Ontario Review Board
Re: Ashley Coulson
ORB File No: 7398
Hearing held on: Thursday, April 2, 2026
Place of Hearing: Brockville Mental Health Centre
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Mr. C. Flanagan
Members: Dr. Y. Alatishe
Dr. W. Loza
Ms. M. Chamberlain
Mr. S. Duffy
Parties Appearing:
Accused: Ashley Coulson
Counsel: Ms. M. Munsterman
The person in charge of hospital: Representative: Dr. A. Adiele
Attorney General of Ontario: Counsel: Mr. K. Schultz
REASONS FOR DISPOSITION
(Dated May 14, 2026)
Introduction
On July 31, 2018, Ashley Coulson was found not criminally responsible on account of mental disorder (“NCR”) on charges of possession of a weapon for a dangerous purpose, mischief under five thousand dollars, and mischief-interfering with lawful enjoyment of property, all contrary to the Criminal Code.
Mr. Coulson is currently subject to the terms of a Disposition dated March 3, 2025, which detains her at the Secure Forensic Unit of the Brockville Mental Health Centre - Member of the Royal Ottawa Health Care Group (“the hospital” or “BMHC”) with privileges including to enter the community of Brockville, indirectly supervised, travel passes up to 7 days accompanied by staff or a person approved by the person in charge, and to attend residential addictions treatment program within the Province of Ontario, as approved by the person in charge of the BMHC.
On April 2, 2026, a panel of the Board convened to review the Disposition in accordance with the requirements of s. 672.81(1) of the Criminal Code. Ms. Munsterman, counsel for Mr. Coulson, attended the hearing as Mr. Coulson did. A Hospital Report dated March 16, 2026, and a CPIC Response Report were filed as Exhibits 1 and 2, respectively at the hearing. In addition to the documentary evidence, Dr. A. Adiele, the attending psychiatrist, gave evidence at the hearing.
The issues to be determined are whether Mr. Coulson continues to represent a significant threat to the safety of the public, as defined in section 672.5401 of the Criminal Code, and if so, the necessary and appropriate Disposition to manage that risk, having regard to the criteria set out in s. 672.54 of the Criminal Code.
For the reasons set out below, this Board concluded that Mr. Coulson continues to represent a significant threat to the safety of the public and that the necessary and appropriate Disposition is the continuation of the existing Detention Disposition with the addition of both a community living condition and a reporting frequency condition.
Initial Position of the Parties
At the outset of the hearing, the parties were canvassed as to their recommendations to the Board.
Dr. Adiele, on behalf of the Hospital, recommended the continuation of the existing Detention Disposition on the same terms and conditions with the addition of a condition to live in accommodation in Southeastern Ontario approved by the person in charge.
Mr. Schultz, on behalf of the Attorney General of Ontario, supported the recommendation of the Hospital for the continuation of the Detention Disposition. Mr. Schultz submitted that he would prefer a radius regarding community living, such as within 200 km of the hospital.
Ms. Munsterman, on behalf of Mr. Coulson, conceded significant risk and supported the Hospital’s recommendation.
Index Offence
- The circumstances giving rise to the index offence are abstracted from the Hospital Report as follows:
“Mr. Coulson has a lengthy history with the police and community mental health services of the Pembroke area. He has had 39 police contacts with the former Pembroke Police and 62 contacts with the Upper Valley OPP. Recently, Mr. Coulson was assisted in placement in the Deep River area, at the Maple Lodge apartments, in Deep River.
On March 2, 2018, the victim was helping her brother, who was moving into one of the Maple Lodge apartments. She was standing in the main lobby, having a conversation with the Superintendent of the building who was seated in her office. Mr. Coulson left his apartment and entered the hallway approaching the victim. She thought nothing of it until she saw Mr. Coulson had a hatchet in his hand. He was carrying it in a manner that was at his side and the blade of the axe was pointing towards the victim. He immediately began to yell and scream, cursing and swearing. He said statements such as, "I am going to kill those fucking dogs. I can't fucking sleep with those fucking dogs barking outside all night. This is my apartment and I deserve to get some fucking sleep." He then said, "I have had enough of this fucking bullshit." During this time, the accused was tapping the axe against the wall. He then turned to walk back to his apartment at which time the superintendent grabbed the victim and brought her into her office where they locked the door and called 911.
Police arrived a short time later. They spoke to both female complainants and made their way down the hall to Mr. Coulson's apartment. When they got to a set of fire doors, they heard a very large "Bang" sound. Police asked the superintendent if the accused had a gun given it sounded like a gunshot. Mr. Coulson then exited his apartment door. It became evident the loud bang was the accused driving the axe through his apartment door. Police spoke to him and tried to convince him to come out and speak to the officers. They asked him a number of times to put down the axe. He then raised the axe and yelled, "Shoot me, shoot me," a number of times. He advised police to "not fucking come near" him and went back into his apartment and closed the door. During this exchange, police had secured the fire doors between them and the accused in case he rushed them. The accused then broke off any further communication with police.
