Ontario Review Board
Re: Nathaniel Presta-Hislop
ORB File No: 7789
Hearing held on: Tuesday, April 7, 2026
Place of hearing: Ontario Shores Centre for Mental Health Sciences 700 Gordon Street, Whitby
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Mr. J. Weinstein Members: Dr. K. Hand Dr. M. Kalia Hon. A. Sosna Mr. J. Cyr
Parties Appearing:
Accused: Nathaniel Presta-Hislop Counsel: Ms. M. Perez
The person in charge of hospital: Counsel: Mr. L. Crowell
Attorney General of Ontario: Counsel: Ms. N. MacDonald
REASONS FOR DISPOSITION
(Dated April 30, 2026)
Introduction
[1]. On October 20, 2020, Mr. Nathaniel Presta-Hislop was found not criminally responsible on account of mental disorder, on a charge of aggravated assault, contrary to the Criminal Code of Canada (“Criminal Code”).
[2]. Mr. Presta-Hislop is subject to a Decision and Disposition of the Ontario Review Board (the “Board”), dated April 7, 2025, which ordered that he be detained at a General Unit of the Forensic Program of Ontario Shores Centre for Mental Health Sciences (“Ontario Shores”).
[3]. On April 7, 2026, the Board convened a hearing at Ontario Shores to conduct the annual review of the current Disposition.
[4]. Mr. Presta-Hislop was present at the hearing and was represented by his counsel, Ms. M. Perez.
[5]. A Hospital Report dated March 10, 2026 (the “Hospital Report”), was entered as Exhibit 1.
[6]. The issues at this hearing were whether Mr. Presta-Hislop is a significant threat to public safety, as defined in s. 672.5401 of the Criminal Code, and, if so, the necessary and appropriate Disposition in the circumstances, bearing in mind the factors enunciated in s. 672.54 of the Criminal Code.
[7]. For the reasons set out below and based on the expert evidence and opinions before us, the Board concluded that Mr. Presta-Hislop continues to pose a significant threat to the safety of the public. The Board found that the necessary and appropriate Disposition in the circumstances is the continuation of the existing Detention Order.
Current Psychiatric Diagnoses
[8]. Schizophrenia Alcohol Use Disorder, moderate, in early remission Cannabis Use Disorder, mild, in early remission Cocaine Use Disorder, mild, in early remission Tobacco Use Disorder, moderate
Position of the Parties
[9]. Counsel for the hospital and for the Attorney General were recommending no change to the existing Disposition.
[10]. Counsel for Mr. Presta-Hislop advised that her client was seeking an Absolute Discharge. In the alternative, he was seeking a Conditional Discharge, with terms to include: a consent to treatment clause, pursuant to s. 672.55(1); a specified residence, if necessary; all the prohibitions set out in paragraph 4 of his current Disposition; and a condition requiring that he be returned to Ontario Shores, pursuant to s. 672.93.
Index Offence
[11]. The circumstance giving rise to the Index Offence are extracted from last year’s Board Reasons, as follows, with appropriate redactions to protect the identity and addresses of the victim:
“On February 15, 2020, police responded to an address in Mississauga. They located the victim, the accused's mother, suffering from several wounds caused by a bladed weapon. The victim resides with her son, the accused. She related that she was seated in the living room when her son then abruptly came towards her with a large kitchen knife attempting to stick it repeatedly into her left side. A struggle ensued and the victim was able to remove the knife from the accused's hand, but he once again came towards her attempting to squish her with a wooden bar stool. The victim managed to barricade herself in her bedroom and called 911. The accused continued his attack by forcing his way into the bedroom and wrapping his hands around the victim’s throat, choking her. He discontinued his attack and left the room, but re-entered, once again attempting to strangle his mother. The accused then left the room again, returning with a pair of scissors which he used to stab various parts of the victim’s body, including her stomach, back and chest. He abruptly stopped this attack and then the police arrived at the home. The victim believed that her son was attempting to kill her.
