The King v Garfel Ephraim

SAINT LUCIA THE EASTERN CARIBBEAN SUPREME COURT IN THE HIGH COURT OF JUSTICE (CRIMINAL) CASE NO. SLUCRD2022/0087A,0088A,0089A THE KING vs. GARFEL EPHRAIM Defendant Before: The Hon. Mde. V. Georgis Taylor-Alexander High Court Judge Appearances: Mr. Linton Robinson for the Crown The Defendant present via zoom from the Bordelais Correctional Facility and unrepresented ____________________________ 2025: May 28; _____________________________ Judgment Excerpt – Fitness Hearing Trial Pursuant to Sections 14 and 66 of the Evidence Act, Cap. 4.15 of the Revised Laws of Saint Lucia

[1]TAYLOR-ALEXANDER J: This matter comes before the court for a Fitness Hearing Trial in accordance with Sections 14 and 66 of the Evidence Act, Cap 4.15 of the Revised Laws of Saint Lucia (hereinafter referred to as ”the Act”). The Defendant stands indicted for the offence of Burglary and has a well-documented and prolonged history of mental illness.

[2]The Defendant is unrepresented by legal counsel; however, his sister was present during the proceedings on his behalf. The court received oral evidence from Dr. Julius Gilliard, who was deemed to possess specialist knowledge pursuant to Section 66 of the Act, based on his qualifications, training, and extensive experience. The Court relied on his expert opinion on in arriving at its judgment.

[3]The report of Ms. Siona Huxley, Consultant Psychologist, was tendered into evidence. Although she was not available to give oral testimony, her report was admitted as evidence. Ms. Huxley had conducted multiple interviews with the Defendant and prepared her findings for the assistance of the Court.

Dr. Julius Gilliard

[4]He is a medical doctor specializing in Psychiatry. He was trained by the Instituto Superior De Ciencias Médicas De Villa Clara, Cuba, (2004), DM Psychiatry. He is trained with the University of the West Indies, St. Augustine Campus, Trinidad (2017) and has undertaken Expert Witness Training facilitated by the University of Toronto and the St. Lucia Forensic Science Services Laboratory (April 2018). He is licensed to practice in St. Lucia by the Medical and Dental Council. This license expires in 2026. Pursuant to Section 66 of the Act, he was deemed an expert in Psychiatry.

[5]Dr. Gilliard interviewed the Defendant on two occasions and subsequently prepared two reports based on his evaluations. The following is a summary of the contents of those reports, which were tendered into evidence and relied upon by the Court during the trial.

JG1 (Report Dated the 4th of December 2023)

Substance Use History

[6]The Defendant stated that he started using alcohol since he was “little”. He did not give further information. He uses cigarettes daily, adding that “I smoking it more now”. He also stated that he has only “tried” marijuana on a few occasions, and that he has never used any other substances of abuse.

Psychiatric History

[7]The Defendant was admitted multiple times to a mental hospital in the United Kingdom (The UK). He was diagnosed with Schizoaffective Disorder, and was being treated with oral antipsychotic medications. He has a long history of non-adherence with medications whilst in the UK. He was first seen at the Outpatient Clinic of the St. Lucia National Mental Wellness Centre (SLNMWC) in July 2012, during one of his visits from the UK. At that time, he was noted to be treated with antidepressant medications from the UK. No note was made on the behaviour that he was exhibiting, but a prescription was written for antidepressants, and he was discharged. He was next seen at the SLNMWC on January 25, 2018, after he became very aggressive towards his mother. He was diagnosed with Schizoaffective Disorder, and started on oral antipsychotic medications. He was discharged four days after his admission. Since his first admission, he has been re-admitted to the SLNMWC six times, always with a history of non-adherence to medications, excessive marijuana use, and “strange” and aggressive behaviour in the community. He is always discharged on oral medications. He attends the Outpatient Clinic, and is usually brought in by his mother or sister. His sister reported variable adherence to prescribed medications. The Defendant has been seen regularly at the Bordelais Correctional Facility (The Facility) by the visiting Psychiatrist. He is continually managed with oral medications, and remains symptomatic. He remains symptomatic even on medication. This may be because he continues to use marijuana, and he may not be monitored at the Facility especially in the evening, when medication is to be taken. Dr. Gilliard opined that the stress he encounters at the Facility may cause him to be impatient, irritable and non-compliant with medication.

