Re: Sandra Alexander
ORB File No: 7561
Hearing held on: Wednesday, May 6, 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: Sandra Alexander Counsel: Mr. A. Rai
The person in charge of hospital: Counsel: Ms. M. Warner
Attorney General of Ontario: Counsel: Mr. D. Brandes
REASONS FOR DISPOSITION
(Dated June 12, 2026)
Introduction
[1]. On June 14, 2019, the accused, Sandra Alexander, was found not criminally responsible on account of mental disorder on charges of assault with a weapon (x3), utter a threat to cause death or bodily harm, and assault (x3), all contrary to the Criminal Code of Canada. By reason of Disposition of the Ontario Review Board (“ORB”) dated May 12, 2025, Ms. Alexander was ordered to be discharged on conditions as set out in the Disposition dated May 12, 2025. On May 6, 2026, the ORB convened a hearing at the Centre for Addiction and Mental Health (“CAMH”) for the purpose of the annual review of Ms. Alexander's Disposition pursuant to s. 672.81(1) of the Criminal Code. Ms. Alexander did not attend the hearing but was represented by counsel, Mr. Rai. Mr. Rai requested that Ms. Alexander be permitted to be absent and with the consent of all parties, Ms. Alexander was excused pursuant to s. 672.5(10)(a) of the Criminal Code. Ms. Warner appeared as counsel for the hospital and Mr. Brandes as counsel for the Attorney General of Ontario.
Index Offences
[2]. The circumstances of the index offences are summarized as follows:
“In summary, the first three index offences occurred on July 6, 2018. Ms. Alexander was causing a disturbance at a Tim Hortons store in Mississauga. When asked to leave, she burned a customer with a cigarette and threatened to burn another person who attempted to assist the first victim. She also spat on a third customer. Police arrested her a short distance from the store.
Ms. Alexander was detained in custody at the Vanier Centre after her arrest. On July 10, 2018, she was transferred to the Oakville Trafalgar Hospital, where she presented as manic with disinhibited behaviour. She reported auditory hallucinations and paranoid persecutory delusions. She was verbally abusive to staff and correctional officers. Once stabilized with treatment, she was returned to the Vanier Centre on July 20 and was discharged from that facility on July 26, 2018.
On July 29, 2018, Ms. Alexander was causing a disturbance at a bus shelter in Mississauga. She uttered racial slurs to one of the victims and flicked a lighter at her, threatening to burn her. The second victim tried to intervene, and Ms. Alexander attempted to rip off that person’s hijab. Ms. Alexander then turned to the third victim and tried to take away her sunglasses. When she was unsuccessful in doing so, she spat on that person.
She was arrested by police, charged and released on a promise to appear.
On August 5, 2018, Ms. Alexander was brought to the ER at Trillium Health Partners, presenting with bizarre behaviour secondary to polysubstance use and medication noncompliance. Her urine toxicology screen was positive for methamphetamine, MDMA, amphetamine, cannabis, and benzodiazepines. She had prescribed her “usual” antipsychotic medications and discharged home two days later.
On August 18, 2018, Ms. Alexander confronted and then punched a person who had just finished a purchase at a lottery booth.
All of the victims of the index offences were strangers to Ms. Alexander.”
Current Diagnoses
[3]. The current diagnoses as taken from the Hospital Report are:
Bipolar 1 Disorder;
Substance Use Disorder;
Borderline Personality Traits.
Criminal Record
[4]. Full details of Ms. Alexander's prior criminal history are incomplete. The Hospital Report indicates that on October 27, 2003, Ms. Alexander was convicted of assault with a weapon and received a suspended sentence. On the same date she was placed on 12 months’ probation for obstructing a peace officer.
Background and Personal History
[5]. The Hospital Report, which was filed as an exhibit at the hearing, contains a detailed review and information about Ms. Alexander’s background and psychiatric history. Those details will not be repeated in these Reasons. By way of summary of Ms. Alexander’s background, Ms. Alexander is a 43-year-old woman currently supported by the Ontario Disability Support Program (“ODSP”). Her daughter, who was born when Ms. Alexander was 19 years old, resides in Muskoka with her two children. Ms. Alexander also has a 10-year-old son who resides in the Barrie area with his father. It is reported that Ms. Alexander was sexually assaulted by a friend of her mother’s when she was a child. She left home at the age of 15. Ms. Alexander acknowledges substance abuse up until the birth of her daughter when she stopped. At the time of the index offences Ms. Alexander was using cocaine and methamphetamine.
