Court File and Parties

Court File No.: CV-25-00746489-0000 Date: 2025-09-03 Superior Court of Justice - Ontario

Re: J.J., Appellant (responding party) And: Dr. Jason Joannou, Respondent (Moving party)

Before: L. Brownstone J.

Counsel:

• J.J., appearing on his own behalf
• David Shannon, amicus curiae
• Sarah Rosales Zelaya and Holly Pellatt, for the Respondent

Heard: September 2, 2025

Endorsement

Nature of the Proceeding

[1] The respondent moves to lift the stay of a decision of the Consent and Capacity Board pending appeal. The CCB decision confirmed the applicant's involuntary status and confirmed the respondent's findings that the applicant is incapable of consenting or refusing consent to treatment with antipsychotic medications.

[2] The CCB decision was made on June 23, 2025, with reasons released on June 30, 2025. On June 24, 2025, the applicant served a notice of appeal. He does not have counsel and has taken no steps to move the appeal forward.

[3] The respondent requested this urgent hearing date for its motion under s. 19 of the Health Care Consent Act 1996, S.O. 1996, c. 2, Sched. A ("the HCCA") and requested the appointment of amicus for the motion.

[4] Mr. Shannon attended the hearing as amicus. He and J.J. argue that the motion should be dismissed, and the appeal expedited. The respondent agrees the appeal should be expedited, but maintains that an order pending even an expedited appeal is required.

Background

Events from June 2025 to Present

[5] J.J. was taken to CAMH on June 12, 2025, after his sister obtained an order for examination (Form 2) from a justice of the peace. She did so because J.J. had been living on her porch for two months without her permission, had been deteriorating mentally, and had behaved aggressively, including by banging on her door and threatening her and her daughter. She was growing afraid of him. Once at CAMH, J.J. was held on a certificate of involuntary admission (Form 3). Certificates of renewal were obtained on June 26, 2025, and July 25, 2025.

[6] J.J. was agitated, hostile, and argumentative when admitted to CAMH. He threatened staff and was deemed a safety risk to others; he required seclusion and chemical restraints in the emergency department. A psychiatrist noted he was experiencing severe decompensation. J.J. has also been delusional while in hospital. He was in seclusion in the high intensity side of the psychiatric intensive care unit.

[7] In hospital, J.J. acted aggressively, including by approaching staff, reaching at them through a Dutch door, and threatening to kill hospital staff if they tried to medicate him.

[8] The CCB hearing was held on June 23, 2025. At the CCB hearing, Dr. Park opined that there was a likely risk of serious bodily harm to another person unless J.J. remained in hospital to be treated. J.J. also testified. The CCB found that J.J. "remained untreated in hospital and was exhibiting the symptoms of schizophrenia during the current hospitalization and during the hearing." The CCB confirmed J.J.'s involuntary status and confirmed the finding that he was incapable of consent to treatment with antipsychotic medications. As noted, J.J. served a notice of appeal the following day.

[9] Further incidents occurred after the CCB hearing. On June 25, 2025, J.J. was shouting and threatening staff, resulting in him being physically escorted to a step-down area and placed in mechanical restraints to reduce his risk to others.

[10] On July 20, 2025, J.J. assaulted another patient, without provocation, resulting in a Code White being called. J.J. kicked the other patient in the head, face, wrist, and back. The patient was transferred to a medical hospital due to his injuries. He suffered multiple facial fractures and a fractured wrist.

[11] J.J. faces an assault charge in relation to this incident.

[12] On August 7, 2025, J.J. was writing disorganized text on the wall of his room (with the text measuring about 15 feet wide by 7 feet high). Additionally, he was naked and exposing himself through his window to staff and the public and was not responding to staff redirection.

[13] Dr. Joannou opined in his affidavit in support of the motion that J.J. continues to be psychotic and paranoid and is an extreme risk of violence. He opined that J.J. remains a high risk of assaulting staff during clinical interactions, and staff have been directed to minimize interactions to maintain safety. They are to approach J.J. only in groups or with security.

Events That Preceded June 2025

[14] J.J. has been hospitalized five times since 2015. The evidence about those previous hospitalizations establishes that he has been diagnosed with schizophrenia since 2006, that he does not tolerate the antipsychotic medication Zuclopenthixol well, but does tolerate and respond well to the proposed treatment, Paliperidone, a long-acting injectable antipsychotic medication.

