Re: David Charbonneau
ORB File No: 8359
Hearing held on: Wednesday, March 25, 2026
Place of hearing: Waypoint Centre for Mental Health Centre
Pursuant to: Section 672.81(2.1) of the Criminal Code
Before:
Alternate Chairperson: Mr. P. Hageraats
Members: Dr. R. Sheppard Dr. J.C. Rose Ms. J. Fuller Mr. A. Mete
Parties Appearing:
Accused: David Charbonneau Counsel: Ms. M. Perez
Person in charge of Hospital: Representative Ms. J. Lefebvre
Attorney General of Ontario: Counsel: Ms. Y. Curry
REASONS FOR DECISION
(Dated April 13, 2026)
Note to Reader: For more complete background information, please refer to recent Reasons for Disposition, dated December 22, 2025
Introduction:
On July 26, 2023, Mr. David Charbonneau was tried in court under the Criminal Code of Canada on charges of assault and assault causing bodily harm. At the trial, expert psychiatric established that his mental condition was seriously affected by a psychiatric disorder when he committed the offences.
Based on that evidence, the court determined that he was Not Criminally Responsible on Account of Mental Disorder (“NCR”).
Mr. Charbonneau is currently subject to a Disposition of the Ontario Review Board (“ORB” or the “Board”), dated December 8, 2025, detaining him at the High Secure Provincial Forensic Programs of the Waypoint Centre for Mental Health Centre (“Waypoint” or “the hospital”).
By letter dated January 22, 2026, and pursuant to s. 672.56(2) of the Criminal Code, Waypoint notified the Board that Mr. Charbonneau’s liberty had been restricted as follows: On January 14, 2026, Mr. Charbonneau was placed into seclusion for more than seven days.
On March 25, 2026, the Board convened a hearing at Waypoint to review the restriction of liberty, pursuant to s. 672.81(2.1) of the Criminal Code.
Mr. Charbonneau attended the hearing in person. He was accompanied by hospital staff. Throughout the two-hour hearing, Mr. Charbonneau wore ‘Pinel Restraints’ applied to his wrists and waist - but no longer to the ankles. He was represented by counsel, Ms. Mercedes Perez.
Mr. Charbonneau’s mother and father attended by videoconference from their home in Ottawa.
A Hospital Report, dated October 8, 2025, was received in evidence along with a Restriction of Liberty Hearing Report, dated March 9, 2026.
The issues at this hearing are whether the hospital’s decision to increase the restriction on Mr. Charbonneau’s liberty was warranted, necessary and appropriate at the time of its onset and whether it continues to be so.
Positions of the Parties:
Counsel for both Waypoint and the Attorney-General were of the view that the decision to place Mr. Charbonneau in seclusion on January 14, 2026, was necessary and appropriate; it represented the least onerous, and least restrictive, measure at the time it was imposed, and continues to be warranted and necessary.
Counsel for Mr. Charbonneau took no position about the restriction of liberty and instead preferred to hear the evidence. At the conclusion of the hearing, Ms. Perez advised that her client had instructed her to take no position about his seclusion or whether it was still needed.
For the reasons outlined below, the Board found that the restriction of Mr. Charbonneau’s liberty, by placing him into seclusion on January 14, 2026, was significant. The Board also determined that it was necessary and appropriate at the time, representing the least onerous, least restrictive, measure. The Board further found that it continued to be necessary as of the date of the hearing.
Current Psychiatric Diagnoses:
Schizoaffective Disorder, Bipolar type
Attention-deficit/hyperactivity disorder, predominantly inattentive presentation
Mr. Charbonneau’s condition has been treated with prescribed long-acting injectable psychiatric medication, Paliperidone Palmitate, 150mg IM Q21D, which he has not accepted.
Mr. Charbonneau will at times accept oral PRN (as needed) medications.
Capacity to Consent to Treatment:
At the time of the hearing, Mr. Charbonneau had been declared incapable of consenting to treatment. His father has taken on the role of substitute decision maker (“SDM”).
On March 3, 2026, Mr. Charbonneau sought a review of the incapacity finding. A review hearing before the Consent and Capacity Board (“CCB”) was scheduled for later in the afternoon of the present hearing date, March 25, 2026.
