The first person Shawn O’Neill stabbed that chilly Sunday morning was Christopher Young. O’Neill jumped at him on the Church St. sidewalk and plunged a kitchen knife into his lower right abdomen.

John Tedesco was jogging past Maple Leaf Gardens minutes later when O’Neill drove the same knife into the small of his back.

Sally Kaack, an Australian ballerina, was next. The blade punctured her right lung.

Finally it was Jennifer Tran, a St. Mike’s hospital resident walking home from a night shift. O’Neill stabbed her through her winter coat and the knife broke against an iPhone in her left breast pocket, above her heart.

Police later called it “a rampage.” None of the victims died or were grievously injured, and last week, a Superior Court judge ruled that 62-year-old O’Neill is “not criminally responsible on account of mental illness” (NCR), for the quadruple stabbing on Jan. 25, 2015.

Even so, impact statements included in the ruling highlight how the incident has marked the lives of O’Neill’s victims ever since, prompting anxiety and stress and fear of strangers. The pain, it seems, can linger like an unfading bruise.

But the ruling also underscored a sense that the ordeal could have been avoided.

One year before the attacks, O’Neill was freed from court-mandated psychiatric treatment for paranoid schizophrenia and substance abuse. He entered the system in 1996 when he was deemed “not criminally responsible” for the first time after brandishing a knife on Queen St. For more than 17 years, O’Neill was treated for mental illness, closely monitored by doctors and subject to annual hearings at the Ontario Review Board, a provincial body that oversees roughly 1,500 people deemed NCR by the legal system.

After the board granted O’Neill’s absolute discharge in January 2014 — a move opposed by his family and doctors at the Centre for Addiction and Mental Health — he no longer had to visit the hospital every day. And no one could force him to take medicine.

So he didn’t. According to the recent judge’s ruling, O’Neill fell into a spiral of drinking and weed smoking, and stopped taking medication to control his psychotic symptoms. In late January 2015, “while labouring under delusions” that he needed to stop a murky conspiracy to abuse children, O’Neill grabbed a kitchen knife, went out to the street and stabbed four people.

The judge said that, while O’Neill won’t be criminally sentenced, he is expected to be institutionalized and forced into mental health treatment for a long time.

“This decision is made with the expectation that Mr. O’Neill will always be carefully monitored and supervised in the future,” wrote Justice Gary Trotter in his March 18 decision.

In their impact statements submitted in court, victims of O’Neill’s spree questioned how this could have happened at all.

“The anger is no longer directed toward the perpetrator,” wrote Alison Tedesco, wife of the jogger who was stabbed. “(O’Neill) is a victim of his own illness and of a system that has failed him. This system has allowed him to walk freely through the streets, to be off his medication.”

Tran, the doctor whose life was possibly saved by her fortuitously placed iPhone, urged the court to commit O’Neill to a secure psychiatric facility for long-term treatment.

“I want to be able to feel safe walking home after work on a Sunday morning, and I want that for my fellow citizens as well,” she wrote.

Chris Murphy, a lawyer who represented O’Neill after the stabbings, said that, in retrospect, it was the wrong decision for the Ontario Review Board to relinquish oversight of his client. Though he had been living under supervision and tight conditions in the community for almost a decade, O’Neill repeatedly tested positive for drugs, sometimes broke the conditions of his treatment, and disappeared for days at a time, Murphy said.

Loading... Loading... Loading... Loading... Loading... Loading...

Moreover, at the hearing before he was discharged from treatment, O’Neill’s hospital team expressed concern that, without any requirement to check into the hospital, O’Neill would start drinking and using drugs more heavily. This could increase the chance that he would abandon his medication and his psychotic symptoms would return.

“Obviously he did pose a risk to the public. That’s clear now,” said Murphy, noting that a significant factor in O’Neill’s discharge was the lack of violent episodes and criminal activity in the 17 years after the 1996 knife incident.

“But in Canadian law you can’t limit a person’s liberty forever,” he added. “At some point a person is entitled to his or her liberty, unrestrained.”

It’s that balance between an individual’s right to make their own decisions and the imperative to keep the public safe that the Ontario Review Board is tasked with striking.

Though difficult to predict, incidents like the O’Neill stabbing spree are rare, said Jennifer Chambers, executive director of the Empowerment Council, an organization that advocates for people deemed NCR. Research from a national project on mental health shows 1 per cent of NCR detainees given absolute discharge reoffend in a seriously violent manner in the three years after release.

“The reality is — which is something psychiatrists don’t like to advertise — there’s really no way of predicting whether someone is going to be dangerous or not,” Chambers said. “It’s also true that you can’t lock people up for the rest of their lives based on the possibility that they might do something violent.”

Paul Berstein, a lawyer and former president of the Criminal Lawyers’ Association, said that, in some ways, NCR patients released on absolute discharge are “set up to fail.” He compared it to teaching a child to ride a bike without following them down the road as they wobble unsupervised into the distance. They are set up for life in the community during treatment, and then, abruptly, they’re on their own.

“As soon as someone looks like they’re doing OK,” Berstein said, “the system certainly wants to believe that it doesn’t have to focus its attention on that individual any more.”

O’Neill’s sister, Maureen, said she’s always believed her brother is better off in treatment. Before his first NCR decree, his life was a rolling litany of crime and short-term hospitalization. He was relatively stable in treatment, she said.

Now, after the shock and the remorse of the 2015 stabbings, she’s relieved to think of him back in the system, even if that’s the case for the rest of his life.

“That’s what he needs. He needed that management because he was never capable of managing his disease on his own,” she said.