The victim received multiple wounds including multiple puncture and slash wounds to her abdomen and chest, severe bruising to her abdomen and chest area, numerous cuts and slashes to her right hand and thumb and a severed ligament on her right thumb. She required reconstructive surgery to her right hand."
Course Since Last Disposition
[12]. Mr. Presta-Hislop’s course since his last Disposition is set out in detail in the Hospital Report. The following extracted paragraphs are relevant to this hearing:
“Following Mr. Presta-Hislop’s re-admission to Ontario Shores on February 12, 2025, he was discharged back to Collaborative Residents Enabling Assisted Transitional Engagement (CREATE) – a program run by the Durham branch of the Canadian Mental Health Association (CMHA) on March 31, 2025. Mr. Presta-Hislop has continued to reside at the CREATE Kirkland location in Oshawa during this reporting period. This transitional housing model provides a structured environment for individuals navigating community reintegration, offering staff presence for four hours daily and 24/7 on-call support via the Whitby location.
Mr. Presta-Hislop’s positive trajectory and stability allowed his weekly visits from his Forensic Outpatient Services (FOS) clinician to be reduced beginning in July 2025, moving from four weekly visits to three.
Mr. Presta-Hislop continues to make significant strides in his community reintegration through consistent academic and vocational pursuits. He remains enrolled part-time at Ontario Tech University, where he is actively working toward a Bachelor of Science in Physics. During the Fall 2025 semester, Mr. Presta-Hislop successfully completed two courses with passing grades, and he has maintained this momentum by enrolling in an additional two courses for the Winter 2026 term.
A significant milestone in Mr. Presta-Hislop’s community reintegration occurred in November 2025 with the initiation of partial medication self-administration. Based on his consistent punctuality and reliability in attending evening medication dispensing without CREATE staff intervention, Mr. Presta-Hislop was granted the privilege of carrying two days' worth of his prescriptions a week. This protocol requires Mr. Presta-Hislop to manage his Clozapine independently and return the empty blister packs to staff every Tuesday for verification.
Another significant achievement in Mr. Presta-Hislop’s rehabilitative journey was the successful transition of his Long-Acting Injectable (LAI) administration to the CMHA Nurse Practitioner-Led Clinic. Previously administered by the FOS, the move to a community-based clinic was identified by the treatment team as a vital step in fostering greater medical autonomy and reducing reliance on forensic-specialized services.
While Mr. Presta-Hislop has maintained his stable housing at CREATE during this period, his functional progress has been characterized by both stability and a one notable area for continued intervention. He remains compliant with general household chores; however, he continues to have some challenges with financial literacy, specifically regarding the selection of appropriate nutritional items. Clinically, there was a brief regression in residential stability where staff observed a return of previous maladaptive behaviours in early December 2025. These included voiding on the property exterior, not attending house meeting, a decline in bedroom hygiene, and a lack of cooperation regarding scheduled room inspections.
A primary indicator of Mr. Presta-Hislop’s clinical stability has been the successful, graduated expansion of his Leave of Absence (LOA) privileges to his mother’s house. This progression began in July 2025 with infrequent one-night stays and advanced to an extended two-night stay during the December 2025 holiday period.
Notable Incidents and Presentation Since Last Report
On December 11, 2025, CMHA staff reported a cluster of behavioural and residential concerns to Mr. Presta-Hislop’s FOS clinician. Mr. Presta-Hislop had been frequently loitering in the staff office, citing "curiosity" rather than specific needs. Furthermore, Mr. Presta-Hislop failed to attend a house meeting on December 8 despite scheduling accommodations, during which a peer who resides in the household reported evidence of inappropriate voiding on the property.
