeful that Ms. Davies will be able to work on realistic goals.
Ms. Davies` Request for Community Access
- Ms. Davies’ indicated through Amicus that she requested a total of 16 hours community access 12 hours accompanied and 4 hours indirectly supervised. The Board notes that her current disposition allows for accompanied community access and there has been no suggestion by any of the parties that it should be removed. However, the Board finds that at this time Ms. Davies’ risk currently requires intensive supervision and that indirectly supervised access to the community is not appropriate. Should there be a significant change in Ms. Davies stability, an early Board can be requested to consider indirectly supervised community access.
Summary
- The Board finds that:
Ms. Davies continues to represent a significant threat to the safety of the public.
The necessary and appropriate disposition is a detention order with the terms as recommended by the hospital including a prohibition from the possession and use of cannabis and the deletion of the privilege of community living. Indirectly supervised community access is not appropriate at the present time.
A treatment impasse has been reached and the Board orders an independent assessment of Ms. Davies’ diagnosis and treatment including consideration of whether another hospital would be better able to assist in her treatment.
A transfer to the Southwest is not appropriate based on the evidence currently before the Board.
- The Board encourages Ms. Davies to collaborate with the independent assessor in finding the best way for her to move forward.
Dated this 27th day of March 2026 at the City of Toronto, in the Toronto Region.
Robert Bigelow
Alternate Chairperson
Office of the Registrar
Ontario Review Board
Footnotes
- The summary of notable incidents in the Hospital Report takes up 9 pages (120-129)
- Mazzei v. British Columbia (Director of Adult Forensic Psychiatric Services) 2006 SCC 7, [2006] 1 SCR 326, para 42