Re Zhan, 2026 CanLII 39759

Re: Tian Hui “Jeff” Zhan

ORB File No: 8906

Hearing held on: February 18, 2026

Place of hearing: St. Joseph’s Healthcare Hamilton, West 5^th Campus

100 West 5^th Street

Pursuant to: Section 672.47(1) of the Criminal Code

Before:

Alternate Chairperson: Dr. K. Connidis

Members: Dr. J. Cheston

Dr. S. Bouskill

Mr. D. D’Intino

Ms. B. Little

Parties Appearing:

Accused: Tian Hui “Jeff” Zhan

Counsel: Mr. A. Confente

The Person in Charge of Hospital: Counsel: Mr. S. O’Brien

Attorney General of Ontario: Counsel: Ms. K. Malkovich

REASONS FOR DISPOSITION

(Dated April 27, 2026)

Introduction

1. On November 14, 2025, Mr. Tian Hui “Jeff” Zhan 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. On that day, the Court declined to make a Disposition and referred the matter to the Ontario Review Board (ORB) for an initial hearing.

3. On February 18, 2026, a panel of the Ontario Review Board (ORB) convened in person and a hearing was held at St. Joseph’s Healthcare Hamilton (SJHH). The purpose of the hearing was to determine if Mr. Zhan represents a significant threat to the safety of the public as defined in the Criminal Code of Canada, and if so, to decide on the necessary and appropriate Disposition.

4. For the reasons set out below, the Board unanimously finds that Mr. Zhan meets the threshold for significant threat to the safety of the public and that the necessary and appropriate Disposition is a Detention Order with the following terms and conditions:

a) to attend within or outside of the hospital for necessary medical, dental, legal or compassionate purposes;

b) hospital and grounds privileges, escorted by staff;

c) hospital and grounds privileges, accompanied by staff or person approved by the person in charge;

d) hospital and grounds privileges, indirectly supervised;

e) to enter the community of Hamilton, escorted by staff;

f) to enter the community of Hamilton, accompanied by staff or person approved by the person in charge;

g) to enter the community of Hamilton, indirectly supervised; and

h) refrain from having in their possession any firearm, ammunition, or other offensive weapons, or being in the company of any person possessing a firearm other than a peace officer;

i) abstain absolutely from the non-medical use of alcohol or drugs or any other intoxicant;

j) submit samples of her urine and/or breath to the person in charge of St. Joseph’s Healthcare Hamilton, West 5th Campus or his or her designate for the purpose of analyzing whether the accused has ingested alcohol, drugs or any other intoxicant.

5. However, the Panel split on the issue of whether Mr. Zhan should be granted passes to enter the community of Hamilton, indirectly supervised. As such, the Legal Member has written a dissenting opinion at the end of these reasons.

Current Psychiatric Diagnosis:

• Schizophrenia.

Index Offences:

6. The facts arising from the index offences were set out in the Hospital Report and are reproduced as follows:

“On Thursday January 16th, 2025, Mr. Tian ZHAN was arrested for an Aggravated Assault that occurred in broad daylight, at around 3:00pm. The elderly 70-year-old victim, Mr. Robert OVERBAUGH, was transferred to the Hamilton General Hospital in life threatening condition.

Mr. OVERBAUGH was traveling on a Hamilton City Bus and was a stranger to the accused, Mr. ZHAN. Mr. OVERBAUGH was already on the bus when Mr. ZHAN got on the bus and sat next to him. Mr. OVERBAUGH had only a brief conversation with the accused before Mr. OVERBAUGH got up from his seat and moved to another area of the bus. Mr. OVERBAUGH told Mr. ZHAN that he moved seats because he thought Mr. ZHAN would want two seats to himself since he had a large bag with him.

A short time later, Mr. OVERBAUGH got off the bus and Mr. ZHAN followed him. Mr. ZAHN then placed his bag on the sidewalk, removed an expandable baton and struck Mr. OVERBAUGH 12 times. Most of the strikes landed as Mr. OVERBAUGH was lying on the ground.

Mr. ZHAN then collapsed his baton and walked towards the corner of Barton and Sherman Street, about one block to the next bus stop where he was arrested by police. Along this walk, he threw the baton into a bush in front of 604 Barton St E, a short distance from the bus stop where the attack took place.

