A report into a triple stabbing at a festival in Vancouver’s Chinatown last year says that while the accused had been let out of his psychiatric hospital 99 times without incident in the years prior, an attack like the one that occurred was “more likely to occur at some point than not.”

The province hired former Abbotsford police chief Bob Rich to conduct an external review into the Sept. 10, 2023 attack that left three people injured at the Light Up Chinatown Festival.

Blair Donnelly has been charged with three counts of assault with a weapon in the incident and has been returned to the psychiatric hospital in Port Coquitlam where he has lived for the past 17 years.

The report concludes policies at B.C.’s Forensic Psychiatric Hospital, better known as Colony Farm, “were generally being adhered to,” but makes several recommendations on how to handle “higher-risk patients” in the interest of public safety.

The province says it has accepted all of the recommendations, some of which are already being implemented.

Violent history

Donnelly killed his daughter in Kitimat in 2006 but was found not criminally responsible by way of a mental disorder (NCRMD) after the court found he was suffering from a psychotic delusion that God wanted him to kill her.

Since then he has been living at Colony Farm, the province’s only secure facility for people who have been ruled unfit to stand trial or NCRMD.

In that time he was granted unescorted day passes at various points, and subsequently involved in several violent incidents, leading Rich to raise concerns about his 2023 release.

“The risk assessment evaluation for Mr. Donnelly was too short-sighted,” the report found.

“The question was not whether it was an acceptable risk to the public each time he went out. It is essential to consider what the level of risk was over a much longer period of time.”

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In 2009, while on an unescorted day pass, Donnelly stabbed another man and was convicted of assault.

He subsequently went eight years without any incidents but attempted to assault another patient at Conly Farm in 2017. He was charged in that incident but found again to be NCRMD the following year.

In the years following his unescorted day pass privileges were restored, leading to the string of 99 outings without issue between August 2022 and September 2023 before the Chinatown incident.

“My opinion is that long periods of time without a relapse was not an indication that there was no longer a serious risk if Mr. Donnelly was given unescorted access to the community,” Rich wrote.

“It is my opinion that an assault, like the one on September 10, 2023, was more likely to occur at some point than not. ”

Changes needed

Rich’s review included 17 interviews with staff and leadership, four with others connected to the province or Donnelly’s case and two outside experts.

The review found that most patients at Colony Farm remain there under full custody for fewer than four years, even in cases where the violent incident that landed them there was extreme.

It found the treatment culture is “positive and helpful,” with a core focus on reintegrating patients into society.

But it also concluded that staff must accept there is a tension between the goal of reintegration and the need to protect the community and manage risk.

“It is my opinion that there will be situations where further treatment, programs, or therapy, will not resolve the underlying risk that a patient’s illness poses to the public,” Rich found.

“This assertion sits in contrast to the underlying presumption (and legal obligation) of always trying to re-integrate patients back into the community.”

Rich made seven recommendations, including ensuring that all patients have a consistent “triad” managing their file throughout their care at the facility, including a psychiatrist, a nurse and a social worker.

It also called for updated policies on granting leave privileges, and an “elevated-risk patient policy,” as well as more staff training in forensics and how to use risk-management tools.

The report further calls for new risk-management technology for patients on leave, such as a GPS tracking system.

“All recommendations have been accepted and actions to address the recommendations are underway, such as recruitment planning and following new policies for granting leave privileges at the hospital,” the Ministry of Health said in a media release.

“Innocent people get hurt”

Port Coquitlam Mayor Brad West said he was pleased to see the recommendations in the report, which he said were”way overdue.”

But he said the report failed to include some answers the public was looking for.

“What is missing is the failure to address why this happens. We have a system that has been shifted to favour release and the rights of the offender over public safety,” he said.

“The system has no problem rolling the dice, saying that people are a low risk to hurt someone, release them, and what happens time and time again? Innocent people get hurt.”

Victims’ rights advocate Dave Teixeira who represents the family of victims of Alan Schoenborn, another high-risk patient held at the facility, said he was “quite hopeful” the report would kickstart systemic reforms at Colony Farm.

Teixeira argued a lack of resources and secure facilities to handle a high volume of high-risk patients have led to pressure to get patients out of the hospital rather than getting them healthy, something he said needs to change.

“Now the real work begins because this is going to take someone with true leadership to put someone with a strong mindset to lead a team to make these changes,” he said.

“This is a facilities problem, this is an operations problem, it’s a cultural problem and it’s a leadership problem.”

Donnelly is due back in court in Vancouver in March 2025.