Ontario Review Board
Re: Blair F. Coling
ORB File No: 6954
Hearing held on: Tuesday, May 5, 2026
Place of hearing: Centre for Addiction and Mental Health
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Mr. G. Beasley
Members: Dr. Y. Alatishe
Dr. L. Leong
Ms. J. Ferguson Mr. W. Apted
Parties Appearing:
Accused: Blair F. Coling
Counsel: Ms. C. Whillier
The person in charge of hospital: Counsel: Ms. G. Meaney, student-at-law
Attorney General of Ontario: Counsel: Mr. D. Brandes
REASONS FOR DISPOSITION
(Dated June 3, 2026)
Introduction:
1On May 11, 2016, Mr. Blair Coling was found not criminally responsible on account of mental disorder (“NCR”) on charges of mischief not exceeding $5,000 (x2), and assault causing bodily harm, all contrary to the Criminal Code of Canada.
2Mr. Coling is currently subject to the terms of a Disposition of the Ontario Review Board dated May 27, 2025. That Disposition requires him to be detained in the General Forensic Unit of the Centre for Addiction and Mental Health (“CAMH” or the “hospital”), with privileges up to and including living in the community in supervised accommodation approved by the person in charge.
3On May 5, 2026, the Board convened to hold Mr. Coling’s annual hearing pursuant to s. 672.81(1) of the Criminal Code. Mr. Coling was represented by counsel, Ms. Whillier.
4At the outset of the hearing, the Board noted that Mr. Coling was not in attendance. Ms. Whillier advised that she had instructions and was prepared to proceed in her client’s absence and asked that he be excused. The Board conducted the hearing in Mr. Coling’s absence and he was excused from attending the hearing pursuant to s. 672.5(10)(a) of the Criminal Code.
5The issues to be considered at this hearing are whether Mr. Coling is a significant threat to the safety of the public as now defined in s. 672.5401 of the Criminal Code and, if he is found to be a significant threat to the community, the determination of the necessary and appropriate Disposition in the circumstances bearing in mind the factors enunciated in s. 672.54 of the Criminal Code.
6For the reasons set out below, this Board concluded that Mr. Coling continues to represent a significant threat to the safety of the public. This Board is satisfied that Mr. Coling’s continued detention at CAMH within a General Forensic Unit on the same terms and conditions as are set forth in his existing Disposition remains necessary and appropriate.
Positions of the Parties:
7At the commencement of the hearing, the parties were canvassed as to their, without prejudice, recommendations to the Board. The hospital’s representative advised that the hospital took the position that Mr. Coling remains a significant threat and was recommending that Mr. Coling continue to be subject to the terms of his existing Disposition with the exception that reporting be reduced to no less than once per month. Counsel for the Attorney General was supportive of the hospital's position including the amendment. Ms. Whillier indicated that she also agreed with the hospital’s position and the proposed amendment. Therefore, a joint submission was made to the Board.
Index Offence:
8The circumstances giving rise to the index offence are set out in last year’s Reasons for Disposition dated June 18, 2025, as follows:
“On May 16, 2015, Mr. Coling, who was an involuntary psychiatric patient at the Freeport Hospital in Kitchener, Ontario, exited his room. When he was directed to return to his room, he became agitated and caused approximately $300 in damages to his room.
Approximately two hours after damaging his room, when a male nurse told Mr. Coling that it looked like he had had a difficult night, he became enraged and an altercation ensued during which he bit the nurse once in the chest, breaking the skin and punched him several times in the stomach and head. Other staff intervened and restrained Mr. Coling. As the victim was being taken away for treatment, Mr. Coling stated "I'm going to kill your children".”
Personal Background/Psychiatric & Legal History
9The Hospital Report dated April 29, 2026 (the “Hospital Report”) sets out in detail the background, long and complex psychiatric history of Mr. Coling and need not be repeated here. Briefly, Mr. Coling is a 45-year-old man who was born in Waterloo, Ontario.
10Mr. Coling reported that he did not always get along with his father, who his mother described as being physically and verbally abusive towards herself and her son. His parents eventually separated and Mr. Coling spent the majority of his childhood and adolescence in structured residential treatment facilities.
11Mr. Coling began presenting with behavioural problems at a very early age. Between the ages of 6 and 19 he was placed at different programs including the St. Agatha Community and Home Support Program, the Charlestown Residential School for two years, an assessment and residential treatment centre called Lutherwood for six months when he was 16 and the Pioneer Group Home at age 16 for the next three years.
12Mr. Coling had significant behavioural and academic problems in school and eventually quit during his first year of high school.
13His only employment history was working for approximately two months at McDonald's restaurant when he was 19.
14Mr. Coling has a significant history of substance abuse starting in his teens. He has used a variety of substances including crack cocaine, heroin, acid, marijuana, ecstasy and alcohol.
15Mr. Coling’s involvement with the criminal justice system and acts of aggression and violence began in 2005 and continued into 2015 when the index offences were committed, which offences resulted in a finding of NCR. Mr. Coling has faced multiple criminal charges since 2005, which include counts of assault, assault with a weapon, theft under $5,000, failure to comply with a probation order, possession of a weapon, uttering threats, assault causing bodily harm and mischief under $5,000.
