TORONTO -- An external review of procedures at the Centre for Addiction and Mental Health (CAMH) in Toronto has now been released following community concerns about a number of patients who left the facility without authorization this past summer, including a man found not criminally responsible for the 2014 murder of his roommate.

In June and July of this year, three cases of missing patients garnered significant media attention, including patient Zhebin Cong, who disappeared from the downtown facility on July 3 and boarded an international flight on the same day.

Cong was charged in the fatal stabbing of a roommate in 2014 but was ultimately found not criminally responsible (NCR).

Police tried to locate Cong for 11 days before notifying the public that the man had disappeared from the facility, located near Queen Street West and Ossington Avenue.

At the time, police also said they were told Cong was a "low risk" to public safety despite a May 2019 Ontario Review Board (ORB) document obtained by CP24 that states Cong continued to pose a "significant threat" to the safety of the public.

Another patient who disappeared from the facility this summer proceeded to commit two robberies before being apprehended.

Following the incidents, both Toronto Mayor John Tory and Premier Doug Ford called for an external review of the facility’s passes and privileges.

The review, which was released Wednesday, states that in the wake of the incidents, CAMH took a number of steps to reduce the rate of patients absconding from forensic units, which offer treatment to individuals who have been in contact with the criminal justice system.

The review also notes that it is “very rare” for patients who leave the facility without authorization to partake in criminal offences or acts of violence.

The review states that over the last decade, only one CAMH patient who absconded from the facility was involved in a violent incident.

It also stated that in 2018-19, only 0.031 per cent of passes issued resulted in a patient not returning to the facility when required. Of those instances, about one third were simply a late return.

“The largest part of the remainder accounted for by drug-seeking or other inappropriate but not criminal behaviour,” the report said.

Several recommendations have been made to help the facility further reduce the number of patients who leave the facility without proper authorization.

The review notes that CAMH’s facilities for forensic patients don’t have an “adequate secure perimeter” to allow people to get fresh air, exercise, or move around outside of their units without the risk of patients leaving the facility without authorization.

“This leads to a situation where even taking of fresh air for general security patients now involves a two-security guard escort along with another CAMH staff member,” the report states.

“CAMH analyses show that 47 per cent of total passes per week are used for hospital grounds and exercise which makes pass administration unnecessarily cumbersome.”

The review recommends creating a secure perimeter to allow for access to fresh air without the need for passes.

“This action will reduce motivations and opportunities for absconding, and reduce the number of passes that require daily review. It will also reduce the need for escorted passes which will free up staffing resources for therapeutic programming,” the review added.

The authors of the report also stated that there is “still room for improvement” when it comes to communication between CAMH staff and Toronto police.

“Police sometimes lack the information they need to assess risk in (absconding) cases and locate persons in the community,” the review said.

“There is a lack of clarity about the nature and amount of information that can be shared with TPS to assist in their understanding of the patient and the risk they pose, as well as information necessary to assist in the rapid location of the patient.”

One of the recommendations to improve communication is to create a “memorandum of understanding” that provides information about what can be shared between CAMH and police and when it must be shared.

Other recommendations include making passes, privileges, and absconding an “integral” component of the electronic health record as well as working with patients and their advocates to make sure everyone has a solid understanding of the new pass system.

“It is unrealistic to expect that these events will ever be reduced to zero given that risk will remain in the assessment of patients for passes and privileges,” the report continues.

“To reduce both the motivation for (absconding) and opportunities for (absconding), there are continuing needs for changes in the physical setting, in communications, in information technology, and in relevant systems, policies, and procedures.”