The apartment was put under containment and back up was requested. The OPP Emergency Response Team, the Tactical Rescue Unit, incident commander and hostage negotiators arrived.
A number of residents and agencies were affected by this incident:
The residents of the immediate area surrounding the accused were evacuated from their apartments.
Ridge Road was shut down to pedestrian and vehicle traffic for a two-block area.
Paramedics had a number of vehicles assigned to the area and a command post.
Local schools when into a "Hold" and secure mode for students.
The long-term care facility across the street locked down and housed some of the residents of Maple Lodge.
Some of the businesses in the downtown area closed and locked their doors.
After 6.5 hours, Mr. Coulson was taken into custody after police breached the door and arrested him, lying on his bed. He was apprehended under the Mental Health Act and taken to the Deep River Hospital. A Form 1 was completed, and he was transferred to the Ottawa Hospital - Civic Campus.”
Personal Background/Psychiatric History
Mr. Coulson’s personal background and psychiatric history are extensively set out in the Hospital Report, filed as an exhibit at the hearing and need not be repeated in detail in these Reasons.
Mr. Coulson is a 43-year-old man born in Guelph, Ontario. His family moved to Pembroke in 2000. He never married and has no children. He has two younger siblings, with whom he has not had recent contact due to his illness and instability.
According to his parents, at the age of three, Mr. Coulson was having difficulty with aggression and extended periods of screaming. His aggression returned in his early teens, when he punched walls and caused other physical damage. His parents reported that their son's aggression increased over time, along with his illness.
Mr. Coulson's parents believe their son started to use drugs and alcohol around age 15. They explained that his use "got bad quickly" when he was using a variety of drugs and consuming alcohol. He did not finish high school and held several jobs briefly but could not sustain employment due to paranoid delusions.
Mr. Coulson “ran away” from home around the age of 16 and lived in a "home for troubled teens" in Brantford, Ontario. He lived there briefly prior to being kicked out and turned to living on the street. According to his parents, he had a girlfriend while residing on the streets in Brantford, Ontario. They reported he had delusions that he fathered two children with this girlfriend, despite the termination of their relationship. In 2012, he began sending her threatening messages in relation to his delusions of parenthood. He was involved in a second relationship that terminated just prior to Christmas 2009. His parents recalled that his mental health deteriorated rapidly subsequent to this break-up, and he began drinking excessively.
Mr. Coulson has a criminal record. On August 5, 2015, he was convicted of assault and failing to comply with probation. He received a suspended sentence (28 days presentence custody) and probation for one year. On March 15, 2016, he was convicted of causing a disturbance with suspended sentence (4 days presentence custody) and probation for 18 months.
At the age of 18, Mr. Coulson's mental health worsened. In April 2003, he received a diagnosis of schizophrenia and received follow-up from the Ottawa Hospital’s (“TOH”) First Episode Psychosis Program. Given his challenges with medication adherence and significant poly substance use, which resulted in psychotic symptoms, he became well known to various mental health services including four admissions due to his psychotic decompensation over the 2003-2006 period.
In approximately 2013, Mr. Coulson moved in with his brother and the two lived together for approximately 2 years. This ended in 2014 when Mr. Coulson’s delusions led him to threaten his brother and damage apartment furniture.
Over the next few years leading to the index offences, Mr. Coulson continued to have extensive contact with mental health agencies and community ACT teams. These episodes are all set out in detail in the Hospital Report. In this regard, he underwent multiple ER visits and hospital admissions at different hospitals, due to episodes of psychosis characterized by paranoid delusions, auditory hallucinations, and disorganized thinking, occurring in the context of substance use and/or nonadherence to treatment.
On March 2, 2018, the day of the index offences, the ACT team, police and the Pembroke Regional Hospital met to discuss how to better manage Mr. Coulson's risk in the community. Mr. Coulson reportedly stopped all medications in December 2017.
Mr. Coulson was found NCR on July 31, 2018. He was subsequently transferred to the Royal Ottawa Mental Health Centre (“ROMHC”) under the jurisdiction of the Review Board. Notably, Mr. Coulson received a Conditional Discharge from the Board in 2022. This was followed within months by three hospitalizations under the Mental Health Act, repeated positive urine drug screens for amphetamines, the commencement of a delusional relationship, and the keeping of a knife near his front door for self-protective purposes - conduct closely paralleling the index offence in structure and content. Mr. Coulson was transferred to Brockville Mental Health Centre in March 2025.