Mr. Presta-Hislop initially resisted a scheduled room inspection on December 11, requiring multiple prompts to comply. The eventual inspection revealed a significant decline in hygiene and safety, including a pervasive odor, excessive clutter, and disorganized, exposed electrical wiring. These incidents indicate a recent regression in Mr. Presta-Hislop’s functional stability and a need for reinforced residential boundaries and housing contract agreement. These behavioural concerns echo similar tendencies that were taking place prior to his re-admission on February 12, 2025.
When Mr. Presta-Hislop’s FOS clinician addressed the recent behavioural and residential concerns, Mr. Presta-Hislop offered rationalizations for each of the identified issues. To further review these shifts in his presentation, a follow-up appointment was scheduled with his treating psychiatrist. During the discussion, Mr. Presta-Hislop demonstrated insight into the treatment team’s perspective and committed to adhering to program expectations and maintaining residential standards moving forward. Since this intervention, Mr. Presta-Hislop has remained stable, and there have been no further notable incidents.”
Evidence at the Hearing:
[13]. The Board had available to it the evidence and documents forming the Record, the Exhibits, and oral evidence from Dr. Pallandi. Dr. Pallandi co-authored the Hospital Report. He testified as follows:
a) One of the primary risk factors is that there is a high likelihood of treatment non-adherence without the Board jurisdiction.
b) Mr. Presta-Hislop is on an oral medication, clozapine, which requires 100 percent compliance, and even two or three missed days can cause destabilization, requiring a full restart of his medication.
c) Mr. Presta-Hislop has a long history of non-adherence, including multiple episodes of stopping medication. If Mr. Presta-Hislop were to stop his medication, partially or completely, there is a real risk of relapse of his psychosis, with a rapid return of symptoms.
d) Mr. Presta-Hislop is also being treated with a long-acting injectable (“LAI”) antipsychotic medication, which does provide some protection, but not enough to prevent breakthrough symptoms if he were to miss a dose of clozapine.
e) Substance use is a destabilizing factor for Mr. Presta-Hislop, and it has repeatedly triggered deterioration in his mental stability. Following his discharge into the community in January 2025, he had to be returned to hospital on February 12, 2025, when his urine drug screen (UDS) returned positive for cannabis use. Mr. Presta-Hislop denied using cannabis, but it was found in his room during a search, on February 19, 2025.
f) In December, the staff at Mr. Presta-Hislop housing reported the following concerning behaviours: he was loitering in staff areas; he missed required house meetings; he was urinating around the property; he exhibited poor hygiene; and he kept a disorganized and malodorous room. This episode could be described as a “near miss” to a readmission to CAMH, as these behaviours were early indicators of destabilization during his prior relapses.
g) This deterioration in December occurred despite negative drug screens and apparent medication adherence. Some fluctuations are simply due to the nature of the illness, which increases the need for close monitoring of Mr. Presta-Hislop.
h) Because of the nature of the Index Offence, which involved extreme violence, multiple weapons and near-lethal behaviour, even small signs of deterioration must be taken very seriously.
i) Mr. Presta-Hislop lives in partial support housing (CREATE housing). Staff are on-site only part of the day but are available on call. This level of structure is still necessary. A Conditional Discharge would remove the essential tools for timely intervention to protect public safety and would, therefore, not be appropriate.
j) Mr. Presta-Hislop has had many positive steps this reporting year, including medication adherence, education, family contact, and partial independence of self-administration of his clozapine, with the start of a lock box program. A lock box program allows Mr. Presta-Hislop to start moving toward independent administration of his own medication. This program has just started, and Mr. Presta-Hislop is about to move to a three-day lock box program.
k) Should Mr. Presta-Hislop continue his stability in the coming reporting year, a Conditional Discharge may be realistic the following year. However, it is currently premature, because the risk factors already mentioned outweigh the progress that Mr. Presta-Hislop has demonstrated.
l) Under a Conditional Discharge, the hospital would lose the ability to intervene quickly enough to manage Mr. Presta-Hislop’s risk. A Detention Order allows earlier preventative intervention that is essential, given the seriousness of the potential risk if Mr. Presta-Hislop were to use substances, cease his medication regimen or show signs of deterioration, as he did in December 2025.
