Ontario Review Board
Re: Van K. Luong
ORB File No: 6323
Hearing held on: Tuesday, September 23, 2025
Place of hearing: Waypoint Centre for Mental Health Care
Pursuant to: Section 672.81(1) of the Criminal Code
Before:
Alternate Chairperson: Ms. T. Mann
Members: Dr. K. Hand Dr. G. Kerry Ms. A. La Viola Ms. R. Chopra
Parties Appearing:
Accused: Van K. Luong Counsel: Mr. T.R. McIver
The Person in charge of Hospital: Counsel: Ms. T. Murdock
Attorney General of Ontario: Counsel: Ms. S. Curry
REASONS FOR DISPOSITION
(Dated January 16, 2026)
Introduction
[1]. On April 9, 2013, Van Luong was found not criminally responsible on account of mental disorder on four counts of mischief not exceeding $5,000, contrary to the Criminal Code of Canada (“the Criminal Code”). Mr. Luong is currently subject to a disposition of the Ontario Review Board (“the ORB” or “the Board”) dated September 5, 2024, which detains him at the Waypoint Centre for Mental Health Care – High Secure Provincial Forensic Programs (“Waypoint” or “the Hospital”), subject to a condition that he refrain from having in his possession any firearm, offensive weapon, ammunition or the like and an envelope of privileges, the most liberal of which permits him discretionary access to hospital and grounds, escorted by a minimum of two staff.
[2]. On September 23, 2025, the ORB convened a hearing at Waypoint to conduct Mr. Luong’s annual review and to make a disposition further to s. 672.81(1) of the Criminal Code. Mr. Luong was present at the hearing and represented by his counsel, Mr. T.R. McIver.
[3]. At the outset of the hearing, counsel for the Hospital and the Attorney General submitted that Mr. Luong continues to represent a significant threat to the safety of the public and there should be no change to the terms and conditions of his current disposition. Mr. McIver, on behalf of Mr. Luong, submitted he did not yet have a position. The Board took this to mean that significant threat and the necessary, appropriate, least onerous, and least restrictive disposition were both at issue in the hearing.
[4]. For the reasons set out below, the Board finds that Mr. Luong continues to pose a significant threat to the safety of the public and that his risk and his care can best be managed on the same terms and conditions as set out in last year’s disposition.
Index Offences
[5]. The details of the Index Offences are set out in the Reasons for Disposition dated September 5, 2024, and are as follows:
On December 16, 2012, at approximately 3:05 a.m., Mr. Luong was observed by two citizens to be breaking windows and an illuminated sign at the Central Baptist Church in Kitchener. Damages were estimated to amount to $2,000. Mr. Luong was placed under arrest nine minutes later, and police then checked the area for additional damage. They found an illuminated sign damaged at St. Mary's Orthodox Church and were later provided with video surveillance footage which showed the accused walking around the church with a baseball bat in his hand.
Additional damage was observed to the front sign of North Bridge Distribution, with an estimated repair cost of $1,100.
Following his arrest, the accused admitted responsibility for damaging the properties and indicated he had damaged other properties as well. He also reported he had recently been prescribed medication by a doctor at Grand River Hospital Crisis Unit, but he had not been taking it.
[6]. When questioned by police regarding the damage, Mr. Luong said he did not know why he does damage to churches. Upon admission to hospital, he admitted to not liking churches, and that he thought “the church” was inciting people to follow him and that if he broke the windows, “the people would stop.”
[7]. Of note, Mr. Luong has a lengthy criminal record dating back to 1994 (Hospital Report, pp 7-8). He has several convictions for mischief and failure to abide by probation orders. In October 2012 he was found guilty of mischief under $5000 and assault police with intent to resist arrest. The Hospital Report contains an extract from a synopsis provided by the Kitchener Crown Attorney’s office which describes the 2012 convictions as stemming from damage to churches in the area (pp 9-10).
Background
[8]. The Board admitted into evidence a Hospital Report dated August 19, 2025, as Exhibit 1. That document provides a great deal of information concerning Mr. Luong’s personal and mental health history as well as his course since coming under the jurisdiction of the Board. As the Hospital Report was made an exhibit, it is unnecessary to reproduce the detailed information contained within it in these Reasons. A brief summary of the relevant details follows.