Mr. OVERBAUGH was observed covered in blood, and there was a large patch of blood on the west side of the bus stop. Mr. OVERBAUGH suffered extensive injuries including: a broken arm, five fractured ribs on his right side, a broken wrist and multiple face fractures."

Background Information

7. The following background information is extracted from the Hospital Report:

• Mr. Tian Hui “Jeff” Zhan was admitted to the Forensic Assessment Unit, Mountain 3, at St. Joseph’s Healthcare Hamilton (“SJHH”), West 5th Campus on May 5, 2025 pursuant to a Form 48 Assessment Order to determine whether he suffered from a mental disorder so as to exempt him from criminal responsibility by virtue of section 16(1) of the Criminal Code. He was charged with one count of Aggravated Assault, contrary to s. 268 of the Criminal Code. Following a series of extensions of the order, Mr. Zhan returned to court on November 14, 2025, and was found Not Criminally Responsible on Account of Mental Disorder (“NCR”). He was returned to SJHH to await his initial hearing before the Ontario Review Board (“ORB”).

• Mr. Zhan was previously under the Ontario Review Board from February 28, 2019, to March 15, 2023, when he was absolutely discharged. Mr. Zhan was acquitted of Murder on the grounds of insanity on September 28, 2011, and pursuant to sections 57, 57A and 59 of the Criminal Procedure (Scotland) Act 1995, the court made a compulsion order in respect of Mr. Zhan detaining him in hospital together with a restriction order restricting his discharge from hospital without limit of time.

• As Canada has a similar law for dealing with an accused who is found not criminally responsible on account of a mental disorder, the compulsion order and restriction order made in Scotland was ordered to be executed in Canada as a Disposition Order under the laws of Canada, specifically Part XX.1 of the Criminal Code. On February 28, 2019, Mr. Zhan was repatriated back to Canada to St. Joseph’s Healthcare Hamilton, Medium Secure Forensic unit, from Rowanbank Clinic, a medium secure forensic facility in Glasgow, Scotland. Mr. Zhan was admitted to Waterfall 3 (formerly Secure Forensic Unit) at St. Joseph’s Healthcare Hamilton to await his initial hearing before the Ontario Review Board.

• The Board ordered a General Forensic Unit Detention Order with privileges up to entering the community of Southern Ontario, indirectly supervised. On July 10, 2019, Mr. Zhan was transferred from Waterfall 3 to Mountain 2 (formerly General Forensic Unit, now undesignated).

• The Hospital wrote to the Board on December 2, 2019, to request an Early Hearing for Mr. Zhan given that he was successfully exercising the maximum level of privileges under his disposition. The Early Review hearing was held on January 22, 2020.

• The Board ordered a continuation of the Detention Order with the addition of community living within Southern Ontario. Mr. Zhan remained a patient on Mountain 2 until the time of his discharge to community living on January 25, 2021.

• He was granted a Conditional Discharge on February 1, 2022, then absolutely discharged from the Ontario Review Board the following year on March 15, 2023.

• Mr. Zhan was born in the Shenyang Province, northeast China, the only child to his parents. His mother is a civil engineer by profession, but later switched careers and now works as a team assistant within the Canadian Health Service. His father worked as a university lecturer but has now retired. Mr. Zhan reports that his father suffers from age-related macular degeneration and is registered blind.

• At age 9, Mr. Zhan and his parents immigrated to Toronto, Canada, in order to access better job and educational opportunities. Mr. Zhan reports that he was able to cope well with the move. He denied any difficulties with integrating, stating that his new primary school had a large number of Chinese born immigrants. He enrolled in an English course and was able to pick up the language quickly. He progressed to high school, and became very active in sports, particularly basketball. He did not excel academically; his mother hired a tutor, but this did not enhance his academic performance.

• Mr. Zhan’s education was interrupted and ultimately cut short, when he became mentally unwell in the 9th grade, aged 14 years in August 2006. He was admitted to hospital due to an acute functional decline and later diagnosed with Bipolar Affective Disorder, Type 1.

• In August 2006, Mr. Zhan’s mother is reported to have enrolled him in a basketball camp, to encourage him to become sociable. Mr. Zhan’s sleep deteriorated whilst at the camp. It is also reported that he became very paranoid and was hearing voices. Mr. Zhan was advised by a coach to be assessed by a psychiatrist because of his presentation. This led to an 18-day admission in hospital and subsequent diagnosis with Bipolar Disorder Type 1, with psychotic features. Mr. Zhan had two other hospital admissions within the Rouge Valley Health System (RVHS), Toronto, Canada. One was from 21st March 2007 to 2nd April 2007, and the other from 30th July 2010 to 4th August 2010.