m) There have been a number of apprehensions under the Mental Health Act (“MHA”), as set out in the Hospital Report.
n) Mr. Presta-Hislop has been deemed incapable to consent to treatment in the past.
o) He has engaged in significant problematic behaviours in the past, including aggression, so the same behaviour could be expected in the future, should he stop his medication or use substances.
p) Mr. Presta-Hislop’s long-acting injectable medications (LAIs) are given by his community mental health services, which would advise the treatment team if Mr. Presta-Hislop were to miss an appointment. This reporting of a missed LAI would not happen under an Absolute Discharge. People who are on clozapine and miss a dose tend to deteriorate more quickly than one may expect on other antipsychotic medication. Even a modest degree of non-adherence with clozapine would reduce its protective factor.
q) The breakthrough symptoms one could expect a patient to experience with even partial non-adherence to clozapine would not be enough to invoke the provisions of the MHA.
r) Mr. Presta-Hislop has been demonstrating good adherence to his clozapine, but he has requested to stop one of the other medications on two occasions. His concern about that medication causing weight gain is valid. However, it is important that patients understand the benefits of medication versus side effects; when someone requests a change of their medication regimen so early in their discharge into the community, one must question their insight into their need for medication. Given Mr. Presta-Hislop’s history of multiple episodes of nonadherence with treatment, this concern is highly relevant. It is quite realistic that Mr. Presta-Hislop would become non-adherent to his medication regimen absent the supervision provided by a Detention Disposition.
s) In December, the treatment team had to threaten Mr. Presta-Hislop with losing the privilege of visiting his parents to change his behaviour and get him to meet with housing staff. Had team members not had the authority to make this threat, they would have had to readmit him to the hospital.
t) Mr. Presta-Hislop would not have met the criteria to be certified under the MHA based on his presentation in December 2025. However, his presentation was concerning, and things could really have gotten worse had the treatment team not intervened in a timely manner.
u) The treatment team is concerned with what could happen should Mr. Presta-Hislop miss a does of his clozapine, especially when one looks at his Index Offence. S. 672.93 of the Criminal Code would not likely be an effective protection of the safety of the public, should Mr. Presta-Hislop cease his clozapine medication, as he would deteriorate quite rapidly. Even with a consent to treatment clause, the treatment team would have to call the police to arrest him. He would be placed in jail and have to appear before a Justice of the Peace, before he could be returned to the hospital. In the interim, he would miss multiple doses of his clozapine, which would pose significant risk to public safety and be detrimental to his mental state going forward. It would take several weeks to re-titrate Mr. Presta-Hislop’s clozapine.
[14]. In response to questions from counsel for the Attorney General, Dr. Pallandi testified:
a) He has never discussed an Absolute Discharge plan with Mr. Presta-Hislop, nor has he taken any of the steps that the hospital would normally take when an Absolute Discharge is even a remote possibility.
b) Clozapine can only be prescribed and monitored through a specialized clinic. It is not clear who would prescribe it for Mr. Presta-Hislop, nor who would perform the mandatory blood work, if he were absolutely discharged.
c) If Mr. Presta-Hislop were granted an Absolute Discharge, the CMHA injection clinic would not be able to report missing injections to the hospital because of privacy restrictions, so the team would lose visibility into his adherence. Even if he were to maintain his current adherence to the medication regimen, any substance use would cause him to become a significant threat to public safety.
d) Substances like cannabis or cocaine have direct effects on Mr. Presta-Hislop’s mental stability, such as increased paranoia, erratic behaviour, sleep disruption, and mood changes as well as indirect effects, such as eroded motivation and reduced willingness to comply with his medication regimen.
e) The Hospital Report notes that Mr. Presta-Hislop was using substances, including cocaine and cannabis, at the time of the Index Offence, and he was acutely psychotic, despite being adherent to his medication regimen. This scenario could reoccur if Mr. Presta-Hislop were to resume substance use.
f) Mr. Presta-Hislop was discharged to the community in early 2025 and readmitted within days because of concerns about substance use.
g) Without the support and structure currently in place, which would be the case after an Absolute Discharge, Mr. Presta-Hislop could deteriorate within a month or less.
