Supreme Court New South Wales Medium Neutral Citation: Attorney General for New South Wales v JR by his tutor Ashley Limbury [2025] NSWSC 159 Hearing dates: 06 March 2025 Date of orders: 06 March 2025 Decision date: 06 March 2025 Jurisdiction: Common Law Before: Sweeney J Decision: (1) Pursuant to ss 121 and 128 of the Mental Health and Cognitive Impairment Forensic Provisions Act 2020 (NSW) I order that James Aaron Ramirez be subject to an order for the extension of his status as a forensic patient for a period of two years commencing on 6 March 2025 and to continue until 5 March 2027. (2) I direct that the Registrar of the Court notify the Mental Health Review Tribunal of the making of the extension order. Catchwords: MENTAL HEALTH — Forensic patient — Extension of status as forensic patient Legislation Cited: Mental Health and Cognitive Impairment Forensic Provisions Act 2020 (NSW), ss 121, 122, 124, 125, 127, 128 Cases Cited: Nil Category: Principal judgment Parties: Attorney General of New South Wales (Plaintiff) James Aaron Ramirez (Defendant) Representation: Counsel: K Curry (Plaintiff) J Brock (Defendant) Solicitors: Crown Solicitor's Office (Plaintiff) Legal Aid New South Wales (Defendant) File Number(s): 2024/321529 JUDGMENT 1. The Attorney General for New South Wales, the plaintiff, seeks an order extending the defendant, JR's, status as a forensic patient pursuant to the Mental Health and Cognitive Impairment Forensic Provisions Act 2020 (NSW) ("the Act") for a period of two years. 2. The defendant appears by his tutor and was represented by counsel. Counsel indicated that the defendant does not consent to the order sought by the plaintiff, but will not make submissions against the extension of the order. The defendant, through his counsel, does not concede that he is an unacceptable risk of causing serious harm to others, that being the statutory test which must be met in order that the court can make the order sought. However, counsel accepted there is sufficient evidence to permit the court to make the order sought. Counsel indicated that the defendant would like to be free of an order in the future, but for now acknowledges he has only been in the community for a short while compared to his time in hospital. 3. Section 121 of the Act provides that the Court may make an order for the extension of the person's status as a forensic patient. Pursuant to s 122 of the Act, the Court can only make an extension order if satisfied to a high degree of probability that the forensic patient poses an unacceptable risk of causing serious harm to others if the patient ceases to be a forensic patient, and the risk cannot be adequately managed by other less restrictive means. 4. An application for an extension order may only be made in relation to a forensic patient if the forensic patient is subject to a limiting term or an existing extension order: s 124 of the Act. The defendant was a "forensic patient" as defined in the Act when the plaintiff's application was made, because he was subject to an extension order made by this Court in December 2022, which expired in December 2024. The defendant is currently the subject of an interim extension order. 5. In determining whether to make an order, the Court must have regard to the matters specified in s 127(2) of the Act, being: the safety of the community, reports from experts who examined the defendant, a report by an expert who assessed the risk of the defendant causing serious harm to others, relevant orders or decisions made by the Mental Health Review Tribunal ("the Tribunal") about the forensic patient, the forensic patient's compliance with any obligations to which he has been subject while a forensic patient, and the views of the court which imposed a limiting term or extension order. 6. I have considered the three folders of supporting documentation required by s 125 of the Act. I am grateful to those who prepared that documentation, which assisted my understanding of the relevant matters. I was also assisted by the written submissions of counsel for each party. 7. JR is a 40 year old Aboriginal man. He has been living in supported independent living accommodation since July 2023 and is subject to reviews by the Tribunal. He has been diagnosed with schizophrenia or schizoaffective disorder, first diagnosed when he was 16, cognitive impairment, substance use disorder, currently in remission in a supervised environment, and complex trauma from childhood experiences. He has a Guardianship Order, Financial Management Order and an NDIS plan. 8. The defendant comes before the Court as a forensic patient in the following circumstances. He was charged with offences occurring in June 2014, being three counts of sexual intercourse without consent and one count of indecent assault. He was found not fit to be tried for those offences by a judge of the District Court of New South Wales on 19 March 2015. After a special hearing before Acting Judge Graham his Honour found that on the limited evidence available, the defendant committed all of the offences charged. On 2 September 2016 Judge Graham imposed four concurrent limiting terms, the longest being of 4 years, expiring on 8 July 2018. The facts found were that the defendant and victim were both inpatients at a psychiatric hospital and the defendant entered the victim's room and sexually assaulted her. In imposing the limiting terms, Judge Graham observed that the offences were opportunistic, not prolonged, and did not involve any gratuitous violence over and above the sexual violence implicit in the assaults. His Honour noted the psychological impact the assaults had had on the victim. 