Course at Waypoint:
- Mr. Charbonneau was admitted to Waypoint on November 21, 2024, on a transfer order from the Royal Ottawa Mental Health Centre. Mr. Charbonneau’s first year at Waypoint was marked by instability. He remained psychotically unwell, presenting with auditory hallucinations, paranoia, thought insertions, ideas of reference and disorganized thinking and behaviour. His risk of violence was assessed as flowing directly from his psychosis. Mr. Charbonneau’s insight into his condition was underdeveloped as he did not appear to appreciate the severity of his mental health challenges or the necessity for treatment and the consequences of a lack of treatment.
The following passage appears in Exhibit 1, the hospital report dated October 8, 2025 - p. 40:
While Mr. Charbonneau has many protective factors, he is again in seclusion after assaulting staff. Mr. Charbonneau has not remained stable for long enough to manage outside of seclusion for more than two months at a time in the last year. He remains psychotically unwell and as his violence directly flows from psychosis, his violence risk remains significant until his psychosis is better and consistently treated. Major barriers to progression are his lack of insight and guardedness around symptom disclosure. It is hoped that both can be improved over the coming year. My focus for the coming year is to obtain adequate symptom control over a prolonged period while ensuring the safety of Mr. Charbonneau and others.
The use of seclusion and highly trained staff remains an important part of Mr. Charbonneau’s treatment plan. Less secure facilities are not equipped to manage his violence, at least in a less onerous and restrictive manner. Indeed, Mr. Charbonneau was transferred to Waypoint a year ago for exactly that reason. He continues to be violent. Thus, it is my view that ongoing detention at Waypoint is required for Mr. Charbonneau. Prognostically, I am hopeful that Mr. Charbonneau’s symptoms can and will be more effectively managed this year. There are many unexplored treatment options. I am hopeful that Mr. Charbonneau will be able to move on from Waypoint beyond the coming year.
The present ongoing restriction of liberty is Mr. Charbonneau’s fourth period of seclusion at Waypoint. The chronology is as follows:
November 24, 2024, to May 22, 2025: 180 days seclusion.
Followed by non-seclusion of 58 days.
July 19 to September 11, 2025: 55 days seclusion.
Followed by non-seclusion of 15 days.
September 26 to November 15, 2025: 51 days seclusion.
Followed by non-seclusion of 59 days.
January 14 to present, March 25, 2026: 71 days seclusion, and continuing.
At the last annual review in November 2025, the Board recognized Mr. Charbonneau’s positive qualities. See recent Reasons, at para. 21:
Notably, despite the heavy psychotic burden that Mr. Charbonneau struggles with, he is described by staff and patients alike as a well liked affable, funny person and is often invited to join activities by co-patients. Mr. Charbonneau is highly intelligent. He has a very supportive family, and his parents who live in Ottawa, visit with him by zoom weekly and have visited 26 times in-person during the year in review. These are protective factors which speak well of Mr. Charbonneau and will stand him in good stead going forward.
In late 2025, the Board further noted that Mr. Charbonneau seemed to be showing some improvement. He was demonstrating more transparency and willingness to take medication. The hospital’s focus was on treating his psychosis with a goal to transfer him back to Ottawa in the following year, assuming that he would be optimally treated.
The Deprivation of Liberty imposed on January 14, 2026
When not in seclusion, Mr. Charbonneau has access to amenities on the hospital unit. He can attend lounge areas, corridors, the dining room, and courtyard and can socialize with other patients, should he choose. When accompanied by staff, he can attend off the unit to access the recreation area and canteen at such times as he is assessed as safe to do so.
As listed above, there were three periods of extended seclusion in 2025. The circumstances and justification for each are documented in the Board’s Reasons, dated December 22, 2025, and in last year’s hospital report, dated October 8, 2025.
In the section of last year’s report dealing with Violence Risk Assessment, Mr. Charbonneau was described as unable to provide much reasoning following his attempts to assault staff. He had difficulty contracting for safety when offered seclusion relief. He tended to ask exit-seeking questions. He would ‘size-up’ staff who were providing seclusion relief as to their training in fighting. This is notable, as he has been described as a trained fighter with a background in high level fitness and various forms of mixed martial arts.