[15]. In response to questions from counsel for Mr. Presta-Hislop, Dr. Pallandi testified:
a) While the hospital has an obligation to prescribe medication if there is no treating psychiatrist in the community, an Absolute Discharge would still be unsafe and premature.
b) The hospital has not undertaken any planning that would normally occur when an Absolute Discharge is even a possibility, such as arranging community follow up, securing professional supports, or ensuring continuity of monitoring.
c) A Conditional Discharge could not safely manage the risks because the risk factors remain too active, and the hospital would lose the ability to intervene early enough. The MHA criteria are reactive versus proactive, and the Board’s current detention powers allow timely, preventive intervention that is essential in this case.
d) It is quite realistic that Mr. Presta-Hislop would become non-adherent to his medication regimen without Board supervision, given his long history of stopping medication and his recent comments about wanting to discontinue it.
e) It is important to remember that clozapine requires near perfect adherence; even two or three days of missed doses can cause destabilization and force a full restart of the medication regimen.
f) Mr. Presta-Hislop is only partway through the lock box progression and still requires oversight.
g) Mr. Presta-Hislop’s behaviour in December, including poor hygiene, disorganization, urination around the property and missed meetings were early warning signs, similar to those seen before in his past relapses.
h) Even though urine drug screens were negative, the episode in December demonstrated the instability of Mr. Presta-Hislop’s mental state and the need for close monitoring.
i) Mr. Presta-Hislop is on a path toward a Conditional Discharge, but it is not yet appropriate.
j) If Mr. Presta-Hislop maintains his stability, abstains from substances, progresses to full medication autonomy, and continues functioning well in his housing and in his educational pursuits, a Conditional Discharge may be realistic in the next reporting year; however, at present, the many risk factors clearly outweigh his progress.
[16]. In response to questions from the panel, Dr. Pallandi testified:
a) The primary Re-offence Scenario for Future Violence set out on page 46 of the Hospital Report is still true today and represents a real risk of harm. It could be described as great and not trivial.
b) Mr. Presta-Hislop does not have a non-forensic team in place that could replace the one that he currently has. He would need such a team if granted an Absolute Discharge.
c) The current plan is to transition Mr. Presta-Hislop to housing that would have less supervision and monitoring. This potential transfer to a less supervised setting is another reason why it is essential to maintain the current Detention Order.
d) Even if Mr. Presta-Hislop were to remain on his long-acting injectable medication and his oral clozapine medication, he could quickly deteriorate, and become a significant threat to public safety, if he were to use certain substances, such as cocaine or cannabis. Taking these substances also increases the likelihood of missing a clozapine dose.
e) Similarly, even if he abstained from drugs but discontinued his clozapine regimen, he would quickly become psychotic and represent a significant threat to public safety. When patients on clozapine stop taking it, they become symptomatic much more quickly.
f) If Mr. Presta-Hislop were to both use substances and stop his clozapine, it would worsen his psychosis and elevate his risk to public safety even more.
g) Given Mr. Presta-Hislop’s complex needs, and the fact that he suffers from a serious and persistent major mental illness, he needs to be associated with a psychiatrist in the community for treatment, not just for the prescribing of clozapine.
h) The monitoring provided by his current residence, and any future residence, is important, as Mr. Presta-Hislop’s mental stability and abstinence from substances still need to be monitored.
i) Mr. Presta-Hislop’s insight into his needs to remain adherent to his medication regimen is improving but not full. His insight into remaining abstinent from substances is also improving, and he has remained abstinent for over a year. However, Mr. Presta-Hislop would have to demonstrate a longer period of stability before his insight could be described as full.