9. On 28 September 2018 Lonergan J of this Court extended the defendant's status as a forensic patient for a period of 4 years, which expired on 29 September 2022. On 23 December 2022 McNaughton J of this Court extended the defendant's status as a forensic patient for a period of 2 years. I have read and considered their Honours' judgments. 10. The defendant also has a criminal history which includes assaults, breaches of Apprehended Domestic Violence Orders and drug possession. Many of his matters have been dealt with by way of diversion under mental health legislation. 11. In the supporting documentation were reports of experts who had previously examined JR, being psychiatrists Dr Kerri Eagle, Dr Anna Farrar and Dr Calum Smith. There were also many reports to and decisions by the Mental Health Review Tribunal. I have read and considered all of those documents. 12. The most recent examinations of the defendant, pursuant to orders made by Hulme AJ in the preliminary hearing, were by Dr Carollyne Youssef, psychologist, whose report is dated 9 January 2025, Dr Calum Smith, psychiatrist, whose report is dated 10 January 2025, and a Risk Assessment Report was prepared by Amanda White, psychologist, in March 2024. Those experts' opinions were not challenged and their reports were relied on without oral evidence or cross examination. 13. Dr Youssef reported that the defendant's mental health began to deteriorate in his adolescence. He was diagnosed with schizophrenia when he was 16 years old and has since been primarily diagnosed with schizoaffective disorder and has had multiple hospital admissions. She said JR has also experienced a gradual decline in cognitive functioning, now falling within the extremely low intellectual functioning range. She said based on the current assessment, JR meets the criteria for schizophrenia, as well as alcohol and cannabis use disorder. She said JR lacks insight into his mental illness and continues to experience some positive symptoms of schizophrenia. Additionally, his cognitive functioning is deteriorating, with impairments in memory, new learning and conceptual reasoning. She said he would likely require long term support and guidance, especially in social interactions and self-care. His inability to recognise his own offending behaviour further limits his self-awareness regarding the potential risks he may pose, compromising his ability to self manage. 14. Dr Youssef said that using assessment tools, which Dr White said should be regarded with care when applied to Indigenous people, the defendant is categorised as at above average risk for sexual offending. She said he has a moderate to high likelihood of committing sexual violence if no special management strategies are put in place. Effective prevention of sexual recidivism will require a high level effort to implement such strategies. She said JR is in a high risk category for violent recidivism, but his risk for sexual recidivism currently appears higher than his risk for violent recidivism. Key dynamic risk factors for him include difficulties in self-regulation exacerbated by deteriorating mental health, substance abuse, unmet sexual needs, interpersonal challenges, attachment deficits and limited insight. She said his primary protective factor is the external controls in place, which assist with his adherence to medication and active engagement with community mental health and disability services. 15. Dr Youssef said the defendant presents a risk of harm to others that could be serious if he ceases to be a forensic patient and is not subject to any other protective measures. She said an extended order would allow for the continuation of conditions and management provisions, such as abstaining from alcohol and illicit substances, attending required interventions, monitoring and building community support, while also enhancing other protective factors and his functional capacity to aid in self-regulation. She said it is unlikely that JR will receive and/or comply with the required level of treatment and supervision if there were no order in place. Therefore, she said, continuation as a forensic patient will allow his risk of causing harm to others to be adequately managed, while continuing to support his reintegration. She recommended a further order of two years. 16. The defendant has been observed and reported over the years to stare and wink at women and wear revealing clothes such as unbuttoned shirts that reveal his nipples and midriff. Dr Youssef noted that during her assessment of JR he wore a white singlet that exposed the lower part of his abdomen and winked at her several times during the assessment. 17. Dr Youssef recorded that the defendant was disoriented with respect to place and date and experienced delusions of grandeur throughout the assessment. 18. In a review of prior reports Dr Youssef noted concerns having been raised about the defendant staring at women in public and winking at women, including female staff, despite being instructed not to do so. She noted he had consistently reported a belief that women are attracted to him and show an interest in him. There was a report that while at a forensic hospital the defendant touched another patient's buttocks. There were also recorded two prior incidents of sexual aggression while the defendant was an inpatient, both in 2010, before the charged offences in 2014. It was reported that on those two occasions in 2010, the defendant entered female patients' bedrooms and on the first occasion had sexual intercourse and on the second attempted to do so. The second incident involved a sedated patient whose vagina the defendant touched. He was reported to display positive symptoms of psychosis at the time of both incidents. The incidents were not referred to police. 