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This past year, the media has been drawing attention to the frequency of ORB inmates escaping from CamH Custody. The highest-profile of these being the escape of Zhebin Cong, “The Meat Cleaver Killer.”

Zhebin Cong made headlines back in 2008 after beheading a passenger on a Greyhound bus. He returned to the news in 2014 when he was declared NCR (Not Criminally Responsible) by reason of mental illness — in this case, schizophrenia.

This summer, he made headlines again with his recent escape from custody at CamH. Cong managed, likely with the assistance of others, to get on a plane and flee the country successfully.

In recent reports claim that as many as 12 to 16 people have escaped over the last six months.

In this article, we examine how CamH patients listed as, “significant threats to the safety of the public,” seem to be escaping with relative ease. To start, we’ll do a quick review of the Ontario Review Board.


The Ontario Review Board is an independent tribunal. It is responsible for reviewing the status of all individuals found not criminally responsible or unfit to stand trial. In the review, ORB determines whether the individual continues to present a significant risk to the public, or themselves.

ORB is responsible for determining and directing the medical and mental health treatment of the individuals in their care. Where the individuals reside for their treatment and care is determined by assessing their:

  • Ability to manage their illness
  • Risk to public or self
  • Fitness

In many instances, individuals that are fit, have good insight into their illness, are pose little or no risk to the public can to reside on their own or with family. If they have a difficult to manage disorder or need assistance/reminders to take medication, the ORB may allow them to reside somewhere that offers treatment and care support. For example, an assisted living home with nurses and social workers.

Others may need to stay in a CamH general forensic hospital with doctors and nurses. In this setting, they can earn privileges to leave the unit for temporary periods. This may be for things like attending counselling, medical appointments, and visiting family. Depending on the risk assessment, this leave may or may not be escorted. This setting is more similar to staying in a hospital, and the privileges can boost recovery and rehabilitation.

Where there is a greater potential risk, they may need to stay at a more secure facility. In this case, they will stay in Secured Forensic Units. This is much more similar to a jail setting, although it is still a CamH facility. While doctors and nurses are available, there are fewer privileges available and the inmates remain in locked wards.


In hospitals and CamH detention centres, ORB inmates can earn privileges by following the rules and expectations. For instance, attending counselling, good behaviour, taking medication, passing blood and urine tests. These privileges grant them the opportunity to use facilities like TV rooms, the gym and the gardens. In some cases, they can even get passes to temporarily leave the hospital grounds.

These privileges help reinforce good behaviours and reward progress. As well, they improve the quality of life during detention and care. The privileges are only given if the treatment team believes the individuals can be trusted.

Unfortunately, the ORB inmates escaping this year indicates that some inmates are abusing their passes. When they get a pass to leave the grounds, they are given a clear time limit.

If they don’t return within their allotted time, the hospital is to notify the police. However, as revealed in the media that may not always happen in a timely fashion. With Zhebin Cong, for instance, the police weren’t notified of his escape for two weeks.


The knee-jerk reaction to these escapes is impacting the recovery of other patients. People who are complying with treatments and participating in counselling have had their earned privileges suspended.

It’s an unfortunate scenario where the system that agrees someone is Not Criminally Responsible decides to treat them as criminals. All this does is further marginalize some of the most vulnerable people in our community.

Although there have been calls for reforms, the simple truth is that CamH suffers from being overloaded and underfunded. The hospital cares for thousands of people with mental health issues and the treatment teams are hardworking people who take their responsibilities seriously.

Instead of reactionary suspensions of privileges, CamH needs better support. This would allow them to provide better monitoring of “public safety concern” inmates and improve stricter reporting policies.

William Jaksa Criminal Litigation

43 Front Street East
Suite 400
Toronto, Ontario M5E 1B3
Fax: 647-439-1566

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