• During this time, Mr. Zhan voiced paranoid delusions, expressing the belief he was being followed, spied on and being poisoned through food and medication. His delusional beliefs are reported to have been often centered on his family and also his mental health team. Mr. Zhan has also held grandiose delusions about his identity and ability. For example, he believed that he would become a professional basketball or tennis player, whilst unable/unwilling to meet most basic developmental expectations.

• It is also noted that whilst on vacation to China from June to August 2007, Mr. Zhan had three admissions in hospital due to deterioration in his mental state. Mr. Zhan reportedly presented in a similar fashion as documented above.

• Following his diagnosis, Mr. Zhan states that he did not return to formal education. He reports that he focused all his energy on his sporting aspirations. It is noted that his ambitions to become a professional basketball player and later, a tennis player, were a product of “rigidly entrenched” grandiose delusions.

• He also reports that in 2007, he and his parents travelled to China for a few months to visit his extended family. Upon his return to Canada in 2008, he began training in tennis. He worked at a gym in Toronto, Canada in 2009. He was reportedly fired a month later due to ‘bad customer service’. He has had no other jobs prior to or since then. Mr. Zhan states that he was in receipt of social support benefits before he left Canada in 2010.

• Mr. Zhan is noted to have a history of poor engagement with mental health services and poor compliance with treatment. It is noted by his Child and Adolescent Psychiatrist in Canada that he was significantly undertreated, as Mr. Zhan refused to alter his existing treatment of Quetiapine 100mg. This decision was believed to be a product of paranoid suspicion and a lack of appreciation for his own impaired function. Mr. Zhan denies any history of substance misuse. He also denies any history of alcohol misuse.

• Whilst Mr. Zhan was under the care of the Rouge Valley Health System in Toronto, Canada, he is noted to have been inconsistent in attending appointments. Mr. Zhan was also not open or adherent to treatment recommendations. His mother also reports that he would only take a portion of his prescribed Quetiapine and express the belief that it was his psychiatrist’s intention to kill him.

• In May 2010, Mr. Zhan called his probation officer at East Toronto Youth Justice Service in a panic, adamant that he needed to be in possession of his passport and identification. Mr. Zhan was reportedly unable to be reasoned with and maintained that his passport was insecure in the hands of anyone but himself, as “they can find it”. He could not indicate who “they” were but noted that it was not his parents or other party known to him.

• Despite being on probation for theft and being required to have his place of residence approved, Mr. Zhan left the city, hence breaching his probation conditions. Mr. Zhan is reported to have absconded to Victoria, British Columbia, where he was hospitalized until his return to Ontario. Whilst on the above probation order, Mr. Zhan had also purchased bus tickets to Montreal and Buffalo, and a plane ticket to Vancouver. He had not spoken to his probation officer about his planned departure from the city. His family had additionally noted that if he left the city and someone was following him, he would “take measures to stop them”.

• His second absconding was to Europe in 2010, which ultimately led to his arrest and subsequent hospitalisation at The State Hospital. Mr. Zhan has reported that he decided to leave Canada and go to Europe in order to enrol in a tennis academy, at a time when he had grandiose delusions about his sporting ability. Mr. Zhan has stated that he flew from Toronto, Canada to Paris, France and then flew to Barcelona, Spain, where he believes he misplaced his passport. Upon rejection by the tennis academy, Mr. Zhan decided to leave Barcelona. Mr. Zhan asserts that he was able to travel without a passport from Barcelona to Hamburg, Germany by bus, and then to Berlin by train. Mr. Zhan further states that he then embarked on a bus journey to London via Calais, where Mr. Zhan reports officials requested for his passport. According to Mr. Zhan, he was allowed to cross the border after he explained to officials that he was a Canadian citizen and had lost his passport. He also reports that he was given a document to present to any officials if he were to be stopped again. Upon arrival in London, Mr. Zhan reports that he visited the Canadian Consulate and was told that he would receive a new passport in a few days. Mr. Zhan decided not to wait and chose to travel to Glasgow in response to auditory hallucinations. It was in this context that the index offence occurred.