In terms of actual physical conduct seen in 2025, Mr. Charbonneau had a pattern of threatening staff, indicating he would fight them if they administered medication, as well as voicing threats to harm them. At times during seclusion relief periods, he would physically demonstrate his intent to be violent. When staff attempted to secure restraints prior to his coming out of the room for relief, Mr. Charbonneau would become stiff and rigid. He pushed at the staff and grabbed at them through the six-inch gap in the door. He has stomped on staff members’ feet. While walking, he tried to leg sweep a staff member. All these behaviours led to unsuccessful periods of relief from seclusion.
As noted above, from mid-November 2025 to January 14, 2026, Mr. Charbonneau succeeded on the unit without needing seclusion.
On January 13, 2026, Mr. Charbonneau was due to receive his long-acting injectable medication. For several days earlier, he voiced that he would not accept treatment. Attempts by staff to provide health teaching and encouragement were to no avail.
On January 14, 2026, Mr. Charbonneau was in his room voicing intent to physically resist treatment. He stayed at his door and was vigilant in case staff entered to administer the medication. Six staff members wearing protective equipment went in to do so. They had to use ‘‘CPI restraint techniques’’ while he resisted.
In the following hours and days, with a seclusion order obtained from the duty doctor, Mr. Charbonneau was monitored. The seclusion order was reviewed daily. Mr. Charbonneau was also seen by an independent psychiatrist for review and assessment at the 72-hour mark, at seven days post-seclusion and then again, at every subsequent 28 days. At each interval, the opinions provided were that Mr. Charbonneau’s safety risk still required ongoing seclusion.
With near daily assessments, seclusion relief was attempted. However, Mr. Charbonneau’s participation varied. Hospital staff faced some serious challenges. Mr. Charbonneau displayed intermittent agitation, ongoing impulsivity, and aggression. His responses over multiple days are well described in Exhibit 2, the Restriction of Liberty Hearing Report.
Mr. Charbonneau would at times cooperate with having Pinel restraints applied to facilitate his leaving the seclusion room for desired activities, such as going for a shower or socializing. At other times, Mr. Charbonneau forcibly resisted and was actively aggressive. In addition to pushing and lunging at staff, he once tried to leg-lock a member. On more than one occasion, he spat at staff, including on March 6, 2026, when he spat into a staff member’s eye.
When later asked to explain his behaviours, Mr. Charbonneau would mostly reply that he did not know. However, once, on January 22, 2026, the following was recorded:
That evening when being provided with dinner, staff inquired as to why he engaged in the behaviour. He was noted to smile brightly and stated, "It’s fun, I like doing it."
Evidence at the Hearing:
The Board also received direct testimony from Dr. A. Bunker, Mr. Charbonneau’s attending psychiatrist. She is a co-author of the Hospital Report and the Restriction of Liberty Hearing Report. Dr. Bunker confirmed the contents of both documents.
Dr. Bunker testified in chief as follows:
a) Mr. Charbonneau’s behaviours have continued. He is not yet ready to leave seclusion. However, he had several successful relief periods starting on March 11 and 12, 2026. On March 16, Mr. Charbonneau began coming out of seclusion daily, which has continued to the present.
b) The hospital is implementing a de-restraint process. On March 24, Mr. Charbonneau began walking without ankle restraints. Before that, his parents visited him in person on March 16, 17, 18 and 19, 2026.
c) The treatment team is looking at removal of the restraint to his non-dominant hand on March 26, assuming today’s seclusion relief is successful. Following three successful days with the non-dominant hand out of restraint, they plan to remove all restraints.
d) Mr. Charbonneau is provided with daily newspapers. He has access to an MP3 audio device and has had several Zoom calls with friends, family, and extended family. When it is not possible to let Mr. Charbonneau out of the seclusion room, staff set up a TV screen which he can watch.
e) PRN (as needed) oral medications are provided, but Mr. Charbonneau refuses to take them. He did ask for Lorazepam in early March. Since January 14, 2026, he had just the one incident requiring an emergent dose of injectable medication. This was on February 16, when he was quite agitated in the shower.
f) The unit’s behavioural analyst is attempting to understand Mr. Charbonneau’s aggressive behaviour. The treatment team members have collaborated and developed a Crisis Prevention Plan. This is a stepwise patient-focused process. Different strategies were described by Dr. Bunker. More recently, Mr. Charbonneau was able to go out to the canteen where several other patients were present. This went without incident.