19. Dr Youssef said the defendant's schizoaffective disorder or schizophrenia was characterised by grandiosity, auditory hallucinations, delusions and limited insight into his mental illness and need for intervention. She said his delusions continue and it is believed that he experiences auditory hallucinations which he has started to try to conceal from supervising staff. He receives medication from a local community health centre. 20. Dr Youssef noted records of the defendant using cannabis from the age of 16, methamphetamine from 18 and having experimented with heroin, ecstasy and cocaine. He has been previously diagnosed with substance use disorder in sustained remission in a controlled environment. 21. Dr Youssef noted from records that in a hospital admission in 2018 – 2019 the defendant's behaviour was noted to be disinhibited and characterised by sexually inappropriate clothing and greetings, such as winking. That was noted to improve, but in a hospital admission in 2020, the defendant was observed to wear inappropriate attire on the ward, continue to have limited insight into his mental illness and to express grandiose ideas. 22. Dr Youssef noted from earlier reports that there had been ongoing concerns about the defendant's behaviour around women in the community as well as him wearing revealing clothing. She said the defendant's staring at women and commenting about their buttocks are redirected by support staff, although the defendant has been reported to become challenging when redirected. In a report of May 2024 it was noted that the defendant had been compliant with his treatment in the community and had attended all his scheduled appointments. 23. Dr Youssef agreed with an earlier opinion of another expert that the defendant's response to psychological intervention will be very limited and the treatment most likely to benefit him is behavioural with external monitoring and support. 24. Dr Youssef said that the defendant continues to engage in extreme minimisation or denial of his sexual offending behaviour and has consistently maintained that the sexual intercourse was consensual. 25. She said that adverse childhood experiences have likely affected his coping mechanisms, attachment style and temperament, all of which may have contributed to his offending. Dr Youssef said the defendant's mental disorder causes disturbances in his behaviour, cognitions and perceptions. She said the relevant risk factor of prior substance use is not a risk factor at the moment. 26. She said the defendant has a lengthy history of breaching conditions and orders and failing to comply with conditions, but at present he appears to be compliant with the conditions of his order and compliant with his medication. She said they are relevant to his risk of reoffending and need to be monitored. 27. Dr Youssef said the defendant continues to have problems with insight, whether in relation to his mental illness or the risk factors he may have. He continues to be unwell, with delusions of grandeur, thought disorder and deficits in adaptive capacity. His mental illness is regarded as a chronic and persistent condition, which remains a significant factor in difficulties with problem solving and initiating and maintaining relationships. Although he is compliant with treatment, the limitation stems from his response to treatment, given the nature of his mental illness and his capacity. 28. Dr Youssef said the defendant lacks the capacity to develop realistic, independent plans, but is likely to comply with services and plans arranged for him, although he lacks the intrinsic ability to initiate them on his own. He is expected to continue facing challenges due to his persistent lack of insight, and while he will likely remain compliant with any interventions imposed or ordered, his responsiveness remains a limitation. 29. Dr Youssef said the defendant displays neurocognitive deficits, likely related to his mental illness. She said there is insufficient evidence to determine whether he can control his impulses, delay gratification or regulate his sexual behaviour and this should be reassessed after he has spent some time in the community, gaining more autonomy. 30. Dr Youssef said the defendant's strongest protective domain is stable housing, while he is receiving NDIS support, with ongoing reviews by the Mental Health Review Tribunal and his finances being managed. She said his current accommodation with external support and control in the form of 24/7 supervision is a protective factor for him, which would continue if he were subject to an extension of his forensic patient status and will potentially be the strongest protective domain for him. 31. Dr Youssef said if the defendant were to reoffend, he is currently more likely to commit a sexual offence rather than a violent one, particularly if he were to have unsupervised access to a vulnerable woman. She said the victim would likely be someone unknown to him or someone he had recently met. They are likely to be in the same living quarters, such as an inpatient unit or group home. The offending behaviour is likely to be intrusive, including sexual penetration. The motivation for his offending is likely to be sexual gratification and the offence is likely to be opportunistic, with little, if any, planning. She said the factors most likely to increase the defendant's risk of a contact sexual offence are victim access, especially if unsupervised, sexual preoccupation and a deterioration in his mental state. 