[15] In his previous hospitalizations, he regularly required seclusion, physical restraints, and chemical restraints or medications. During one hospitalization, he assaulted a psychiatrist while in a secure area of the hospital, an assault J.J. described as justified because the psychiatrist had diagnosed him as schizophrenic and was trying to treat him with antipsychotic medication.

Law and Analysis

[16] Under s. 18 of the HCCA, where a patient appeals a CCB decision, a health care practitioner is not to begin a treatment permitted by the decision until the appeal has been finally disposed of. Section 80 sets out timelines for the exchange of material for the appeal, and the court is required to fix the earliest date for the appeal that is compatible with its just disposition (s. 80(8)).

[17] Despite s. 18, s. 19(2) of the Act permits the court to make an order under which treatment may be administered pending the appeal's disposition. The court may make such an order if it is satisfied:

(a) that,

(i) the treatment will or is likely to improve substantially the condition of the person to whom it is to be administered, and the person's condition will not or is not likely to improve without the treatment, or

(ii) the person's condition will or is likely to deteriorate substantially, or to deteriorate rapidly, without the treatment, and the treatment will or is likely to prevent the deterioration or to reduce substantially its extent or its rate;

(b) that the benefit the person is expected to obtain from the treatment outweighs the risk of harm to him or her;

(c) that the treatment is the least restrictive and least intrusive treatment that meets the requirements of clauses (a) and (b); and

(d) that the person's condition makes it necessary to administer the treatment before the final disposition of the appeal.

[18] The respondent acknowledges that the test sets out a high threshold and is only to be invoked in serious circumstances. A patient's right to autonomy and bodily integrity is fundamental to his self-determination, liberty, and security: Gunn v. Koczerginski, [2001] O.J. No. 4479, 109 ACWS (3d) 808, at para. 8. As the Supreme Court of Canada stated at para. 75 of Starson v. Swayze, 2003 SCC 32, "[t]he right to refuse unwanted medical treatment is fundamental to a person's dignity and autonomy."

[19] The four-part test set out in s. 19 represents an exceptional circumstance in which the court may interfere with this fundamental right: Ducharme v. Hudson, 2021 ONCA 151; 155 O.R. (3d) 281 at para. 33. It is an example of the HCCA's balancing between individual autonomy and the need for effective treatment for those with mental conditions: Starson at paras 9, 11.

[20] The respondent bears the onus of establishing that the statutory criteria are met.

[21] Neither J.J. nor amicus expressly argued that the criteria in the test were not met. Their arguments, however, tie most neatly into the fourth, or necessity, criterion, and I will consider them there. I turn to the criteria in the order in which they appear in the statute.

a) The Treatment Will or Is Likely to Improve the Patient's Condition Substantially and His Condition Will Not or Is Not Likely to Improve Without the Treatment

[22] The court here considers the patient's short-term situation pending appeal: Gunn at para. 10.

[23] J.J. has a longstanding history of schizophrenia. He has responded well to the proposed medication in the past. With treatment, Dr. Joannou believes J.J. is likely to be less paranoid, more organized, and able to attend to his basic needs. He is expected to be less of a risk to others and will not require seclusion or other restraints. He will likely be able to be discharged from hospital.

[24] J.J. has been hospitalized and untreated since June 2025, and his condition has not improved. Dr. Joannou's opinion is that without treatment, not only is J.J.'s condition unlikely to improve, but he will likely need to continue to be detained as an involuntary patient because of ongoing risk of harm to staff and other patients.

[25] J.J. was clear at the hearing of this motion that he strongly wishes to be released from CAMH. That is unlikely to happen without treatment.

[26] I am satisfied that the respondent has established that the proposed treatment is likely to improve J.J.'s condition substantially and his condition is not likely to improve without the treatment.

b) The Expected Benefit of the Treatment Outweighs the Risk of Harm to the Patient

[27] J.J. has tolerated the proposed medication well in the past with minimal side effects. The medication has also led to improvement in his clinical well-being and, as noted above, the treatment is again expected to have this salutary effect. The treatment is expected to reduce J.J.'s distress and to decrease his risk to others.

[28] The potential side effects include hyperlipidemia, weight gain, diabetes, and EPS, which Dr. Joannou described as movement symptoms such as tremors or an effect on gait. However, Dr. Joannou swore that a high level of monitoring would be introduced to ensure any side effects could be quickly noted and addressed appropriately.

[29] Given the expected benefit of the medication, the fact that J.J. has previously tolerated the medication well with minimal side effects, and the fact that the medication will be administered in hospital where any side effects will be picked up by close monitoring and appropriately managed, I find the benefits to outweigh the risk.