j) The proposed conditions for a Conditional Discharge recommended by counsel would not be adequate to protect the safety of the public. Even adding a term requiring Mr. Presta-Hislop to remain detained in hospital would not be enough to stop him from leaving; it would merely cause a breach of his Disposition. He would likely miss several doses of his clozapine during the ensuing delay to bring him back, causing his clozapine level to drop below its therapeutic level. This drop would destabilize him, making him a significant threat to the safety of the public. The continued 100 percent compliance with clozapine is a cornerstone to Mr. Presta-Hislop’s risk management. Any interruption would not only cause him to become quickly symptomatic, but it might amount to a major setback to his progress, requiring a long hospital readmission.
k) As evidenced in the December incident, Mr. Presta-Hislop’s behaviour would not be enough to trigger the MHA. Even substance use, as happened during the incident in February, would not be sufficient to invoke the MHA. For these reasons alone, the hospital needs the provisions of a Detention Order to protect the safety of the public.
l) Attention was brought to the following paragraph on page 47 of the Hospital Report:
“The team agrees entirely with the risk evaluation that is sent out above, inasmuch as there are ongoing concerns about returning to substance use (and its’ clear association with past violent conduct) and underdeveloped true insight into his need for treatment in perpetuity.”
The words “true insight” were deliberately chosen to indicate that Mr. Presta-Hislop’s behaviour has caused doubts about his full insight into his need for medication.
m) Shortly after Mr. Presta-Hislop was discharged into the community, he asked for a change in his medication regimen, twice. These requests cause some concern about Mr. Presta-Hislop’s motivation to remain adherent to his medication regimen.
[17]. No other evidence was called.
Analysis and Conclusions
[18]. Having heard and considered the entirety of the evidence as well as the submissions from the parties, the Board finds that Mr. Presta-Hislop remains a significant threat to the safety of the public.
[19]. In Winko, the Supreme Court outlined that, in coming to the conclusion on the issue of significant risk, a Review Board should closely examine a range of evidence, including: the circumstances of the original offence; the past and expected course of the accused’s treatment; the present state of the NCR accused’s medical condition; the NCR accused’s own plans for the future; the support existing for the NCR accused in the community; and most importantly, the recommendations provided by experts who examined the NCR accused. In coming to our conclusion in this matter, the Board relies on the uncontroverted expert evidence of Dr. Pallandi, in addition to the documentary evidence before us.
[20]. Page 42 of the Hospital Report describes some of Mr. Presta-Hislops’s concerning behaviour, under Notable Incidents:
“On December 11, 2025, CMHA staff reported a cluster of behavioural and residential concerns to Mr. Presta-Hislop’s FOS clinician. Mr. Presta-Hislop had been frequently loitering in the staff office, citing "curiosity" rather than specific needs. Furthermore, Mr. Presta-Hislop failed to attend a house meeting on December 8 despite scheduling accommodations, during which a peer who resides in the household reported evidence of inappropriate voiding on the property.
Mr. Presta-Hislop initially resisted a scheduled room inspection on December 11, requiring multiple prompts to comply. The eventual inspection revealed a significant decline in hygiene and safety, including a pervasive odor, excessive clutter, and disorganized, exposed electrical wiring. These incidents indicate a recent regression in Mr. Presta-Hislop’s functional stability and a need for reinforced residential boundaries and housing contract agreement. These behavioural concerns echo similar tendencies that were taking place prior to his re-admission on February 12, 2025.
When Mr. Presta-Hislop’s FOS clinician addressed the recent behavioural and residential concerns, Mr. Presta-Hislop offered rationalizations for each of the identified issues. To further review these shifts in his presentation, a follow-up appointment was scheduled with his treating psychiatrist. During the discussion, Mr. Presta-Hislop demonstrated insight into the treatment team’s perspective and committed to adhering to program expectations and maintaining residential standards moving forward. Since this intervention, Mr. Presta-Hislop has remained stable, and there have been no further notable incidents.”