32. Dr Youssef said the defendant lacks insight into the seriousness, severity, and even the presence of his mental illness and related vulnerabilities. She said this lack of awareness is typically a symptom of schizophrenia. He has treatment resistant schizophrenia and his cognitive functioning is progressively deteriorating. He will likely need lifelong support and guidance, particularly regarding his interactions with others. Since he does not recognise his offending behaviour, his self-awareness regarding the potential risk he may pose is further limited. 33. Dr Youssef said impaired judgement and impulse control are common in people with schizophrenia due to cognitive deficits, so that people with schizophrenia may engage in risky or inappropriate behaviour, including sexually inappropriate behaviour, particularly if they have reduced insight into their condition. Also the defendant has delusions and hallucinations that can influence behaviour, leading to inappropriate sexual actions. Substance use may lead to disinhibition and altered perceptions. 34. Dr Youssef concluded that the defendant does present a risk of harm to others that could be serious if he ceases to be a forensic patient and is not subject to any other protective measures. She said he appears more likely to pose a risk of sexual harm rather than violence. Factors increasing his risk of a sexual offence include victim access, deterioration in mental health, lack of external supports and control and desire for sexual gratification. Effective management of his mental health, cessation of substance use, a structured lifestyle, no unsupervised access to vulnerable women, and an increase in protective factors such as involvement in meaningful activities and ongoing NDIS support are likely to lower his risk of reoffending. It is crucial for him to remain abstinent from substance use due to its disinhibiting effect on his behaviour. Ongoing assessment and monitoring is essential to manage and mitigate potential risks effectively. 35. She said if the defendant remains under a forensic patient order, it would help reduce identified risks by providing external support, monitoring, and controls which act as key protective factors. Those measures create a structured environment that mitigates potential harm. The most significant protective factor for the defendant is the external oversight and support he receives. Therefore, maintaining the forensic patient order would lower his overall risk and the likelihood of harm to others by addressing factors such as substance abstinence, stable accommodation, support from mental health services, engagement with NDIS staff and ongoing oversight from the Tribunal. 36. Dr Youssef said continuing the defendant's status as a forensic patient is the most effective way to manage his risk of harm to others, as it ensures ongoing oversight by the Tribunal. She said without a forensic patient order, it is unlikely that the defendant would receive or comply with the necessary level of treatment and supervision. 37. In terms of alternative methods of managing the risk, Dr Youssef said the defendant being an involuntary patient is not currently necessary or sufficient to manage his needs and risks. His history of non-compliance with a Community Treatment Order means that such an order does not address his forensic needs related to his risk of reoffending. The Guardianship Order does not provide sufficient authority and control to manage his level of risk and needs. The NDIS support on its own is not sufficient given its voluntary nature. 38. Dr Youssef said that an extended order that allows for supervision, support, treatment and monitoring is the least restrictive form of management. It is unlikely that the defendant will receive and/or comply with the required level of treatment and supervision if there were no order in place. Based on the defendant's risk of reoffending, an assessment of his dynamic risk factors and his history of decompensation when in the community, resulting in problematic and offending behaviour, she recommends an extension period of two years. 39. Dr Smith had previously reviewed JR in 2022. Dr Smith observed that many of the defendant's responses in the assessment were thought disordered and some were delusional. Dr Smith reported that the defendant failed to understand the nature of the wrongdoing of his 2014 offences, thinking that it was wrong that it occurred in an open place, and that it was consensual. 40. Dr Smith reported that the defendant's long-standing schizophrenia or schizoaffective disorder is clozapine resistant in the sense that although he has had some benefit from it, he remains symptomatic on it. Dr Smith noted that the defendant has significant historical issues with substance use, although there was nothing to suggest he has used illicit substances in a number of years, albeit in highly controlled environments. However, he still lacks insight. 41. Dr Smith observed that the defendant has a history of ceasing or failing to take medications or to engage with psychological rehabilitation, he has absconded from treatment and has in the past breached bail and ADVO's. Talking therapies for his substance abuse or his 2014 offending have been treatment failures for the defendant. He has negligible insight into his offending, his risk, or his mental state and the need for medications. While there has been some degree of improvement, he remains grossly psychotic. He is currently compliant with medications in a highly restricted environment. His offending shows a degree of chronicity. He is in frank denial of his sexual offending, albeit in the context of gross mental illness. His ability to reflect on his mental state is extremely limited. He has little insight into his history of substance abuse. 