[6]. Between 2014 and 2018, Ms. Alexander had multiple admissions to hospital in the context of non-adherence of medication, substance use and aggressive and bizarre behaviour in the community. She reported experiencing sleeplessness, agitation, anger, confusion, and paranoia. When she felt stress or went through a major life event, she would experience insomnia when her symptoms would return.
Position of the Parties
[7]. At the outset of the hearing Ms. Warner submitted that Ms. Alexander continues to represent a significant threat to the safety of the public and that the necessary and appropriate disposition was a continuation of the current Conditional Discharge without amendment. Mr. Brandes supported the opinion and recommendation of the hospital as did Mr. Rai, on behalf of Ms. Alexander. All parties conceded that there would be no challenge to a finding that Ms. Alexander continues to represent a significant threat.
Evidence
[8]. The evidence on behalf of the hospital was presented by Dr. Kravtsenyuk, the author of the Hospital Report which was filed as an exhibit. Dr. Kravtsenyuk stated that she is Ms. Alexander’s most responsible physician. Dr. Kravtsenyuk said that there were no updates to the Hospital Report which was dated April 23, 2026. Ms. Alexander was stable, doing well and residing in the community.
[9]. Dr. Kravtsenyuk stated that Ms. Alexander is “one of her best patients.” She is connected to the treatment team and is working well towards an Absolute Discharge. Dr. Kravtsenyuk said that Ms. Alexander values her connection to the Forensic Outpatient Team (FOPS); she is fully compliant with her antipsychotic medication and has support of her family in the community. Dr. Kravtsenyuk said that Ms. Alexander is “doing very well.” The treatment team are attempting to transition Ms. Alexander to an Absolute Discharge but want to establish a strong connection for Ms. Alexander with a family doctor in the community. Dr. Kravtsenyuk said that not all family doctors are comfortable with responsibility for the medications required for patients suffering from a major mental illness. Ms. Alexander will require the support of the civil mental health system. Dr. Kravtsenyuk said that it is difficult to get a community psychiatrist to accept Ms. Alexander as a patient.
[10]. Dr. Kravtsenyuk was asked about Ms. Alexander’s admitted use of cannabis. Dr. Kravtsenyuk said that Ms. Alexander is candid about her use and that it is primarily as a sleep aid and she uses “gummies” for that purpose. There has been no observable decompensation in Ms. Alexander's mental status as a result of this use. Dr. Kravtsenyuk said that the treatment team are able to fully support Ms. Alexander and manage her risk to the community under the terms of the current Conditional Discharge. Given Ms. Alexander's high degree of cooperation with the treatment team, the provisions of the Mental Health Act (“MHA”) are sufficient to protect the safety of the community.
[11]. Mr. Brandes did not have any questions for Dr. Kravtsenyuk.
[12]. In response to questions from Mr. Rai, Dr. Kravtsenyuk acknowledged that Ms. Alexander had stopped taking one of her medications in May of 2025 due to side effects. There was no observable decompensation in her mental status at that time. Dr. Kravtsenyuk said that Ms. Alexander is, however, very sensitive to dosage changes in her antipsychotic medications, but she has good insight into her need for medications and her illness and works with the treatment team. Ms. Alexander is capable to make her own treatment decisions. Dr. Kravtsenyuk characterized Ms. Alexander's level of insight as “excellent.”
[13]. Dr. Kravtsenyuk was asked by a member of the Board how the treatment team came to the conclusion that Ms. Alexander continues to represent a significant threat. Dr. Kravtsenyuk stated that Ms. Alexander’s mental status is controlled by her compliance with her antipsychotic medications. If there was any change to her current full compliance, along with an increased use of cannabis or other substances then there would be a high risk of deterioration. Dr. Kravtsenyuk characterized Ms. Alexander's reaction to the above scenario as a rapid and intense decompensation in her mental status and the resulting significant risk to the safety of the public. Dr. Kravtsenyuk stated that Ms. Alexander is sensitive to changes in her sleep or mood and would recognize the decompensation in her mental status. Ms. Alexander would reach out to the treatment team for support.
[14]. Dr. Kravtsenyuk was asked when the treatment team might be in a position to recommend an Absolute Discharge. She stated that this recommendation would come when Ms. Alexander has established a connection with a parallel mental health service in the community. Ms. Alexander would also have to be psychologically prepared for the transition away from the current treatment team and support of the hospital. Dr. Kravtsenyuk stated that an Absolute Discharge at the present time would cause Ms. Alexander considerable stress. She emphasized that it would take some time to complete a transition with the safety net of the civil system. The treatment team are working to find a civil referral for Ms. Alexander but as described earlier, this has been difficult. Dr. Kravtsenyuk did say that if the Board decided to issue an Absolute Discharge, the treatment team would bridge services until a civil support team was in place. Dr. Kravtsenyuk said that if Ms. Alexander were told that there was no longer an ORB order in place, this would cause Ms. Alexander significant stress. Again, Dr. Kravtsenyuk characterized Ms. Alexander as a “model absolute discharge patient.”