[21]. Dr. Pallandi emphasized a critical need for strict medication adherence, which means that an Absolute Discharge, or even a Conditional Discharge, would expose the public to an unacceptable level of risk.
[22]. Dr. Pallandi’s evidence to the panel was unequivocal that an Absolute Discharge is unsafe, because there is no plan in place for continued care, and no ability to monitor or intervene quickly enough to protect the safety of the public.
[23]. A Conditional Discharge is also premature, because the hospital would lose the early intervention powers needed to prevent a relapse in Mr. Presta-Hislop, who has a history of extreme violence, substance-related deterioration and fragile stability. Only a Detention Order provides the structure, oversight and clinical tools necessary to manage the ongoing significant threat.
[24]. In particular, the Board relies on the following extracted paragraphs from the Hospital Report as rationale for the finding that Mr. Presta-Hislop remains a significant threat to the safety of the public:
“The primary risk relevant factor remains Mr. Presta-Hislop’s insight across the three foundational domains (diagnosis, violence/aggression, treatment needs). Mr. Presta-Hislop’s less than robust awareness of his mental illness contrasts with his strong intellectual capabilities. He maintains other explanations as preferable for his past actions when he was acutely unwell (e.g., influenced by substance use, “brooding,” provided with a medication against his will), encompassing the index offence and other past aggressive incidences. This impressed as minimization or deflection of responsibility, which is influential in future risk concerns. Similar to prior years and overlooking past unsuccessful attempts, Mr. Presta-Hislop requested to entirely discontinue or change his antipsychotic medication regimen to address a perceived aversive side-effect (i.e., weight gain); it was his team’s impression that his personal life choices were the more likely culprit which would be more easily modifiable without consequence than altering his medication. He has repeated this request several times over the reporting period, most recently in early January 2026. This is further evidence of a gap in Mr. Presta-Hislop’s insight, which continues to influence his decision making. As such, externalized supports appear to primarily scaffold his stability and risk management. It is noteworthy, though, that Mr. Presta-Hislop is treatment capable and has been highly amenable to discussions with his psychiatrist about this. To date, he has not opted to alter his medication regimen. However, the rationale was seemingly entirely externalized (e.g., to not jeopardize community living) rather than internalized and in recognition of the risks of a potential return to psychosis and/or violence with a medication adjustment. Similarly, Mr. Presta-Hislop discusses his interest in a return to “medicinal cannabis” without the depth of understanding regarding its potential impact on his psychotic symptoms; he can appreciate, however, that use could prolong his tenure under the ORB, within the parameters of his current disposition. Treatment and supervision remains a secondary risk factor of import, given Mr. Presta-Hislop has not addressed pertinent risk factors via psychosocial interventions for another year (totaling three years since he has engaged in any form of rehabilitative services), thus sidestepping any opportunity to maintain, challenge, or deepen his understanding in the identified key areas.
Overall, given the currently available information, Mr. Presta-Hislop is opined to present as a Moderate risk for violence if he were awarded a standard Conditional Discharge. Given Mr. Presta-Hislop has had a positive year, his risk level has decreased from last year (Moderate-High). Static risk combined with the dynamic risk factors identified above, though, informs the current risk estimate under a standard Conditional Discharge. A continuation of a Detention Order would reduce this violence risk potential to Low, as the provision of externalized scaffolding would continue to support effective risk management, whilst providing a safety net for increasing autonomy (e.g., administering his own oral medication every day, reduction of weekly reporting, navigating financial stresses/pressures of purchasing a vehicle, longer duration of abstinence in the community).
The team agrees entirely with the risk evaluation that is sent out above, inasmuch as there are ongoing concerns about returning to substance use (and its’ clear association with past violent conduct) and underdeveloped true insight into his need for treatment in perpetuity.
We are also mindful that Mr. Presta-Hislop required a reasonably lengthy admission to hospital for stabilization during this interval.