42. Dr Smith said he believes that medication, abstinence from drugs and a restrictive environment are effective in treating the defendant's illness, modulating his behaviour and containing his risk. 43. Dr Smith said that he found that the defendant had improved somewhat from his previous review of him. However, he remains delusional and thought disordered, his overall functioning is very low and his insight into his mental illness and his offending is poor. 44. Dr Smith said that using assessment tools, the defendant's increasing age has affected his assessment but he is still categorised as in the above average range for sexual violence risk. He said the defendant's risk has multiple different causes, but in large part is driven by his psychosis. He said his previous formulation of the defendant's risk still stands. Both his violence and sexual violence risk appear linked to impulsivity and disinhibition. The acts do not appear to be planned but have an impulsive and erratic character that is likely influenced by mental illness, traumatic experiences and substance abuse. 45. He said the defendant has few protective factors. He said while the overall picture is one of containment and safe management in the current context of being on medication in a restricted environment and abstinent from drugs the concern is should that change the risk could change. He said his assessment of the defendant was in keeping with the formal findings of his extremely low intellectual functioning. 46. Dr Smith said while the defendant has improved clinically, he remains grossly psychotic. He still requires prompting to engage in basic activities of daily living, such as showering. He still needs prompting and guidance and often behaves in a bizarre manner. 47. Dr Smith said the level of supervision is fundamental to the defendant's improvement and therefore crucial to the ongoing management of his risk. He said the defendant is better because of the overall treatment package, including the monitoring, the medications, the NDIS package and the constant prompting. 48. He said the defendant continues to lack insight into his offending, illness, substance abuse and need for treatment. 49. The active and high level current management has meant the defendant has had success in terms of his transition to the community which has been achieved safely. 50. In considering less restrictive means of managing the defendant's risk, Dr Smith said the defendant does not need inpatient care currently. He said the defendant seemed settled in his residence and with his mental health team, but without a forensic patient order, if he ceased to take his medication or live in the residence he could not be forced to do so. He said he believes the defendant poses a risk of causing significant harm to others if he ceases to be a forensic patient and that an extension order should be made. 51. Dr Smith said that in terms of the further order the defendant has continued to make progress, so it is possible that he can make more, and there is evidence that the longer someone in the community is managed as he is, the better the outcome is likely to be. Dr Smith is of the opinion that two years is a reasonable time for a further order. 52. In her Risk Assessment Report of 25 March 2024, Dr White said that in his current context, where he is well supported and supervised, the defendant's current risk of sexual and violent reoffending is relatively well-managed. She said his risk of sexual reoffending is expected to significantly increase in the absence of adequate support and supervision, and he would be at risk of another serious offence, particularly in the context of medication non-compliance, worsening of mental illness, substance use and unmet sexual needs. She said given the limited time the defendant has had on conditional release and living in the community after about nine years in secure forensic mental health settings, and the chronicity and severity of his mental health conditions, there was presently a lack of evidence to support sustained improvement in the presence of any stressors. She said the defendant believes that under his current order he is in gaol and this is considered to be a major deterrent to his reoffending, but he continues to display sexually inappropriate behaviour which is contained by his support workers. She said he poses a risk of causing serious harm to others if his status as a forensic patient is terminated. She said a further order of two years is recommended. 53. The defendant told Dr White that in public he does not stare at women, but does "have a geez" and is currently hiding his sexual interest, which is "a bit stressful". He said workers will direct him not to look at women, but he was unsure why. He could not see any issue with looking. He said lots of women in public were attracted to him and showed interest in him, often younger women. He said he knew what he did previously was wrong and next time he would go to a private location to have sex. He said of his 2014 offending that what was wrong was that they had sex in a public place. 54. Dr White reviewed records which noted that while in forensic units the defendant engaged in sexually inappropriate or disinhibited behaviour with staff, displayed a persistent belief that his offending behaviour was consensual, and wore shirts unbuttoned down to his belt and winked at staff. Since he transitioned to supported independent living there had been reported instances of him staring at women in the community and unbuttoning his shirt to expose his chest and wearing revealing clothing in the community. He has been reported to be transfixed on women in public, staring at women in an intimidating way, and has mostly been manageable with intervention and redirection from staff, although in February 2024 had ignored attempts to redirect him. The defendant remains in line of sight of support workers when in the community. 