• It is important to note that the details of this absconding to Europe are all from Mr. Zhan’s account; and have been difficult to verify. Nevertheless, it is clear that the absconding took place within the context of intercurrent mental illness and very limited resources. Therefore, it must be considered a significant risk factor in the future if Mr. Zhan were to become unwell again at any stage.

• On 13th October 2010, Mr. Zhan committed his index offence, which was the murder of a stranger in Glasgow, Scotland, whilst he was grossly psychotic. On 20th September 2010, Mr. Zhan paid for a same-day flight from Toronto to Barcelona via Paris, with the return journey planned for 26th October 2010. Mr. Zhan states that his intention was to pursue his dream to become a professional tennis player. Mr. Zhan reports that he trained at a tennis club for a week and left after coming to the realisation that his goals were perhaps unattainable. Mr. Zhan then travelled to Glasgow, where he stabbed and killed a stranger in the City Centre on 13th October 2010. Having committed the offence, Mr. Zhan fled from the scene, hid at a hotel in Glasgow and purchased a ticket for a flight to Holland.

• Mr. Zhan states that following the index offence, he was able to travel from Glasgow to Amsterdam, again without a passport. However, at the Amsterdam airport, Mr. Zhan was refused onward travel to Canada without a passport and was taken to a detention centre. He was subsequently arrested for the index offence. Mr. Zhan was charged with defeating the ends of justice and attempting to defeat the ends of justice by fleeing the country after the alleged offence of homicide.

• Mr. Zhan left Scotland for Amsterdam, Holland, where he was arrested. He was detained at Schiphol Airport Detention Centre between 14th October 2010 and 22nd October 2010; and then transferred to a prison, PI Amsterdam Over-Amstel, in Amsterdam between 22nd October 2010 and 28th December 2010. On 29th December 2010, Mr. Zhan was received at HMP Polmont OI, where he was initially assessed by a psychiatrist and deemed to be sane and fit to plead.

• Mr. Zhan was admitted to The State Hospital on 2nd February 2011 for the assessment of his mental health because of his guarded behaviour and at times slightly bizarre presentation. In the initial few months of the admission, it is reported that Mr. Zhan failed to discuss his index offence. Once he did initiate the conversation regarding the index offence, it came to light that there was enough evidence to support a plea for not guilty by reason of insanity. In September 2011, Mr. Zhan was acquitted of the offences, was placed on a Compulsion Order and Restriction Order and was admitted to The State Hospital.

• It is reported that following Mr. Zhan’s arrest and placement in custody, his parents revoked their support for his bail, thus requiring his return to custody. As a result, Mr. Zhan threatened both of his parents with death. There have been no reported incidents of assault on his parents.

• There were a number of incidents of challenging behaviour and violence during Mr. Zhan’s admission in The State Hospital:

  • February 22nd, 2011, Mr. Zhan engaged in a heated verbal dispute with another patient over borrowing goods.

  • March 2nd, 2011, Mr. Zhan challenged the nurse in charge to a fight.

  • November 18th, 2011, when Mr. Zhan was asked to move tables in the dining room, he became abusive towards staff and eventually had to be restrained. Once he was moved to the quiet area, he attempted to assault staff and required to be taken to the floor. These incidents took place within a context of intercurrent mental illness but may be reflective of underlying violent attitudes. Mr. Zhan has never expressed any other attitude suggestive of support of violence.

  • November 22nd, 2011, Mr. Zhan launched an unprovoked assault on another patient. Mr. Zhan was removed to a quiet room and was given emergency medication.

• Prior to his admission to the State Hospital, Mr. Zhan was assessed at HMYOI Polmont. Mr. Zhan did not appear thought disordered and denied experiencing any form of hallucinations. However, his history was described as “patchy and vague”, appearing guarded at times. Mr. Zhan reportedly denied his involvement in the alleged offence. He described his mood as “great”, despite being held in custody in a foreign prison. There was no evidence of low mood or mania, although it was noted that he did display grandiosity, describing himself as a “gifted student”. Given his presentation, there was some dubiety about the presence of a mental disorder or lack thereof. Consequently, Mr. Zhan was admitted to the State Hospital in February 2011 for a period of assessment.