g) Since March 9, 2026, there have been no acts of violence to staff or co-patients. Mr. Charbonneau’s history of involvement in mixed martial arts and jiu-jitsu is relevant in that he has skills which other patients do not have, including the ability to ‘leg-sweep,’ hence the need for ankle restraints.
h) Presently, it is difficult for the team to completely discontinue all restraints: it takes several days for the team to become confident that Mr. Charbonneau will not be violent toward others. Given a history of extreme assaults, a measured approach is needed.
i) Mr. Charbonneau currently receives long-acting injectable Paliperidone. He has stated that if his capacity to consent to treatment is restored to him, he will refuse all medication. This would then leave Mr. Charbonneau’s illness untreated.
j) Psychiatric medication is a highly protective factor. Before his illness, Mr. Charbonneau had no history of violence. His aggression flows from the illness. According to Dr. Bunker, there is abundant evidence that, without medication, his violence risk would be much higher. It is highly likely that seclusion would then be needed again.
Counsel for the Attorney-General, Ms. Curry, had no questions for Dr. Bunker.
Dr. Bunker responded to questions from Ms. Perez, counsel for Mr. Charbonneau:
a) When not in seclusion in the summer of 2025, from May 22 to July 19, he did quite well. Prescribed to receive a dose level of 100mg Paliperidone, he did the best he’s done at Waypoint. He was able to access individual off unit passes for up to four hours, while participating in activities like yoga, laps in the pool, socializing and board games.
b) Mr. Charbonneau was not assaultive in the lead-up to January 14. However, he was decompensating in the days approaching his medication due date. On January 14, with the dose past due, when six staff wearing protective gear - not ‘riot gear’ - entered his room to administer the injection, he punched a staff member.
c) Mr. Charbonneau’s condition is exacerbated by stress. Dr. Bunker has suggested he be involved in recreational programming and that he pursue CBT for psychosis.
d) While in seclusion, he is not placed in his usual room. Additional monitoring is needed, given a significant history of suicide ideation and attempts. There is also some history of his having weapons, including in his room.
e) Regarding mood stabilizing medication, Dr. Bunker has repeatedly spoken to him about this. Only available in oral form, she has prescribed it, but he refuses to take any.
f) There is hope Mr. Charbonneau will get out of seclusion soon. A distinction must be made between use of restraints as opposed to seclusion. Restraints appear to be an issue for Mr. Charbonneau as he can become agitated when they are about to be applied. The team is in a ‘Catch-22’ trying to assess alternatives. Strategies attempted earlier did not work when they tried to have him leave the seclusion room without a struggle.
g) When he received his most recent dose of injectable medication on March 18, 2026, no restraints were needed.
h) Mr. Charbonneau has at times told staff that he can’t control his impulsivity, which he attributes to ADHD. Dr. Bunker finds this very difficult to assess. He refuses oral medication and declines CBT. The team is trying different things, but Mr. Charbonneau is unwilling to share his thoughts.
i) The behavioural analyst has been involved since November. At debriefing sessions with the analyst, he does not seem to learn very much and does not share information. Aggression and spitting continued thereafter.
j) Dr. Bunker agrees with the goal expressed at the last ORB hearing, namely, to establish trust. This is difficult to do with seclusion. However, the hospital’s priority must be the safety of others. Fortunately, Mr. Charbonneau is now able to shower without restraints and has been using these occasions appropriately.
k) Mr. Charbonneau has told Dr. Bunker that he knows he will be violent if he is without medication and that this does not bother him.
l) Counsel asked Dr. Bunker if seclusion is traumatic for Mr. Charbonneau. Dr. Bunker replied that ‘he does not give me very much’ for her to really know.