Mr. Coulson is unemployed and financially supported by the Ontario Disability Support Program (“ODSP”) and remained in hospital at the time of the hearing.
Current Diagnosis
- Mr. Coulson’s diagnoses consist of schizophrenia, multiple episodes (in partial remission), stimulant use disorder (severe) and cannabis use disorder (in sustained remission).
Evidence at the Hearing
The Hospital’s evidence was presented through the oral testimony of Dr. A. Adiele to supplement the Hospital Report, filed as an exhibit at the hearing.
On March 11, 2025, Mr. Coulson was transferred to BMHC from the ROMHC. As reported in the Hospital Report, Mr. Coulson's interpersonal presentation throughout the reporting period has been notably withdrawn. He spends extended periods of time in his room and engages minimally with both peers and staff, interacting primarily to communicate immediate needs. His cultural needs have been supported through continued access to smudging with Spiritual Care.
Mr. Coulson has been adherent to his medication regimen throughout the reporting year and there have been no incidents of violent behaviour. Dr. Adiele advised Mr. Coulson is an accomplished guitar player, who also enjoys skateboarding.
During the reporting year, there were several incidents involving substance use. On July 4, 2025, Mr. Coulson eloped from his approved itinerary while on a unit transfer pass. He later disclosed that "I went outside on my itinerary and met a guy who gave me crack, I came back to the unit and staff found a vape in my pocket." A urine drug screen was collected with a positive result for cocaine. In this regard, Dr. Adiele advised that cocaine is a very strong psycho stimulant that has the potential of significantly increasing the risk for aggression and violence.
On October 30, 2025, urine toxicology screening returned positive results for cocaine. No changes were noted in his mental state. About a week prior, Mr. Coulson was observed by video approaching a SUV outside the hospital grounds where he was not permitted. Mr. Coulson initially denied use but admitted it several weeks later. He advised he continues to have cravings for stimulants.
In March 2026, Mr. Coulson enrolled in the Cognitive Behavioural Therapy (“CBT”) for substance use program, a ten-week, twice-weekly group facilitated by a Behavioural Therapist and an Addictions Counsellor. On March 12, 2026, he did not attend the scheduled session and was advised that non-attendance on more than two occasions may result in discharge from the group. Dr. Adiele advised that Mr. Coulson has since attended and is also engaged in 1:1 counseling from an Addiction Counselor.
By way of update, Dr. Adiele advised that a urine drug screen taken on March 23, 2026, returned on March 27, 2026, with a positive result for cocaine. As a result, Mr. Coulson’s privileges were suspended, allowing only staff accompanied passes to the hospital’s secure yard. The doctor reported that there were no noted changes in Mr. Coulson’s mental state at that time. Mr. Coulson advised the doctor that he still struggles with cravings, although it is taking longer for him to use which he sees as positive. Dr. Adiele highlighted that Mr. Coulson engages with the substance groups but doesn’t apply the skills learned when he experiences cravings and/or is offered substances.
Mr. Coulson demonstrates partial insight into his mental illness and his plan of care. Dr. Adiele advised that Mr. Coulson has poor insight into substance use. His impulse control and judgment have been documented as poor during this reporting period, as evidenced by the incidents of substance use. Dr. Adiele advised that it is the treatment team’s intention to have him attend a residential treatment group, over the next year, an existing condition in his Disposition.
Dr. Adiele agreed that residential placement for three months would be helpful given his ongoing substance issues. The doctor advised that a placement has not been explored as the treatment team was hoping to make progress with his substance counseling towards a discharge but in light of the most recent substance use, the doctor supports a three-month intensive residential placement.
Dr. Adiele advised that successful completion of this program may lead to community discharge, but he was not optimistic given the number of positive tests for stimulants over the reporting year. In any event, the doctor confirmed that the hospital was requesting a living in the community condition to include Southeastern Ontario. On a question from a Board member, the doctor agreed given the ambiguity of what constitutes “Southeastern Ontario”, it might be preferable to impose a kilometer radius.
Dr. Adiele adopted the Hospital Report that states that Mr. Coulson is a significant threat to the safety of the public and should remain on a Detention Order. As stated, on page 114 of the Hospital Report:
“His [Mr. Coulson] risk is assessed as being in the Moderate to High range at the current time, reflecting the combination of his substantial and enduring historical risk burden and the relatively recent nature of confirmed community substance use and elopement during this admission. Appropriate and proportionate clinical and supervisory conditions are assessed as necessary and capable of mitigating this risk to a manageable level over the forthcoming period.”
- No further evidence was presented at the hearing.