[9]. Mr. Luong is currently 52 years of age. Mr. Luong’s early years were marked by disruption in significant relationships and dislocation. He was born in Vietnam at a time of war and regime change. His biological father died when Mr. Luong was a baby. His mother remarried a businessman who owned a factory. The factory was confiscated by the government and the family fled to a refugee camp in Thailand. Mr. Luong moved with his family to Canada when he was five, initially living in Toronto but eventually settling in the Kitchener area. Mr. Lyong found the transition difficult. At some point, Mr. Luong’s stepfather left the family. It was around this time that Mr. Luong learned he was not his biological father, which affected him greatly. When Mr. Luong was a teenager, his mother had a child with her boyfriend. Mr. Luong did not get along with his mother’s boyfriend and occasionally their disagreements escalated to the point of physical fighting between them.
[10]. Mr. Luong’s secondary school education was hampered by the onset of mental illness. He graduated from high school after attending adult education classes. He reported having lived in shelters and group homes at various times in his life but resided with his mother from approximately 1998 to 2012. After leaving his mother’s home in 2012, he discontinued his psychiatric medication and decompensated.
[11]. Mr. Luong was first hospitalized for psychiatric illness at the age of 20. He was hospitalized a second time after breaking windows in his mother’s house. A court order prevented Mr. Luong from returning to his mother’s house upon being discharged from hospital. Records also indicate that in the early 1990s Mr. Luong threatened to burn down churches. He believed that people were after him, and because they had hurt him in some way, he was entitled to exact retribution.
[12]. Throughout his 20s, Mr. Luong periodically required hospitalizations and was eventually diagnosed with Schizophrenia. He was prescribed a number of different medications but often became non-compliant with treatment and follow-up.
[13]. In approximately 1998 Mr. Luong lived on the streets of Toronto for about a year. His mother eventually found him and brought him back to Kitchener. He was admitted to Grand River Hospital and started on Clozaril [generic name: clozapine]. His condition improved markedly. He was able to reside with his mother and did not require hospitalization. He was seeing an outpatient psychiatrist on a regular basis. Unfortunately, in August 2012, Mr. Luong stopped living with his mother due to feeling they were not getting along. At the same time, he began reducing his medication, explaining that Seroquel [generic name: quetiapine] made him “cuckoo” and Clozaril made him feel tired. Eventually, Mr. Luong stopped taking both medications and by September 2012, he had decompensated, incurring criminal charges stemming from his delusional beliefs. This occurred again in December 2012 and resulted in his current NCR finding.
[14]. As noted above, Mr. Luong accumulated numerous criminal convictions from 1994 to 2012. The convictions included theft, mischief, assault, obstruct peace officer and charges of failing to comply with court orders.
[15]. Mr. Luong does not have a history of alcohol or substance abuse.
Progress Under the Board’s Jurisdiction
[16]. Following the commission of the Index Offences, Mr. Luong was detained at Waypoint until August 19, 2017, when he had stabilized sufficiently to be transferred to a medium secure setting, St. Joseph's Healthcare Hamilton (“SJHH”). While at SJHH, Mr. Luong was able to remain violence-free for a number of years. He showed a lack of initiative and general reluctance to engage in therapeutic and rehabilitative programming. He tended to spend significant amounts of time in his room and was disinclined to interact with co-patients. He did not like to socialize in groups. Although mostly pleasant and cooperative with staff, his interactions with them were typically brief and needs-based. He eloped on multiple occasions to the point where SJHH had to implement an elopement prevention plan to better manage this risk.
[17]. On August 24, 2022, Mr. Luong struck a co-patient in the head for no discernable reason. He was placed in seclusion for the protection of other patients. Mr. Luong’s explanation for this assault was that the co-patient was playing music at a volume that bothered him.
[18]. On May 5, 2023, Mr. Luong punched the same co-patient repeatedly in the head. His reason for assaulting this patient for the second time was that the patient was following him around. Mr. Luong was secluded. On July 31, 2023, the other patient was transferred to another unit and Mr. Luong was no longer restricted to his room.
[19]. Within hours, Mr. Luong was sitting across from a new patient he had not previously met, waiting for dinner. Mr. Luong got up, walked away, came back and quickly delivered two jabs to the co-patient’s face. Investigation revealed that Mr. Luong had stabbed the new patient using the nail file end of a nail clipper he had failed to return to nursing staff after completing his hygiene routine. The puncture wounds caused by the pointed end of the nail file were close to the co-patient’s eyes. During subsequent reviews, Mr. Luong explained he stabbed the co-patient for looking at him the wrong way and further that he had to attack first before he himself could be attacked.