• During this period, Mr. Zhan was noted to be mildly elevated and inappropriately humorous at times, for example laughing whilst stating “I’m in for murder”. There was evidence of pressure of speech, and his thought content contained some persecutory themes. For example, Mr. Zhan would express that the Canadian Consulate might deliberately be providing false information about him. Background information was obtained regarding Mr. Zhan, and it was agreed by the clinical team that there was good collateral evidence for the presence of mental disorder, namely Bipolar Affective Disorder (BPAD). However, the team was not thoroughly convinced of the accuracy of the diagnosis.

• Mr. Zhan continued to present as guarded, argumentative and suspicious of staff motives. He would also express paranoid ideation. On 14th November 2011, a letter addressed to the Advocacy department was found in Mr. Zhan’s room. In this letter, he had expressed beliefs that staff were attacking him and forcing drugs into him, presumably in reference to the antipsychotic medication he was being treated with, namely Olanzapine. Staff reportedly tried to discuss this letter with Mr. Zhan, but he chose to tear it up, stating that it had been written some time ago.

• It is reported that Mr. Zhan was given a diagnosis of “Mild Retardation” in Beijing, China in 2007, when he was aged 15 years while he was an inpatient in Beijing, China. His IQ was measured to be around 70. Notably, this assessment was completed in Mandarin, which may have affected his performance.

• In February 2011, Mr. Zhan completed the Wechsler Abbreviated Scale of Intelligence (WASI) whilst an inpatient at The State Hospital. Results indicated that Mr. Zhan’s general intellectual functioning fell within the low average range, between 87 and 95. It was also noted that his verbal IQ fell within the low average range whereas his performance IQ fell within the average range.

Without Prejudice Positions of the Parties:

8. At the commencement of the hearing, the parties were canvassed for their initial positions.

9. The Hospital took the position that Mr. Zhan meets the threshold for significant threat to the safety of the public and that the necessary and appropriate Disposition was a Detention Order with terms and conditions allowing up to indirect passes to enter the community of Hamilton.

10. Counsel for the Attorney General supported the Hospital’s position with respect to the Detention Order but did not agree with the inclusion of privileges to enter the community indirectly supervised.

11. Counsel for the accused agreed with the Hospital’s position. Thus, the parties were ad idem on the type of Disposition but not on the privilege ceiling that it would confer to Mr. Zhan.

Evidence at the Hearing:

12. The Board had available to it the evidence and documents forming the Record, the Exhibits, and oral evidence from Dr. Ferencz who is Mr. Zhan’s attending psychiatrist.

13. Dr. Ferencz testified by way of update to the Hospital Report that a recommendation was made to Mr. Zhan to switch from oral medication to a long-acting injection (LAI), which Mr. Zhan agreed to consider.

14. Dr. Ferencz opined that Mr. Zhan is now quite improved compared to when he first arrived at SJHH, at which time he was experiencing residual psychotic symptoms, was energized and had difficulty sleeping, and was overly talkative. With adjustments to his medication regime, Mr. Zhan became and has remained clinically stable.

15. Dr. Ferencz observed that in the past, it has been the case that no matter how well Mr. Zhan has done, he has ultimately discontinued his psychiatric medications and when he has done that, he has posed a significant risk to the safety of the public and continues to do so to date.

16. In short, Dr. Ferencz testified that getting Mr. Zhan well is not the challenge: the challenge is keeping him well.

17. Dr. Ferencz explained that in order for Mr. Zhan to continue to progress through the forensic system, the treatment team wants to see him more engaged in structured recreational and therapeutic activities.

18. Dr. Ferencz also noted that in the past, Mr. Zhan was doing quite well in the community. He had a good living arrangement and he was working, so he had been stable, but in hindsight, Dr. Ferencz now believes that greater supervision for a longer period of time is required to mitigate the risk posed by Mr. Zhan to the safety of the public.

19. Dr. Ferencz also explained that the Hospital does not support Mr. Zhan’s Rule 13 transfer request, doesn’t see a point to it, but won’t oppose it either. He understood that Mr. Zhan intended to withdraw this request.

20. In response to questions by the Crown Attorney, Dr. Ferencz testified that after previously receiving an Absolute Discharge by the Board, Mr. Zhan was being followed by the Schizophrenia Outpatient Clinic (SOC), who were also supposed to be monitoring his medication compliance.

21. Mr. Zhan was able to convince the SOC to reduce his prescribed medication dosage and later told Dr. Ferencz that he had no trouble hiding his medication non-compliance from the SOC.