- In response to questions from panel members, Dr. Bunker testified:
a) On February 4 and 25, 2026, Mr. Charbonneau put up a fight while receiving his injections. On the following medication due date, in mid-March, he made it clear he did not want it, but grudgingly accepted.
b) Asked about the recent behavioural improvement, Dr. Bunker stated there is a clear temporal link to the parents’ visiting him here in early March. She also felt it has to do with an increase in the medication dosage.
c) Mr. Charbonneau told Dr. Bunker the other day that medication has improved his mental health and his liberty. However, he added that, if given the choice, he would refuse medication. When she asked him to reconcile this contradiction, he could not.
d) Breakthrough symptoms, leading up to January 14, 2026, included blocked thoughts, increasing preoccupation, vacant staring, and signs of auditory hallucinations. Mr. Charbonneau had also told Dr. Bunker about a military conspiracy in which his parents were involved.
e) Without being able to predict or promise just when seclusion would no longer be needed, it is possible this could happen within the next thirty days.
f) As the patient slowly progresses out of seclusion, a step-down seclusion suite can be used, including having the patient secluded in their own familiar room.
The parties presented no other evidence.
The Board invited Mr. Charbonneau’s parents to offer any information or observations which they might care to share.
Mr. Charbonneau’s mother spoke on her and her husband’s behalf. She advised that they have much faith in the hospital staff who are very kind. She added, they also have much faith in Dr. Bunker.
Submissions of the Parties:
On behalf of hospital, Ms. Lefebvre advised that the restriction of liberty was imposed following Mr. Charbonneau’s decompensation on the same day he had assaulted staff. He continued to lunge and spit at them all the way up to March 5. He still resists their directions. On each occasion when allowed out of the seclusion room, he has been restrained. The situation has now improved to the point that ankle restraints have been removed. Restraints to the non-dominant hand are about to come off.
Counsel for the hospital further submitted that no current alternative is available to deal with the patient’s behaviour. Chemical restraint has not been used since February 16, 2026. Progress is happening with Mr. Charbonneau receiving support from his family and from his otherwise positive relationship with hospital staff.
On behalf of the Attorney-General, Ms. Curry agreed with the hospital’s submissions.
Speaking for Mr. Charbonneau, Ms. Perez advised that he had instructed her to take no position on the initial restriction of liberty. Ms. Perez further stated, they wished to take no position as to whether the ongoing restriction of liberty is needed.
Ms. Perez noted that what led to the restriction of liberty was staff reporting that Mr. Charbonneau did not want to receive his injection, which in turn led to his resisting and aggression.
Counsel questioned whether the use of restraints on its own represented a restriction of liberty in the sense that her client’s liberty norm was negated by being forced to leave the room only in restraints and, at times, while bound to a wheelchair.
Ms. Perez concluded her submission, expressing hope that Mr. Charbonneau will return to the regular ward and to his own room within the next thirty days.
Observations and Conclusions:
Pursuant to the decision of the Ontario Court of Appeal in R v MLC (2010 ONCA 843), as well as in Regina v Campbell (2018 ONCA 141), the Board finds that a serious restriction of liberty has occurred. When Mr. Charbonneau was required to enter clinical seclusion, he lost the ability to live in his room or to circulate normally within the hospital setting. With seclusion of this duration, it is difficult to imagine a more onerous and restrictive deprivation of one’s liberty.
The Board accepts the hospital evidence that Mr. Charbonneau assaulted staff and continued to do so in the manner and on the occasions described. His counsel correctly points out that seclusion began when Mr. Charbonneau first became physically violent at the time he was being administered prescribed injectable medication.
Starting on January 14, 2026, and thereafter, the hospital was dealing with a difficult intractable problem. Mr. Charbonneau was medically in need of medication. His violence to staff was driven by his psychosis involving some kind of persecutory delusional belief system.
While Mr. Charbonneau is not anti-social, the same repeated violence had been happening for too many years in a variety of mental health facilities. The degree of violence exhibited was extreme, to the point that staff members, and potentially other patients as well, have been, and are being, exposed to an unacceptably high risk of serious physical harm and even psychological harm.
The hospital is making serious efforts to have Mr. Charbonneau progress out of seclusion. It is encouraging to see that, starting in March 2026, Mr. Charbonneau is now displaying less aggression, following the recent increase in medication dose level and successful visits from his parents.
However, as he moves forward to needing less physical restraint and shorter periods of seclusion, it is realistic to anticipate that he may repeat the cycle of refusing to accept injectable medication.
Mr. Charbonneau’s capacity to consent to treatment is about to be reviewed. Depending on the result of the pending CCB hearing, his treatment with psychiatric medication may or may not continue. The evidence before us tends to show that, without treatment, Mr. Charbonneau’s violence will likely continue.
