Zhebin Cong’s disappearance and flight out of the country is the second of three instances in two months that a patient with a violent past has failed to return to the country’s largest mental-health hospital.

On Wednesday, Toronto’s Centre for Addiction and Mental Health said that it will review all patient privileges and day passes but did not provide details for how or when this would occur.

Mr. Cong was reported missing to police July 3 while on a day pass in the community. He boarded an international flight the same day but police have not revealed where he had flown. The other two patients have been found.

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Patients not voluntarily returning to the CAMH facility expose the challenges of balancing the rights of patients found not criminally responsible with the need to keep them under supervision. The goal of the system is to rehabilitate patients with the hope of reintegrating them into the community.

Sandy Simpson, chief of forensic psychiatry at CAMH, said: “We do understand that the public is concerned about these things. We will constantly look to try and improve.” He said Mr. Cong’s actions amount to an abuse of a system designed to rehabilitate patients. “That’s an affront.”

Mr. Cong repeatedly told medical staff that he wanted to go back to China, his country of birth and where his mother lived. His desire to leave Canada seemed to be a point of contention as he contemplated a future discharge from hospital, which required him to arrange for accommodation in this country.

He communicated every few weeks with his mother by Skype. “It appears that Mr. Cong can be more forthcoming with his mother about his internal thoughts and feelings, but not with members of the treatment team,” said a June, 2018, Ontario Review Board decision. The ORB is an independent tribunal that sets the parameters of supervision and management for people found not criminally responsible.

While it was aware of Mr. Cong’s wish to leave Canada, the hospital would not recommend that he be issued a travel pass, the June decision said. (Later dispositions made no further mention of travel passes.)

“He is stuck on this, and seems a little surprised that his discharge can only be done by the hospital approving his accommodation,” a May, 2019, decision from the ORB said, adding that Mr. Cong had a “very fixed view about how it should be.”

Mandarin interpreters were available and at least one of the physicians who treated him spoke Mandarin, but the panel heard in 2018 that it was not clear if there were other Mandarin speakers in Mr. Cong’s unit. By 2019, he was determined to return to China and was “fairly adamant” that he didn’t want to take English classes.

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Mr. Cong, 48, was committed to CAMH in 2016 after killing another boarder in his rooming house with a meat cleaver. He was diagnosed with schizophrenia and found not criminally responsible (NCR). Violence by people with schizophrenia or other mental illnesses is rare.

Open this photo in gallery Zhebin Cong, 48, was committed to CAMH in 2016 after killing another boarder in his rooming house with a meat cleaver. Handout

People with an NCR designation are detained in the forensic units of psychiatric facilities and their cases are managed by external review panels, like the ORB, which can determine whether they are eligible for privileges, such as supervised or unsupervised community visits.

Mr. Cong went missing while he was on an indirect supervision pass from CAMH, meaning he was allowed into the community unescorted, but a CAMH staff member could check in on him. Mr. Cong used his indirect supervision privileges on a number of occasions, including to visit the Hong Fook Asian Mental Health Centre for “socialization.”

The Toronto police were notified of Mr. Cong’s disappearance on July 3 but did not make it public until July 14. Because of privacy concerns, the force didn’t disclose that it was CAMH who reported him missing.

In a statement, the service said it had been informed that Mr. Cong “was a ‘low risk’ to public safety, to himself and was allowed on regular, unaccompanied public passes.”

The statement said officers then checked shelters, hospitals and addresses associated with Mr. Cong. They confirmed on Tuesday that he had left the country.

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As police investigated Mr. Cong’s disappearance, Geoffrey Le Feuvre went missing from CAMH on July 15. He was located two days later.

Mr. Le Feuvre, 68, has a lengthy psychiatric history. He was found not criminally responsible after a series of unprovoked assaults in 2007 where he punched people or swung at them with his walking cane.

In early June, Kleiton Da Silva, 44, had gone missing from the CAMH overnight and robbed a convenience store and a bakery before he was found. Mr. Da Silva was an NCR patient who had stabbed two men with whom he was smoking crack cocaine, killing one of them.

Dr. Simpson said the case is only the second time in CAMH history when an NCR patient left the facility and was charged with a criminal offence.

CAMH has about 200 forensic patients and of those, about 160 are NCR. Dr. Simpson said the hospital takes the disappearance of any patient seriously, but that in the vast majority of cases, they are found quickly.

Mathieu Dufour, associate chief of psychiatry at the Royal Ottawa Mental Health Centre, said there are about 1,600 patients across the province who are being overseen by the Ontario Review Board. There is a system in place to ensure they receive treatment while managing any potential risks they may pose.

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“We need to be able to re-integrate them into the community while still being safe for the community,” Dr. Dufour said. “There’s a very careful process.”

Dr. Dufour highlighted a Canadian study that found 17 per cent of NCR patients reoffend within three years of their discharge. Only 0.6 per cent of NCR patients commit offences involving serious violence. The rates are much lower than they are for the criminal justice system, Dr. Dufour said.

Unlike Mr. Cong’s case, other incidents where NCR patients go missing didn’t appear to be planned moves.

In 2015, for example, Thomas Brailsford, who was at the CAMH after killing his mother, was escorted in a taxi for a medical appointment. While the nurse was paying the driver, Mr. Brailsford ran out of the car. Police found him the next day.

George May was at the CAMH after he fatally strangled another psychiatric patient. In January, 2012, he was taken to the Toronto General Hospital for a CT scan. He got into a dispute with the technician and security led him out of the building without telling the CAMH escort.

Police found him three days later. He said he had gone to the Sunnybrook hospital emergency to get help but waited nine hours without seeing a doctor.