22. Dr. Ferencz testified that Mr. Zhan does not question his need for medication now, but rather, that he tends to negotiate around dosages and method of delivery of his medication. Mr. Zhan is considering switching to an LAI which would give the treatment team more confidence that Mr. Zhan’s long-term risk to the safety of the public can be successfully managed in the community.

23. Furthermore, Dr. Ferencz explained that a decompensation in Mr. Zhan’s mental status would take much longer to occur in the event of medication discontinuation were he receiving an LAI, compared to an oral antipsychotic.

24. In response to questions from Defence Counsel, it was established that Mr. Zhan did indeed wish to rescind his Rule 13 transfer request and that the patient wishes to have his attending psychiatrist changed to Dr. Naidoo, which Dr. Ferencz said he can ask to be completed but noted that he has no control over that decision.

25. Dr. Ferencz agreed that Mr. Zhan understands that he is expected to take antipsychotic medications indefinitely, but Dr. Ferencz was not certain that Mr. Zhan actually believed this to be true. Dr. Ferencz further explained that while Mr. Zhan knows that he has an illness that requires ongoing treatment, he believes that he can make or negotiate adjustments to his treatment.

26. In response to questions from the Panel, Dr. Ferencz testified that there was no evidence of any cognitive impairment in Mr. Zhan. With treatment, Mr. Zhan presents very well – he is sociable and a “really nice guy” according to the doctor.

27. When asked to resolve an apparent contradiction at page 64 of the Hospital Report in relation to different adjectives used to describe Mr. Zhan’s degree of insight, Dr. Ferencz described this as a “moving target” – he always says the right thing, but his behaviour is inconsistent with what he says.

28. Dr. Ferencz explained that on the surface, Mr. Zhan presents well, but as you get to know him better it becomes apparent that he is always looking for opportunities to negotiate something. For example, Dr. Ferencz stated that Mr. Zhan has consistently said over time that he has wanted to remain under his care, and yet at the hearing he expressed a desire to be transferred to Dr. Naidoo.

29. Dr. Ferencz agreed with the suggestion that it was concerning that Mr. Zhan knows the right thing to say. Dr. Ferencz replied that the team always has to be on its guard with Mr. Zhan.

30. Dr. Ferencz testified that he believes that Mr. Zhan has insight into what led to the offence committed in Scotland and that Mr. Zhan was very unwell at the time. When asked about what Mr. Zhan believes has led him to once again come under the jurisdiction of Board, Dr. Ferencz responded that Mr. Zhan recognizes that he wanted less medication and became unwell as a result.

31. According to Dr. Ferencz, the logic behind Mr. Zhan’s negotiations for lower doses of medication come from things that he has read, and as a result, Mr. Zhan has “certain ideas about what proper doses [of those medications] are.” This is partly why Dr. Ferencz finds Mr. Zhan capable of consenting to treatment. Dr. Ferencz stated he is open to Mr. Zhan’s ideas around nutrition and health in order to enhance his treatment but stressed this would not replace it. Dr. Ferencz would not object so long as Mr. Zahn was not supplanting his psychiatric treatment and there was no anticipated harm.

32. As it concerns Mr. Zhan’s degree of risk to the public, Dr. Ferencz concurred with the results of the HCR-20 v3 which assessed Mr. Zhan as presenting a high risk of future violence on an Absolute Discharge, but a low risk while under the Board’s jurisdiction.

33. Dr. Ferencz also opined that should the Board decline to grant Mr. Zhan indirect community passes, it would not have any major negative effect on his recovery.

34. In re-examination by the Crown Attorney, Dr. Ferencz testified that he is always concerned that Mr. Zhan may be engaging in impression management. While Mr. Zhan is forthcoming with respect to anxious symptoms, Dr. Ferencz felt that was not the case with subtle psychotic symptoms, which merit “close clinical observation”.

35. At the conclusion of the evidence, all parties maintained their initial positions.

Analysis and Conclusions: Disposition and Majority Decision on Terms & Conditions

36. Having heard and considered the entirety of the evidence as well as the submissions from the parties, the Board unanimously finds that Mr. Zhan does meet the threshold for significant threat to the safety of the public and finds that a Detention Order Disposition is the least onerous and least restrictive, necessary and appropriate Disposition in the circumstances.

37. The Panel has come to this decision after a careful review of the Ontario Court of Appeal decision in Ramos (Re), 2025 ONCA 820. While the facts in Ramos differ significantly from that of the present case, the ratio decidendi is relevant to all cases that the Board hears.