55. Dr White said in previous risk assessments the defendant's future level of risk has reportedly always been moderated by his strong external support and level of supervision. Drug and/or alcohol use, medication non-compliance and deterioration in his mental health have repeatedly and consistently been acknowledged as significant risk factors. His neurocognitive limitations have been noted to restrict further progress, resulting in continued need for intensive supports long-term. 56. She said that on one actuarial risk assessment tool the defendant's score has decreased due to his increase in age, so that he is now in the above average risk category for sexual reoffending. 57. Dr White reported that during her assessment of the defendant he expressed delusional and grandiose beliefs and winked at her several times in the interview while rubbing his chest and puffing it out. 58. Dr White said the defendant's risk factors for future sexual violence are chronicity of sexual violence, problems with denial of sexual violence, problems with self-awareness, problems with stress and coping, major mental disorder, problems with substance use and problems with relationships. He has a lack of capacity to engage in treatment and a history of difficulties with supervision. 59. Dr White said the defendant's sexual offending occurs in the context of treatment resistant chronic mental illness with persistent delusions, grandiose beliefs and impaired insight about his illness and behaviour. He is impulsive and has behavioural and emotional dysregulation which increases during periods of destabilisation such as homelessness, substance use, medication non-compliance, lack of social connection in relationships and heightened active positive symptoms of psychosis. During those periods is when he is more likely to sexually offend. His sexual offending history was noted to have involved vulnerable adult women who themselves had mental health concerns and/or reported cognitive impairment. There were reports of inappropriate sexual behaviour from a young age, suggesting long-term difficulty regulating his sexual behaviour and distorted views of the same. He also has a history of reactive aggression. Intoxication causes him to react in a more unregulated way. 60. Dr White said risk scenarios for sexual violence are most likely to occur in the context of inadequate or unstable supervision and formal supports, deterioration in mental health, which may be associated with medication non-compliance, and interpersonal stress. Offending is likely to be opportunistic, impulsive and unplanned and involve adult women, but especially vulnerable women in settings where there is potential deficit in supervision. Offending is likely to involve contact sexual offences. Dr White said the defendant's treatment resistant schizoaffective disorder is complicated by factors including a history of medication non-compliance, drug and alcohol use, cognitive impairment, homelessness, and lack of community connection. 61. She noted that in his supported independent living accommodation he has reportedly been compliant with medications and treating team recommendations though requires supervision and encouragement for same. She said his mental health appears to be relatively stable, although he has persistent symptoms of grandiose ideation and delusional behaviour and impaired insight. His environment and interactions are controlled and moderated by staff. If he were to consume alcohol or drugs this would be highly problematic in terms of his risk and general functioning, specifically if not supervised, so it is imperative that this is managed proactively. Dr White said the defendant believes that his current placement is still part of his jail sentence or order and this appears to be a major motivating factor for him to comply with conditions, but despite that he continues to present with inappropriate sexual behaviours, including winking and staring at women in public, requiring intervention of support workers and redirection due to lack of insight, and engaging in physical contact when an opportunity presents, such as with support workers and a dance teacher. 62. Dr White said given the severity and treatment resistant nature of the defendant's mental health condition it is unlikely that he will ever experience a complete resolution of symptoms, even with ongoing management. His cognitive impairment coupled with his mental illness are likely to result in significant difficulties in his day to day functioning and require long-term intensive supports. He is expected to have cognitive impairment long-term, based on the nature and severity of his presentation. 63. He has a history of substance abuse. There is no reported use of nonprescribed drugs or alcohol since 2014, but the defendant reports cravings for alcohol. 64. Dr White said deterioration in the defendant's mental health and worsening of his psychotic symptoms increase the risk for violence and sexual violence given his distorted beliefs and impaired insight and judgement. The defendant's cognitive deficits, including impulsivity, poor planning and capacity for consequential thinking, impact his behaviour and capacity to regulate it. He is at increased risk of acting in response to his sexual urges and has less capacity for restraint in the absence of external monitoring and behaviour supports. Any future illicit substance use is likely to increase his level of cognitive impairments including disinhibition, problems with decision-making and impaired judgement. 