We agree with Ms. Perez about the unfortunate combination of circumstances that brought Mr. Charbonneau into seclusion. Once put into seclusion, as the evidence shows, it is hard to get him out in a safe manner. Mr. Charbonneau is highly reactive to the use of medication just as he is to the use of restraints. Unfortunately, for all concerned, including the patient himself, the hospital cannot take shortcuts when there is an ongoing risk to staff members. The likelihood of injury to staff and to Mr. Charbonneau is all-too real every time his delusional reactions escalate to violent conduct.
As stated earlier, Mr. Charbonneau does not have an anti-social personality. That said, the hospital is dealing with the further serious challenge that he tends not to communicate or share his thoughts.
Dr. Bunker describes Mr. Charbonneau as very intelligent. This may contribute to his sense of feeling alienated from the hospital staff and his treating physicians. Their task is made more difficult by his reluctance to share information or to consider their worthwhile suggestions regarding the benefits of counselling, including recreational and vocational counselling and CBT for psychosis. Before any such involvement can begin however, Mr. Charbonneau’s violence needs to end.
The Board shares the concern of all parties that both seclusion and the use of restraints have extended for such a long time. By enlisting the behavioural analyst, the hospital has come up with an individualized plan to provide relief and to have the patient move forward. It is encouraging that for the last ten days, Mr. Charbonneau has not shown much at all by way of negative behaviours. It is also encouraging to note that for the two hours when he attended the hearing, he did so calmly while restrained at the waist and wrists.
The Board is mandated to inquire whether the patient's liberty interest is being compromised by inappropriate or unnecessary treatment methods. The evidence does not suggest anything other than that the hospital treatment team members are doing their very best to manage the situation with the best interest of the patient in mind.
That said, the Board is concerned that Mr. Charbonneau is at risk of potentially becoming stuck in a repeating cycle of violence, leading to future restrictions and seclusions with restraints. Whether this is purely a behavioural issue, a mental processing issue or due to a combination of factors, the longer this cycle of violence/seclusion/restraints/de-restraining continues, the more entrenched this cycle will become for Mr. Charbonneau and hospital staff.
It is documented that Mr. Charbonneau has a breadth and depth of protective factors. These are listed in last year’s hospital report dated October 8, 2025 (Exhibit 1). Quoting from page 41, with emphasis added:
He does not seem to suffer from a personality disorder and there is no compelling history of pre-morbid violent attitudes. He has no criminal record. He does not suffer from a significant substance use disorder. Mr. Charbonneau is a highly intelligent individual with a history of secure attachment, positive coping, and a history of a high degree of discipline and self-control. This is with the caveat that he does seem to suffer from legitimate and likely severe attention deficit hyperactivity disorder; I suspect impulse control issues may, at least in part, relate to this diagnosis.
The Board appreciates that there are significant staff safety issues and that the hospital staff are working with a behavioural analyst to assist everyone in providing care and support for Mr. Charbonneau. However, if a clinical piece is missing, things are not going to improve. In this light, the hospital may wish to consider the need to further explore the extent to which Mr. Charbonneau’s impulse control issues could relate to a possible added diagnosis, whether it might be ‘severe attention deficit hyperactivity disorder,’ as was noted above in late 2025, or even a form of autism.
If so, this could mean that his mental processing speed needs to be considered when tailoring interventions. Information will need to be provided to him in smaller chunks and at a slower pace to make sure he has time to actually take in what he is being told.
The Board acknowledges that our limited role does not extend to issuing any specific directions about treatment. That said, these latter thoughts are offered for the hospital to consider, based on the documentation and evidence provided.
For the reasons and considerations and having regard to the primary need to keep the public safe, while balancing Mr. Charbonneau’s mental condition, his reintegration and other needs, the Board finds that the restriction of liberty as described was and remains necessary and appropriate. It was and remains warranted and represented the least onerous measure that the hospital could adopt in all the circumstances.
We thank the parties and counsel for their assistance.
DATED this 13th day of April 2026, at the City of Toronto, in the Region of Toronto.
Mr. P. Hageraats Alternate Chairperson
__________________
Office of the Registrar Ontario Review Board