38. In summary, the case of Ramos requires the Board to:

39. Remain attentive to constitutional protections and avoid the influence of stereotypes or prejudice;

40. Give thoughtful weight to the reasonable wishes and preferences of NCR individuals, while still prioritizing community safety;

41. Undertake a careful, individualized assessment that avoids assuming permanent or inherent dangerousness and instead evaluates the person’s present clinical and social circumstances;

42. Keep the legal thresholds distinct from hospital preferences or institutional rule compliance, recognizing that clinical convenience cannot substitute for the legal test and conducting a holistic assessment which acknowledges strengths and improvements;

43. Exercise its own independent judgment when reviewing professional opinions; and

44. Approach hearsay evidence with care, ensuring that any reliance on such information is fair, balanced, and consistent with the Board’s dual role of protecting both individual rights and public safety.

45. A 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.

46. In determining whether Mr. Zhan represents a significant threat to the safety of the public, the Board has 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 and the definition of the term in s. 672.5401 of the Criminal Code.

47. Mr. Zhan suffers from a psychotic disorder which is largely treated by his current medication regimen within the structure and supports of the forensic mental health system. When unwell, Mr. Zhan has suffered from severe psychotic symptoms which led to the death of a person in Scotland and serious violent offences against members of the public while in Canada.

48. Mr. Zhan has a long-standing history of psychiatric hospitalizations, medication noncompliance or negotiating his doses and methods of administration, fluctuating insight into his need for treatment, and having concealed medication nonadherence and psychotic symptoms from mental health practitioners.

49. The uncontested evidence of Dr. Ferencz was that Mr. Zhan does well in a highly structured forensic setting and that getting him psychiatrically well isn’t the challenge: it is keeping him well on a long-term basis and under less stringent supervision and less structure.

50. Mr. Zhan has been before this Board previously. He has progressed through the forensic system and into the community previously. He has been absolutely discharged previously. He has been unable to remain medication adherent and eventually through negotiation and the concealing of his psychotic symptoms, has become unwell and committed a serious violent criminal offence once more.

51. As a result of his intelligence and his prior experience in the forensic system, it appears that Mr. Zhan has learned how to say the right things and to appear more well (on a superficial level) than he actually is. While Dr. Ferencz and the treatment team at SJHH are well aware of this concern and know that they have to question further with Mr. Zhan to get a true indication of his insight and his overall stability, those experts and support people without that familiarity may be deceived.

52. It is for those reasons that the Panel agrees with the parties that a Detention Order is the necessary and appropriate disposition, because Mr. Zhan’s risk cannot be managed in the community at this time under a lesser disposition.

53. Given the caution with which the Hospital has testified it will proceed when extending privileges to Mr. Zhan, the majority of the Panel agrees that there is a therapeutic benefit to extending indirectly supervised visits to the community, should Mr. Zhan progress in his recovery to the degree that he can exercise that specific privilege.

54. In consideration of all the evidence, the submissions of the parties, the wishes of Mr. Zhan and the criteria set forth in s. 672.54, the paramount consideration being the safety of the public, in addition to the mental condition of Mr. Zhan, his reintegration into society and his other needs, the majority of the Panel finds that a Detention Order Disposition with privileges up to entering the community of Hamilton indirectly supervised is the necessary and appropriate Disposition.

Dissenting Opinion of D’Intino, D.

49. For the reasons set out above I would agree with my colleagues and the joint submission that a Detention Order is the necessary and appropriate, least onerous and least restrictive Disposition, but I agree with counsel for the Attorney General that indirect community passes are premature and not appropriate at this time.

50. Mr. Zhan has history of committing acts of horrific violence when he is untreated or insufficiently treated. This is not his first time under the jurisdiction of the ORB.

51. Mr. Zhan is adept at progressing quickly through the forensic system and into the community, despite his continual attempts at negotiating the dosage and route of administration of his psychiatric medications. Dr. Ferencz testified to much of that at the hearing. Dr. Ferencz testified that he presents well and for those unfamiliar with him, they may not recognize that he suffers from a major mental illness.

52. The combination of his presentation, his skill and persistence of negotiating medication dosages apparently is what led to his relapse and the commission of the index offence for which he was brought again before the ORB. Mr. Zhan admitted to Dr. Ferencz that he had little difficulty concealing his medication nonadherence from the Schizophrenia Outpatient Team.