Current Diagnoses:
16Mr. Coling’s current diagnoses are:
Autism Spectrum Disorder;
Intellectual Disability, mild;
Schizoaffective Disorder, bipolar type;
Polysubstance Use Disorder, in remission in controlled environment; and
Possible Antisocial and Borderline Personality Traits.
Evidence at the Hearing:
17Evidence at the hearing consisted of the Hospital Report dated April 1, 2026, and the oral evidence of Dr. Chan, who took over his treatment from Dr. Van in 2025.
18The Hospital Report dated April 1, 2026, set out the following with respect to Mr. Coling’s last reporting year as follows:
Overall, Mr. Coling had a relatively stable reporting year with no critical incidents though he had three notable incidents. He remained compliant with treatment recommendations, and there were no concerns of recurrent substance use. Although he remained superficially cooperative, he became irritable and dismissive, especially when his illness or index offence were brought up. He continued in endorse delusional sentiments and respond to internal stimuli. Attempts to explore these thoughts were met with hostility. He remained reluctant to engage with staff and organized programming.
Notable Incidents
On July 15, 2025, Mr. Coling was noted by his case manager to be elevated, irritable, and unhappy with his housing. Part of his concerns were delusional, describing Reena as a “Jewish organization” and referencing “WWII and oppressive practices used then.” He also voiced concerns with the food, his roommate, and his neighbours, suggesting they were making it difficult for him to sleep. However, there were no hostile or aggressive behaviours noted. There were also no concerns for substance use or medication non-compliance. When he was seen by his psychiatrist the following week, he was noted to be near his baseline. No changes were made to his care plan.
On December 18, 2025, Mr. Coling’s UDS came back positive for antipsychotic medications that he was not prescribed. There were no recreational drugs identified. There were no associated behaviour concerns or incidents. Upon reviewing this with his case worker, itwas different that week due to the holiday period.
On March 19, 2026, Mr. Coling did not attend his virtual psychiatric follow up appointment. His housing was contacted and his appointment was scheduled for later in the day. This was likely due to a miscommunication with the housing staff. Mr. Coling was at his baseline when he attended the appointment later in the afternoon.
Mental Health and Insight
Mr. Coling remained with treatment resistant schizophrenia. He continued to display chronic psychotic symptoms, including grandiose delusions, having “zillions of dollars,” multiple wives and children, as well as Capgras delusions, believing his family and mother are not his real family. At times he endorsed racist sentiments, stating that he wanted a Caucasian provider, and he did not get along with “Sikhs.” Although he repeatedly denied experiencing any auditory hallucinations, he was periodically seen laughing and talking to himself. At times, this occurred in the middle of the night. These symptoms persisted throughout the year despite medication optimization and compliance. Despite these residual symptoms, Mr. Coling’s behaviours did not escalate. They did not lead to any physical violence or property destruction. They responded well to redirection.
Mr. Coling has a diagnosis of autism spectrum disorder (ASD), complicated by his antisocial personality traits and traumatic upbringing. Changes in his routine, specifically his in-person appointments at CAMH, remained particularly triggering for Mr. Coling. He also remained sensitive to situational stressors and interpersonal conflict, including those involving his roommate. His personality construct and autism diagnosis were managed well with a rigid routine, consistent behavioural plan, and a highly structured environment.
Mr. Coling’s insight into his mental illness and current legal circumstances remained poor. He continued to deny having any mental health issues nor any symptoms of major mental illness. He continued to assert that his delusional schemas were all true. Attempts to explore this with him led to irritability and at times, hostility. However, he remained compliant with his medications and indicated that he planned to remain on them in perpetuity. He has acknowledged that they had been helpful, though he had not provided further insight into how they have helped him.
When asked about his index offences, Mr. Coling denied that they occurred. He suggested that he was never at the facility that they occurred at. He said that he did not know anything about them. When attempts were made to discuss details outlined in the synopsis, he became agitated and dismissive.
Mr. Coling remained dismissive of the ORB. He did not feel that the ORB had any authority over him. Attempts were made to discuss his legal circumstance, but he remained dismissive and became increasingly hostile with the discussion. He declined to participate in his annual hearing, which he has done for many years. However, he did not have any concerns with his current living circumstance or his current limitations. He did not describe any desired changes.
19Dr. Chan testified that Mr. Coling had a relatively stable year thanks to his current situation and the stable housing he is in. Mr. Coling has done well with his ongoing medication regimen and has not used any substances. Dr. Chan added that without these factors being in place, Mr. Coling has difficulties which necessitate the need for the treatment team to be able to intervene early to bring Mr. Coling back to hospital if needed. Dr. Chan gave evidence that the housing in which Mr. Coling currently resides is a highly supported, 24- hour supervised facility with locked doors and Mr. Coling is always escorted when he leaves. Dr. Chan added that because of the nature of this secure housing, CAMH doesn’t have to be as closely involved with Mr. Coling.
20In response to a question from Ms. Whillier as to whether Mr. Coling intends to remain on his prescribed medications indefinitely, Dr. Chan testified that Mr. Coling endorses that his medications have helped him but is unable to articulate how they help and Mr. Coling’s insight remains poor.