65. Dr White said in her opinion there is a risk of the defendant causing serious harm to others, most likely sexual harm, if he ceases to be a forensic patient. She said since the previous extension order was made his overall presentation and clinical risk factors remain largely unchanged. He has major mental illness, cognitive impairment, impaired insight into his conditions, deficits in social – emotional reciprocity and long-term substance use, all of which are marked and pervasive. Dr White noted that as at the time of her report, the defendant had only been in the community for about seven months and on conditional release for four months. She said his exposure resilience in response to destabilisers remains largely untested. Previous attempts at rehabilitation have been unsuccessful, largely in part due to his mental illness and cognitive impairments such that his risk management is reliant on external sources. She said his reintegration is being carefully and slowly managed with a high level of support and even in that context he displays poor internal capacity to inhibit sexual behaviour and control his urges and impulses; he continues to display inappropriate sexual behaviour. 66. Dr White said currently, with a high level of support, supervision and intervention, the defendant's risk of causing serious harm to others is assessed to be low. His sexual behaviour is prevented from reaching a level of serious harm due to immediate and direct intervention by his support workers. He is in a highly controlled setting, with externally derived routine and structure, due to his forensic status. She said it is unclear how compliant the defendant would be if the order was removed. In her view, if the order and supports were removed, the defendant's risk of sexual reoffending would increase significantly to at least moderate to high risk and the threshold of his sexual behaviour may well reach serious harm. She said there is insufficient evidence to suggest the defendant can be well managed and his risk remain low without extension of his forensic status. She said his risk of causing serious harm to others would be adequately managed by continuation of his forensic patient status. 67. Dr White said classification of the defendant as an involuntary patient is not necessary, nor the least restrictive means to manage his care at present. He has a history of non-compliance with Community Treatment Orders and there is difficulty in how such orders are enforced. His NDIS funding is not related to his level of risk. In her view, no other less restrictive means is currently considered suitable. 68. Dr White said if the order was extended a period of two years would seem reasonable. It would allow for a significant period of community supervision and further gradual easing of conditions with monitoring, supervision and evaluation of his responses under the oversight of the Tribunal, to ensure community safety and that his behaviour can be managed. 69. There is a deal of consistency in the opinions of the three experts. All of them recommend an extension of the defendant's forensic patient order for a period of two years and expressed the opinion that no less restrictive means would adequately manage his risk. Their opinions were not challenged, they are well reasoned and I accept them. 70. In summary, the defendant is at low risk of sexual reoffending while under supervision, but it is considered his risk will increase if he is not under supervision. 71. Dr Smith has seen some improvement in JR since he reviewed him in October 2022, but concerns remain, seemingly the same issues, and his risk assessment level remains the same. 72. He has continuing treatment resistant schizophrenia or schizoaffective disorder, accompanied by extremely low and deteriorating cognitive functioning. He lacks insight into his offending and his mental illness. He has a past history of non-compliance with medication when not under supervision. Effective prevention of sexual reoffending by the defendant requires external controls and supervision, such as a forensic patient order. Even under close supervision, he exhibits concerning sexually inappropriate behaviour. 73. Dr Smith is of the opinion that the defendant is better under close supervision, although even under close supervision there is still some inappropriate sexual behaviour. Dr Smith is of the opinion that further supervision should lead to further progress by the defendant in the community. 74. Having considered all of the material in the supporting documentation, the three expert reports referred to above, and the other factors in s 127 of the Act, including the safety of the community, I am satisfied to a high degree of probability that the defendant poses an unacceptable risk of causing serious harm to others, in the form of sexual assault, if he ceases being a forensic patient, and the risk cannot be adequately managed by other less restrictive means than his continuing to be a forensic patient. Orders 1. Therefore I make the following orders: 1. Pursuant to ss 121 and 128 of the Mental Health and Cognitive Impairment Forensic Provisions Act 2020 (NSW) I order that James Aaron Ramirez be subject to an order for the extension of his status as a forensic patient for a period of two years commencing on 6 March 2025 and to continue until 5 March 2027. 2. I direct that the Registrar of the Court notify the Mental Health Review Tribunal of the making of the extension order. ********** DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 06 March 2025