53. This is an enormous red flag, as is the fact that he continues to negotiate his medications and their routes of administration and suddenly wants to now switch his care to a doctor who is less familiar with his treatment (Dr. Naidoo), combined with his underdeveloped degree of insight into his need for medication.

54. Before the inclusion of indirectly supervised passes are appropriate, I would need to see Mr. Zhan maximize his current privilege ladder, use his directly supervised passes into the community appropriately, develop more robust insight into his illness and the need for medication through CBT-p and other therapeutic programming, and for cease his attempts at negotiating his medication dosages.

55. Once privileges are granted, it is difficult – but not impossible - for the Board to justify rescinding them at a later time. Each increase in privileges brings Mr. Zhan one step closer to an eventual Absolute Discharge. As such, the granting of any additional privileges must be made in a manner that is commensurate with his treatment progress and the degree of risk he poses to the public.

56. The Hospital report concluded that Mr. Zhan’s risk to the public can be managed with the support and strict oversight that comes with a Detention Order Disposition. Absent that, his risk of violence would be high. Historically, that has translated into serious bodily harm and death to victims.

57. The HCR-20 v3 takes into account a number of factors, both static and dynamic, in assessing a patient’s degree of violent recidivism. One of the clinical factors is problems with insight. Unless and until Mr. Zhan further develops insight into his mental illness and the connection between being properly medicated and maintaining his stability, the risk of him ceasing his medication remains high – particularly so long as he remains on an oral antipsychotic.

58. Should he switch to an LAI, Dr. Ferencz opined that the Hospital would be more comfortable with the long-term risk posed to the public by Mr. Zhan. Beyond that, I would like to see long-term compliance with his medications, be they oral or LAI, without the constant negotiation.

59. All parties agreed that Mr. Zhan represents a significant threat to the safety of the public. The exact nature of that threat is clearly articulated by his clinical history. The Hospital’s evidence was unequivocal in that Mr. Zhan does not present any safety or management concerns while in the Hospital. His risk escalates when he is outside of the Hospital.

60. Mr. Zhan has a history of medication noncompliance, which remains a present concern given that he is on oral-only antipsychotic medications. He requires very strict oversight to ensure he is taking his medications and that any successful negotiations regarding dosages do not result in him once again becoming inadequately treated. That oversight must remain long-term in order to ensure that when he is eventually discharged into the community, his risk remains managed for the long-term.

61. S. 672.54 of the Criminal Code sets out a number of criteria to consider when determining the least onerous and least restrictive, necessary and appropriate Disposition for an NCR accused. The paramount consideration is the safety of the public.

62. Furthermore, I considered the ONCA decision of Sookram (Re) 2024 ONCA 823. This case discussed, among other issues, whether the Board erred by not including a community living condition in a Disposition Order, notwithstanding the fact that there was not realistic possibility of that condition being achievable in the current reporting period.

63. I find that this case is distinguishable for two reasons. Firstly, the Court of Appeal in Sookram found that there were practical and well as therapeutic reasons for the inclusion of a community living clause in the Disposition, notwithstanding the unlikeliness that the patient would receive a bed offer and be discharged from the hospital prior to the next annual hearing.

64. Secondly, the ONCA found that there were “significant safeguards and no downside to doing so” – in relation to the inclusion of the community living privilege.

65. In contrast, in our case while we heard evidence from the hospital regarding the potential aspirational benefit of including indirectly supervised passes to the community, we did not hear evidence about “significant safeguards” to protect the public from Mr. Zhan and, as outlined in my dissenting opinion, the “downsides” to including such a provision are set out in detail.

66. In weighing the competing interests set out in s. 672.54 of the Code, I find that granting Mr. Zhan passes into the community indirectly supervised does not accord with the paramount consideration of public safety. Mr. Zhan will be able to access the community under direct supervision, when the Hospital feels that he has made sufficient progress in his course of treatment that his risk to the public can be managed while he is in the community.

67. Alternatively, if he progresses sufficiently rapidly, an early hearing could always be called to determine whether the addition of indirectly supervised passes is appropriate at that time.

DATED this 27th day of April 2026, at the City of Toronto, in the Toronto Region.

Mr. D. D’Intino

Legal Member

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Office of the Registrar

Ontario Review Board