21In response to a question as to how Mr. Coling views substance use, Dr. Chan gave evidence that the treatment team had no concerns regarding Mr. Coling’s use of substances and he has not described substance cravings.
22In response to a question about how many workers were assigned to Mr. Coling, Dr. Chan testified that there are no longer two DSO workers assigned to him now that he has gotten through the big adjustment of adapting to Reena House and that he has now adjusted very well. Dr. Chan noted that there are also no concerns about instability or violence, that Mr. Coling follows direction from staff well. In addition, Dr. Chan indicated that there is no time limit to Mr. Coling’s stay at Reena House.
23In response to a question about access to the community, Dr. Chan testified that Mr. Coling has no access to the community except when he’s escorted, which is a typical practice for Reena house patients to help ease the transition for people with high support needs like Mr. Coling.
24In response to a question noting that Mr. Coling still experiences symptoms of his mental illness including delusions, Dr. Chan testified that Mr. Coling has highly treatment resistant schizoaffective disorder and residual symptoms that did not respond to ECT. However, Mr. Coling does not fixate on them and they are not associated with aggressive or violent behaviour. Dr. Chan noted that Mr. Coling’s diagnosis of schizoaffective disorder presents very much like schizophrenia, especially with respect to Mr. Coling’s symptoms.
25In response to a question about Mr. Coling’s high PCLR score, Dr. Chan testified that it is valid despite Mr. Coling’s disability as the score is based on behaviours. Dr. Chan noted that although Mr. Coling used indirectly supervised passes when in hospital, now he is always escorted when he goes out into the community and that requirement is both one of the “house rules” at his current housing and a requirement of the treatment team. Dr. Chan added that there are lots of differences between being an in-patient and an outpatient and that transitioning to being an out-patient often requires closer support and supervision. However, it is a goal for the future for Mr. Coling to be able to go out unescorted. Dr. Chan gave evidence that, at first, Mr. Coling was unhappy with his housing but that has changed and he is progressing and should, in time, get to indirectly supervised passes from his housing. Dr. Chan noted that there have been no concerns about substance use over the year although there was one urine screen that was not in line with what was expected, but it may be attributable to a mix up in the lab. The treatment team still wants the disposition to include a drug screening clause.
Final Submissions:
26At the conclusion of the hearing, all parties maintained their initial positions with respect to the joint submission that the existing disposition should continue with one change being the reduction in reporting to no less than once per month.
Analysis and Conclusion:
27The Board carefully considered all the evidence and the submissions of all parties and finds that Mr. Coling continues to pose a significant threat to the safety of the public as defined by the Supreme Court of Canada in Winko.
28In coming to this conclusion, the Board takes into consideration that Mr. Coling continues to suffer from a treatment resistant major mental illness and continues to experience residual psychotic symptoms. In addition, he has fairly recently been diagnosed with Autism Spectrum Disorder in addition to his diagnosis of a mild Intellectual Disability. He also has a history of substance use disorder. When unwell, he has acted out with physical violence, as was the case at the time of the index offence. Further, he has a history of violence and criminal behaviour that pre-dates the index offence. As a result of Mr. Coling’s challenges, his insight remains poor regarding his mental illness and its symptoms, the need for treatment in perpetuity and his risk when unwell.
29Mr. Coling has now settled in well to his residence at Reena House after some difficulties when he first arrived. He receives 24/7 support in a locked environment and leaves only with an escort. However, Mr. Coling has made progress this reporting year prompting the treatment team to recommend that his reporting be reduced to not less than once per month. It is clear from the evidence that this high level of support and structure he has had through the current detention order is necessary to ensure both the safety of the public and the continued progress of Mr. Coling toward greater liberties and eventual reintegration into the community. The Board is satisfied by the evidence that, absent such support, Mr. Coling would likely fall away from treatment and/or relapse to substance use, with the attendant likelihood of a deterioration of his mental status and the re-emergence of his residual symptoms of psychosis which would greatly increase the risk to the public of violent behaviour by Mr. Coling.
30The Board is unanimous in its finding that a Detention Order remains necessary and appropriate to safely manage Mr. Coling’s risk to public safety and is the least onerous and least restrictive disposition at this time. This panel agrees with the position of the treatment team that the Mental Health Act would not be sufficient to manage Mr. Coling’s risk to public safety and a detention order also allows the hospital to maintain control over his placement in the community and to pro-actively and promptly address any mental status deterioration and return Mr. Coling expeditiously to the hospital for re-admission should he become unwell in the community.
31Based upon the evidence presented, the Board finds that the necessary and appropriate Disposition in the circumstances is that Mr. Coling continue to be bound the terms of his existing Detention Order subject to an amendment to the reporting provision so that Mr. Coling need report not less than once per month.
32In reaching our decision, this Board has considered the need to protect the safety of the public, Mr. Coling’s major mental illness and his other complex needs, and his reintegration into society.
DATED this 3rd day of June, 2026, at the City of Toronto, in the Toronto Region.
Ms. J. Ferguson
Legal Member
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Office of the Registrar
Ontario Review Board