[20]. Mr. Luong’s behaviour on this occasion, including his escalation to use of a weapon, prompted SJHH to request an early review of his disposition which occurred on August 24, 2023. The Board ordered his transfer to Waypoint. Following the early hearing, but before the transfer to Waypoint could be effected, Mr. Luong assaulted SJHH staff.
[21]. Mr. Luong was admitted to Waypoint on September 20, 2023. Immediately upon admission, Mr. Luong was secluded until September 22, 2023, for assessment, due to an assault on SJHH staff while awaiting transfer. Mr. Luong was secluded on January 23, 2024, for kicking a co-patient sitting next to him in the arm, later stating “he’s lucky I didn’t kick him right in the face…”.
[22]. A restriction of liberty hearing was convened on March 1, 2024, in relation to Mr. Luong’s seclusion commencing January 23, 2024. On March 19, 2024, the Board concluded that the Hospital’s decision to significantly increase the restrictions on Mr. Luong’s liberty was necessary and warranted. Because of the danger to staff and others with whom he may come into contact, he has remained in seclusion since that time.
[23]. In sum, Mr. Luong’s course under the jurisdiction of the Board has been characterized by an uneven trajectory. His early tenure at Waypoint was notable for multiple unprovoked assaults on staff and peers in the context of behavioural instability which has consistently been difficult to predict and manage. While at SJHH, Mr. Luong was noted to have ongoing assaultive behaviour and multiple elopements which ended in September 2023 when he was transferred back to Waypoint in the context of escalating assaultive behaviour.
[24]. Clinical teams working with Mr. Luong at SJHH and Waypoint have struggled to understand the cause of his assaultive behaviour, which is often devoid of logic or precipitant. Mr. Luong himself is unable to provide a meaningful framework within which to understand his behaviours. In the immediate aftermath of an assault, he will sometimes be attributive and unrepentant but there have also been occasions when he has been at a loss to explain why he acted out and has said he does not want to hurt others.
[25]. Mr. Luong is diagnosed with Schizophrenia. There have been a number of changes to Mr. Luong’s psychiatric medication regimen since Mr. Luong was readmitted to Waypoint. Regrettably, none have resulted in any significant attenuation of his paranoia or his assaultive behaviours. Mr. Luong is capable of making treatment decisions.
[26]. Mr. Luong has been detained on the Forensic Assessment Program (“FAP”) throughout the period under review.
Evidence at the Hearing
[27]. The Board had available to it the documents forming the Record, as well as the Hospital Report dated August 19, 2025. In addition, the Board received oral evidence from Mr. Luong’s attending forensic psychiatrist, Dr. A. Mishra. Dr. Mishra assumed responsibility for Mr. Luong’s care from Dr. Muraven in December 2024. Dr. Mishra endorsed the contents of the Hospital Report, and the assessment of significant threat contained in it. In his oral evidence, Dr. Mishra briefly updated the Hospital Report and provided a summary of Mr. Luong’s progress over the period of review.
[28]. From the Hospital Report and Dr. Mishra’s evidence, it appears that Mr. Luong has had another challenging year overall. Mr. Luong’s mental status continues to fluctuate in an unpredictable manner.
[29]. Mr. Luong has committed multiple unprovoked assaults and attempted assaults upon staff. There are no obvious precursors or precipitants which has made it very difficult for staff to develop an effective risk-mitigation strategy. These incidents are enumerated at pp 92-94 of the Hospital Report and include kicking, jumping on staff, striking out at staff, and punching them in the face. Some of the assaultive behaviour has occurred when Mr. Luong was in wrist-waist restraints and appearing calm and co-operative. Several of the incidents resulted in injuries to staff.
[30]. Mr. Luong’s explanations for his behaviour ranged from frustration to wanting to run away to being paranoid. However, for the most part, he was unable to articulate a reason for aggressing. Consequently, the treatment team continues to lack a framework within which to understand the drivers underpinning his risk of violence.
[31]. Despite Mr. Luong having a detailed Crisis Prevention Plan, he has not been able to progress through the de-restraint process. Throughout the review period, Mr. Luong has required the use of waist/wrist and ankle restraints and in some instances, restraint via the use of a wheelchair. Re-assessment of the de-restraint plan is ongoing.