[15]. In response to questions from another Board member, Dr. Kravtsenyuk stated that Ms. Alexander is in contact with the treatment team every two weeks. When asked about the necessity of connection to an ACT team, Dr. Kravtsenyuk said this would have to be determined by the support team arranged in the community. Dr. Kravtsenyuk stated that in her opinion it was necessary to maintain the substance use provision in the current Disposition. She stated that without it, there was a risk that Ms. Alexander’s use would increase resulting in a decompensation in her mental status.
[16]. Dr. Kravtsenyuk acknowledged that Ms. Alexander’s current situation of effectively having two residences, one in Mississauga and one in Barrie, could potentially cause a delay in establishing a strong relationship with a community-based mental health team. Dr. Kravtsenyuk said that she would work with Ms. Alexander to determine which location would be best for her to assume responsibility for her monitoring and treatment in the community. Dr. Kravtsenyuk said that although it was likely that Ms. Alexander could arrange a new family physician, it would be appropriate for her to establish contact with a community psychiatrist who would likely be more comfortable in monitoring her treatment with antipsychotic medications.
[17]. No further evidence was called at the hearing.
Submissions
[18]. At the conclusion of the evidence all counsel reiterated the joint submission made at the outset of the hearing. Ms. Warner acknowledged that Ms. Alexander was “on the cusp” of an Absolute Discharge but for the reasons set out in the Hospital Report and in the evidence of Dr. Kravtsenyuk, continued to require the support of the hospital and the treatment team and until such time as a transition to a civil mental health support team could be arranged. Mr. Brandes supported the submissions of Ms. Warner. Mr. Rai also supported the submissions of the hospital.
Analysis and Disposition
[19]. Both at the outset of the hearing and following the completion of the evidence, the Board was presented with a joint submission from all counsel. As aptly stated by Ms. Warner, “Ms. Alexander is on the cusp of an Absolute Discharge.” Ms. Alexander transitioned from a Detention Order to a Conditional Discharge after her annual hearing in 2025. This was intended to provide to “provide Ms. Alexander an opportunity for more independence which the treatment team encourages.” Dr. Kravtsenyuk has described Ms. Alexander as “one of her best patients” and agreed with the suggestion from a Board member that Ms. Alexander represents a “model patient for absolute discharge.”
[20]. The Board acknowledges that a strong argument could be made at this time for an Absolute Discharge. Dr. Kravtsenyuk described that Ms. Alexander has very good insight into both her major mental illness and her need for antipsychotic medications and ongoing support from the treatment team. Her insight into her illness extends to her ability to recognize the early signs of decompensation which has led to a number of short readmissions over the past several years. Ms. Alexander also has excellent support from her family in the community. However, Dr. Kravtsenyuk stated that what is missing at this time is the support of a civil mental health team and alignment with a community-based psychiatrist. Although the hospital would continue to offer services to Ms. Alexander in the event of an Absolute Discharge, Dr. Kravtsenyuk stated that sudden removal of the oversight of the ORB would cause Ms. Alexander considerable stress and likely result in a decompensation in her mental status. The Board is unanimous in accepting the uncontradicted evidence of Dr. Kravtsenyuk. It is clear from the Reasons for Disposition in 2025, that the Board last year was faced with similar considerations:
- “The Board considered whether an absolute discharge was warranted in this case given the progress that Ms. Alexander has made, particularly over the past two years. We accept Dr. Kravtsenyuk’s expert opinion that at this time, Ms. Alexander would find the complete removal of the support of the treatment team stressful and destabilizing. She sees the forensic services as a stabilizing factor in her life. Better that there be a more gradual transition to an absolute discharge with the expectation that Ms. Alexander will continue to have increased independence and autonomy over the course of the next clinical year. As such, she remains a significant risk.”
[21]. The Board is unanimous in accepting the joint submission of the parties in finding that the necessary and appropriate disposition is a continuation of the terms of the current Conditional Discharge. The Board urges the hospital to continue its efforts to align Ms. Alexander with the mental health supports she requires from the civil system with a view to the final transition to an Absolute Discharge either in the upcoming reporting year or at next year's annual review.
DATED this 12th day of June, 2026, at the City of Toronto, in the Region of Toronto.
Mr. G. Beasley
Alternate Chairperson
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Office of the Registrar
Ontario Review Board