Final Submissions of the Parties
Dr. Adiele, on behalf of the Hospital, maintained his initial recommendation. The doctor submitted that if the Board was not satisfied with the proposed condition “to live in accommodation in Southeastern Ontario approved by the person in charge”, he suggested a radius of 350 km from hospital, which included Pembroke, Mr. Coulson ‘s previous community.
Mr. Schultz, on behalf of the Attorney General of Ontario, maintained his initial position for a continuation of the Detention Disposition. He supported the living out condition in approved accommodation, but with a radius of 250 km from hospital which would include Pembroke. He stated that 350 km would include places like Toronto, which was not the intent of the proposed condition. Mr. Schultz submitted that although Mr. Coulson may not attain community living in the next year, it serves as motivation for him.
Ms. Munsterman, on behalf of Mr. Coulson, reiterated that significant threat was conceded and a Detention Disposition is the most appropriate Disposition. She supported the addition of a community living condition in approved accommodation to the Disposition and asked that the Board consider a radius of 275 km, in light of Mr. Coulson’s ties to the Pembroke area.
Analysis, Conclusion and Disposition
Having considered all the evidence presented at the hearing, this Board finds that Mr. Coulson continues to pose a significant threat to the safety of the public as set out in s. 672.5401 of the Criminal Code. We make this finding based on the oral evidence of Dr. Adiele and the evidence contained in the Hospital Report filed as an exhibit at the hearing, notwithstanding the joint position on significant threat by the parties.
Mr. Coulson index offences involve the use of a weapon during a psychotic episode. He has treatment-resistant schizophrenia, characterized by persistent positive symptoms, negative symptoms and cognitive impairment, as well as two substance use disorders. He has a long history of psychosis, often triggered by substance use and/or treatment nonadherence leading to violent behaviour. His supervision failures are substantial and span both community and inpatient contexts.
As stated above, Mr. Coulson remains a significant threat to the safety of the public. This Board accepts the evidence of Dr. Adiele, and the assessment of risk as outlined on pages 106-114 of the Hospital Report. Substance use remains a significant risk factor for him. Unfortunately, Mr. Coulson has had a number of positive urine screens over the reporting year for stimulant use, notably cocaine, and continues to experience ongoing cravings that have made him susceptible to substance use when available, despite ongoing psychotherapy. In this regard, his impulse control, judgement and insight into such use have been poor.
Despite a stated intention to refrain from substance use, he has not been able to do so, as evidenced by recent cocaine use within two weeks of the hearing. Mr. Coulson will need to learn how to manage his cravings, rather than succumb to them. In this regard, notwithstanding ongoing psychotherapy, it is clear from the evidence that Mr. Coulson requires long term residential treatment to focus on his ongoing substance issue. This Board is hopeful that such a placement can be facilitated in the coming year.
On a positive note, over the reporting year, Mr. Coulson has had no untoward aggressive behaviour and has been compliant with his medication regimen. He is an accomplished guitar player and enjoys activities such as skateboarding. He engages with his treatment team and has a good relationship with his psychiatrist, Dr. Adiele. This Board acknowledges that Mr. Coulson’s addiction is long-standing, entrenched and difficult for him to deal with when presented with opportunity. In this regard, it is noteworthy that Mr. Coulson has reported that although ongoing, his cravings are less frequent.
The Request for a Community Living Condition
This Board agrees that a condition permitting Mr. Coulson to reside in accommodation approved by the person in charge should be added to the Disposition. This Board this hopeful that Mr. Coulson can receive the necessary treatment needed, which at this stage appears to be an intensive residential treatment program to better address his substance use, most particularly, cocaine, and facilitate his ability to deal with his going cravings. Although this may be a difficult road for Mr. Coulson, it may be that successful progress can be made, leading to a potential discharge into the community by the end of the coming year. In this regard, given Mr. Coulson’s ties tom the Pembroke area, this Board agrees to a radius of 275 km from BMHC with a minimum frequency of reporting not less than four times a month.
Although not advanced by the parties, a Conditional Discharge Disposition is not appropriate at this juncture. Notably, given all the current risk factors, the hospital needs to approve Mr. Coulson’s accommodation should he be discharged in the coming year.
For all these reasons, this Board finds the necessary and appropriate, and least onerous and least restrictive Disposition is the continuation of Mr. Coulson’s existing Detention Disposition, with the addition of two conditions, namely:
To live in the community within 275 km radius of hospital in accommodation approved by the person in charge; and
While living in the community, report to the person in charge, not less than 4 times per month.
- In reaching our decision, this Board has considered the safety of the public, Mr. Coulson’s
mental condition, his reintegration into society, and his other needs.
DATED this 14^th^ day of May, 2026, at the City of Toronto, in the Toronto Region.
Mr. C. Flanagan
Alternate Chairperson
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Office of the Registrar Ontario Review Board