[32]. Mr. Luong has been offered seclusion relief (including high-risk showers without physical restraints) during which he is given the opportunity to shower, watch television, use the common lounge areas and the courtyard. He has also been brought off-unit and taken to the canteen area while restrained to a wheelchair. He has not always been deemed suitable for seclusion relief due to his mental status and/or behavioural presentation. There have also been many occasions when he declined to participate in seclusion relief.
[33]. According to the Hospital Report, seclusion orders are reviewed daily. To ensure objectivity, patients are seen by an independent psychiatrist at post-72 hours, seven days, and 28 days of seclusion thereafter. All such consultations have indicated that continued seclusion has been necessary to mitigate Mr. Luong’s risk to others in his proximity.
[34]. Because of the difficulty in finding an effective medication regimen and the length of Mr. Luong’s seclusion, on July 23, 2025, an external seclusion and medication review was obtained from forensic psychiatrist Dr. Y. Naidoo from SJHH. Dr. Naidoo provided the following opinion of the need to maintain Mr. Luong in seclusion:
In my opinion, seclusion continues to be necessary for Mr. Luong. The treatment team has taken a patient- centered and caring approach to manage his risk and to reintegrate him into the unit milieu. Those efforts include daily trial out of seclusion attempts, phone calls with his brother, frequent support, and rapport-building, all with limited effect. However, Mr. Luong continues to exhibit psychotic symptoms, anger and threatening behavior which have been associated with serious violence and aggression on numerous occasions. He has a clozapine refractory psychotic illness and has been adherent with oral antipsychotic medication. Absent seclusion, he would be at extremely high risk for imminently committing violent acts against co-patients and staff.
[35]. As for medication, Dr. Naidoo was of the following opinion, which is summarized from the findings contained from pp 94 – 96 of the Hospital Report:
(a) Given Mr. Luong’s limited response to clozapine and the treatment-refractory nature of his major mental illness, a course of treatment with electroconvulsive therapy (ECT) is the next best option to reduce psychotic symptoms and regression;
(b) Increasing the dose of clozapine, albeit with close monitoring for side-effects, is another option to consider;
(c) Additional adjunctive antipsychotic agents, such as Seroquel or sulpride (the latter requiring approval by Health Canada) might be of assistance, although the likelihood of response is low overall. Depressive symptoms could be targeted by Seroquel or lithium, among other options, and
(d) Features of social anxiety, to the extent they are present, may also respond to Seroquel or pregabalin.
[36]. As for behavioural therapy, Dr. Naidoo approved of the existing plan and suggested that charting actuarial measures of imminent violence might prove helpful, along with the continuation of post-incident debriefing. Dr. Naidoo’s view was that Mr. Luong was not sufficiently stable to benefit from psychotherapeutic interventions, other than supportive listening and reflection, at this time.
[37]. Dr. Naidoo emphasized the importance of providing Mr. Luong with a calm, quiet space with access to music, and an inability to access items that could be used as a weapon, when utilizing seclusion. The doctor approved of the care plan, finding that “The team has a robust care plan which includes antecedents, pre cursor behaviors, crisis prevention, de-escalation, and therapeutic interventions, all of which I agree with. Use of prn Ativan or in future olanzapine, may assist in reducing afternoon aggression.”
[38]. Dr. Mishra plans to consult with an internist to obtain an opinion as to the safety of changes to Mr. Luong’s medication regimen, including any increase in dosages.
[39]. Mr. Luong has not participated in any therapeutic or leisure activities. He likes to listen to music while in his room but has declined to participate and was removed from the Music Therapy wait list. He continues to spend a lot of time writing short stories, often about vampires, but does not share the content of his writing with staff, expressing the worry that “something bad” will happen to them if he does.
[40]. Mr. Luong’s brother continues to be supportive, maintaining weekly telephone calls, virtual and in-person visits when possible. Mr. Luong continues to decline having contact with his mother, notwithstanding having been offered the assistance of an interpreter to facilitate communication between them.
[41]. Mr. Luong continues to await transfer to the highly structured and supervised setting of the Beckwith units. Lack of beds remains the primary barrier to his transfer from the FAP.
[42]. Dr. Mishra explained that although Mr. Luong was only off clozapine for a relatively short period of time prior to the index offences in 2013, he has never been able to regain the level of mental stability he once enjoyed when compliant with treatment. According to Dr. Mishra, this is an unfortunate but not uncommon outcome when therapy with clozapine has been discontinued, particularly in the context of treatment-refractory illness such as that which afflicts Mr. Luong.