As such, we are of the opinion that his risk is currently in the low-moderate range, but well managed within the framework of the current Disposition.”
[25]. In light of the Board’s finding of significant threat, it is charged with shaping a Disposition for the coming year. The Board accepts the doctor’s evidence that the MHA would not be sufficient to protect the public. It is important to note that the MHA sets different thresholds for admission into, and for ongoing detention in, the hospital than does Part XX.1 of the Criminal Code, which is explicit that public safety is the paramount consideration. The Board recognizes its duty to assess the evidentiary record in its current context, taking into consideration: (1) the risk of non-adherence to medication; (2) the mechanisms for securing a patient’s attendance and detention in hospital under the conditional discharge framework; (3) the length of time the steps may take; (4) the effect of delay on Mr. Presta-Hislop’s mental health; and (5) the risk to public safety posed by any delay in treatment. All the evidence before us indicates that a Conditional Discharge is not appropriate. The Board also considered the multiple ways of securing patients’ attendance at the hospital when they fail to comply with a Conditional Discharge (see Valdez (Re), 2018 ONCA 657 and Ramos (Re), 2025 ONCA 820).
[26]. We agree with counsel for the hospital’s submissions that this case is not similar to the facts set out in Ramos. In that case, Mr. Ramos was close to a Conditional Discharge, whereas Mr. Presta-Hislop is not.
[27]. In particular, the Board relies on the following extracted paragraphs from the Hospital Report:
“Similar to last year’s risk assessment, concerns remain that Mr. Presta-Hislop will continue to meet the tangible requirements of his ORB disposition (e.g., reporting frequency) and bypass any opportunities to address (repeatedly) identified gaps in his recovery and associated risk mitigation. There are also concerns that Mr. Presta-Hislop’s discontentedness with his antipsychotic medication will resurface again, resulting in overt or covert non-adherence and associated decompensation given the fragility in his mental health status with medication changes and currently limited insight into same. It is not wholly clear that Mr. Presta-Hislop will be amenable to voluntarily return to hospital if decompensation occurs. Given his high intellect, ability to camouflage symptoms, and inclination towards positive impression management, it may be that a mental health decompensation will be largely unnoticed in the community, until it overwhelms him. Additionally, a similar pattern is evident with respect to substances – whereby Mr. Presta-Hislop expresses a degree of ambivalence towards complete abstinence but will adhere to disposition requirements in order to continue his momentum forward. There is less certainty whether he will not return to problematic substance use absent oversight, particularly without successful completion of concurrent disorders programming.
A possible re-offence scenario given a standard Conditional Discharge includes: Mr. Presta-Hislop will become covertly non-adherent to his oral antipsychotic medication or, due to his treatment capable status, reject or manipulate his current medication regimen that is known to be stabilizing for him. He may return to substance use, which is also a source of destabilization for him, despite medication compliance. His mental illness will become more pronounced (e.g., hallucinations, ideas of reference, delusional persecutory beliefs). He will initially mask the symptoms of his illness successfully, until he becomes increasingly disinhibited by it, by substance misuse, or both combined. This will translate into verbal threats, property destruction (e.g., broken window), and culminate in physical aggression – particularly if he perceives malintent, “mocking,” or an infringement on his body by others – that has a high potential for significant harm (e.g., strangulation, opportunistic use of objects as weapons, use of knives). As noted in a prior risk assessment, targets for violence would include family members or those involved in his personal life or professionals responding to a crisis (e.g., nurses).”
[28]. In consideration of all the evidence, submissions of the parties and criteria set forth in s. 672.54, the paramount consideration being the safety of the public, in addition to the mental condition of Mr. Presta-Hislop, his reintegration into society and his other needs, the necessary and appropriate Disposition is with a continuation of the Detention Order.
DATED this 30th day of April 2026, at the City of Toronto, in the Region of Toronto.
Mr. J. Weinstein Alternate Chairperson Office of the Registrar Ontario Review Board