[30] I am satisfied the respondent has established that the second criterion is met.

c) The Treatment Is the Least Restrictive and Least Intrusive That Meets the Requirements of the First Two Criteria

[31] J.J. is currently facing significant restrictions on his liberty. He is isolated from others. He has been restrained. These restrictions are likely to be ongoing in the absence of treatment.

[32] The respondent states that J.J. is likely to refuse the medication in oral format, as he has in the past. The result is that he will likely need to be restrained to receive the injections. However, this will happen infrequently. J.J. will require two initial doses within the first eight days, followed by monthly injections, which may decrease as treatment progresses.

[33] Further, there are no alternative treatments available. J.J. had a severe reaction to the other available medication in the past.

[34] In the circumstances, I find that the respondent has established this criterion is met. The proposed treatment is the least intrusive means of meeting the first two criteria of the test.

d) The Patient's Condition Makes It Necessary to Administer the Treatment Pending the Final Disposition of the Appeal

[35] Dr. Joannou opined that without treatment, J.J. is likely to continue to suffer from ongoing paranoid delusions which cause him significant distress. He will not be able to be released from the specialized unit. Further, if J.J.'s psychosis remains untreated, it may become treatment-refractory.

[36] As noted above, Dr. Joannou also deposed that J.J. continues to be psychotic and paranoid and is an extreme risk of violence. He opined that J.J. remains a high risk of assaulting staff during clinical interactions, and staff have been directed to minimize interactions to maintain safety. They are to approach J.J. only in groups or with security.

[37] Amicus argued that the court must be careful not to open the floodgates to the use of s. 19 to circumvent an appeal. While the court has jurisdiction to make an order under s. 19, it ought to do so extremely sparingly. The autonomy of vulnerable patients is at stake and must be protected. Section 19 is not a "best interests" test.

[38] Amicus also argues that J.J. is in hospital, surrounded by experts, where he can be appropriately managed pending appeal. He notes there have been no assaultive incidents for the past month.

[39] I note, however, that it is the very experts who are charged with managing J.J. that have advised the court that they view immediate treatment to be necessary. While amicus argues that the team can manage difficult individuals, the evidence before the court is that in this particular case, the treating professionals view immediate treatment as necessary.

[40] J.J. also clearly views the order to be unnecessary. It is evident that J.J. does not want to be treated. He does not believe he has exhibited disorganized thoughts, nor has he given the health care workers any reason to believe he suffers from paranoia. He is of the view that they wish to treat him because they will gain financially from doing so. They have made negative assumptions about him that are incorrect. He wishes to put forth his arguments on appeal, without being subjected to treatment pending appeal.

[41] I find that the following combination of factors render interim treatment necessary: Dr. Joannou's opinion as summarized above, the current restrictions on J.J.'s liberty, the fact that J.J. faces criminal charges from an incident that occurred after the CCB decision and is at risk for engaging in more of the same behaviour leading to potential further involvement with the criminal justice system, and the fact that J.J. remains agitated, in distress, verbally abusive, and threatening: see Elder v. Klukach, 2017 ONSC 677.

[42] I agree with the submission of amicus that s. 19 cannot be used to deny the right of appeal or circumvent it. However, s. 19 cannot be ignored, either. The appeal will be heard. The stay provisions may again take effect, depending on how the matter progresses. Without diminishing the importance of J.J.'s autonomy and bodily integrity pending appeal, I note that the appeal will not be rendered moot.

Disposition

[43] The motion is granted. The evidence indicates that J.J.'s substitute decision-maker, his sister, consents to his being treated in the manner outlined by Dr. Joannou. I authorize treatment with antipsychotic medication, specifically Paliperidone long-acting injectable medication, with initial loading doses of 150mg on day 1, 100mg on day 8, and then 100-150mg every four weeks thereafter, pending a final disposition of his appeal of the CCB decision dated June 23, 2025.

[44] In addition, I order the appeal to be expedited. As discussed at the hearing of this motion, I make the following orders about the appeal:

i. Appeal is to be heard on October 3, 2025, for two hours;

ii. Amicus is required for the appeal;

iii. J.J.'s factum, if any, and that of amicus, to be served by September 9, 2025;

iv. Respondent's factum to be served by September 16, 2025; and

v. All materials to be uploaded to Case Center once served.

L. Brownstone J.

Date: September 3, 2025