[43]. Efforts to optimize his medication regimen are ongoing; some medications cannot be used due to Mr. Luong’s impaired liver function. A trial of lithium carbonate was commenced on July 27, 2025, and the dose is currently being optimized. It is hoped that this medication will augment his antipsychotic medication regimen and reduce the impulsivity that likely drives his unprovoked aggression.
Analysis and Conclusions
[44]. Having heard and considered all of the evidence and the submissions of the parties, the Board has no difficulty in finding that Mr. Luong’s current constellation of symptoms and behaviours are such that he continues to pose a significant threat to the safety of the public. The uncontradicted evidence contained in the Hospital Report, along with the oral evidence of Dr. Mishra, provides ample grounds in support of the finding of significant threat.
[45]. The Board accepts and relies upon this evidence in its entirety, and notes in particular Dr. Mishra’s composition assessment of Mr. Luong’s risk to the safety of others at p. 104 of the Hospital Report:
Mr. Luong is diagnosed with schizophrenia, which is treatment-refractory. He continues to experience active symptoms despite being on clozapine. He has been compliant with clozapine but continues to experience active psychotic symptoms including paranoid delusions, impulsivity, aggression, and auditory hallucinations. Mr. Luong presents a chronic risk of harm to others in the context of a long history of unprovoked physical violence which intensifies as symptoms of psychosis worsen. He has responded inadequately to treatment and has been compliant with oral medication. Environmental structure and support remain key in managing the risk from ongoing symptoms. He continues to present a significant threat to the safety of the public… The threat to public safety emanates from ongoing untreated psychosis despite compliance with treatment. He poses a significant threat to the safety of the public as evidenced by his current level of psychosis and ongoing violent behaviour on a high secure unit.
[46]. Notwithstanding adherence to his medication regimen, Mr. Luong continues to experience psychosis which drives him to commit unprovoked attacks on staff and others who may be proximal to him. He has been secluded since January 23, 2024, because of his behavioural instability and acute risk of serious physical harm to others.
[47]. Although Mr. Luong responded well to clozapine when it was initiated in the late 1990s, despite restarting the medication regimen that worked well for him previously, he has not returned to his prior level of stability. The history set out in the Hospital Report details that many of the medications caused a significant worsening of his aggression or had to be discontinued secondary to minimal effect and/or side effects. Mr. Luong identifies that he would like to stop hitting people, however, the impulse and urge to strike out often overwhelms his stated intentions. Efforts to optimize Mr. Luong's medication regimen are ongoing.
[48]. To his credit, Mr. Luong has been actively involved in medication trials since admission and is cooperative with taking his medication. He would like to make better progress and to stop hurting people. He has at times successfully participated in seclusion relief. Although Mr. Luong is doing his best overall, the symptom burden of his schizophrenic illness continues to pose a significant impediment to his recovery.
[49]. The Board notes the information in the Hospital Report to the effect that the treatment team has spent many hours working with Mr. Luong in an effort to decipher patterns of behaviour, correlation and potential causation related to his violence, but risk-mitigation strategies remain elusive; he continues to display the violent behaviours that necessitated his transfer from a less-secure facility back to the high secure hospital setting at Waypoint.
[50]. The Board carefully considered the measures taken by the Hospital to ensure restraint minimization, relief from seclusion and independent assessment of the need for seclusion over the review period and more particularly since January 23, 2024. The Board finds that on-going seclusion is currently the least onerous and least restrictive means of managing Mr. Luong’s risk to the safety of the public, including clinical staff and co-patients. The Board anticipates that the treatment team will continue to look for opportunities to help Mr. Luong progress through the restraint minimization process and to treat him with care and compassion.
[51]. For the foregoing reasons, the Board is of the view that Mr. Luong poses a significant threat to the safety of the public and that detention within the high secure setting at Waypoint upon the terms set out in its formal disposition is the least onerous and restrictive disposition that is necessary and appropriate in the circumstances.
[52]. In making this disposition, the Board has considered the criteria set out in s. 672.54 of the Criminal Code, which are the safety of the public, which is the paramount consideration, the mental condition of Mr. Luong, the reintegration of Mr. Luong into society as well as his other needs.
DATED this 16th day of January 2026, at the City of Toronto, in the Toronto Region.
Ms. T. Mann Alternate Chairperson
Office of the Registrar Ontario Review Board