Current Status

[8]The Defendant has been housed at the Facility since May 25, 2022. The staff report no significant behavioural issues. He is most times suspicious of the other inmates, who are a bit impatient with him. He stated that he is being picked on by the other inmates, adding “They are jealous of me and trying to use my name to move ahead in life”. The nurses claim that he is adherent with medications given.

Mental Status Examination of Al Ephraim, carried out on 29/11/23:

[9]The Defendant was seen clean, but unshaven, and adequately dressed. He was calm with fair eye contact, and was a bit indifferent towards the interview. When asked about his mood, he stated that he was “Depressed because I need to go home”. His affect was blunted, although at times a bit expansive. His speech was clear, but disorganised at times. He exhibited tangentiality of his thought process. He expressed grandiose ideas that did not reach delusional intensity. He denied having homicidal or suicidal thoughts. He denied experiencing hallucinations. He was oriented to place, and to person, but disoriented to time. His memory was intact. His attention and concentration were intact. His abstract thought was intact. His judgement was impaired, and his insight into his illness was poor. He was significantly impaired in his responses to the questions that assessed his psycholegal abilities.

Dr. Gilliard’s Opinion

[10]1. Using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) tool to conduct his assessment. The Defendant was diagnosed with: − Schizoaffective Disorder, bipolar type. − Alcohol and Cannabis Use Disorder, severe, in a controlled environment. 1. It is Dr. Gilliard’s opinion with a reasonable degree of medical certainty, that the Defendant suffers from a disorder of the mind, Schizoaffective Disorder, Bipolar type. This disorder is diagnosed by the appearance of symptoms of Schizophrenia: delusions being fixed false beliefs, and/or hallucinations (a perception without a stimulus), and/or disorganized behaviour, and/or negative symptoms; (social withdrawal, alogia, flattening of affect, amotivation); in addition to symptoms of Bipolar Disorder; (elevated or expansive mood, increased energy, talkativeness or pressured speech, distractibility, decreased need for sleep, grandiosity, irritability, increased goal directed activity, increased risk taking). [10] The symptoms of this disorder can be exacerbated by concurrent substance abuse. Mental deterioration is likely if the individual experiences multiple relapses which are concurrent with chronic substance use.

[11]When he was interviewed on November 29, 2023, the Defendant was deemed to be unfit to plead in a Court of Law as at that time, he was unable to: (i) understand the nature of the charges, (ii) decide whether to plead guilty or not, (iii) exercise his right to challenge, (iv) instruct counsel, (v) follow the course of Court proceedings, and (vi) give evidence in his own defence.

Dr. Gilliard’s Recommendation(s)

[12]1. The Defendant has a long history of non-adherence or variable adherence with oral antipsychotic medications, resulting in multiple relapses, violent behaviour in his community and towards his family, and a deterioration in his quality of life. In addition, there are no systems in place at the Facility to ensure that he is adherent with oral medications when given on an evening. This may be the reason that his symptoms have persisted whilst he is incarcerated. It is recommended that he be started on regular long-acting injectable antipsychotics, which would help mitigate this issue. 1. In his present mental condition, the Defendant is not a candidate for drug rehabilitation, but this can be explored when the symptoms of his illness are better controlled. 2. Dr. Gilliard found that although the Defendant is in partial remission, he is unable to say if he will ever be symptom free. His cognitive impairment may improve, but not significantly. He needs to be in a location where he can be on medication regularly, and where his symptoms can improve. He is not likely to become a symptomatic while at the Facility. His ability to interact with the legal system will not change while he remains symptomatic and at the Facility.

Exhibit JG-2 (Report Dated the 8th of April 2025

[13]The Defendant was interviewed in the presence of Nurse Natasha Bissette at the Facility. Before the interview started, he was told of the purpose of the interview and that a report would be submitted afterwards to the High Court for use in his case. The Defendant stated that his case was dismissed already but that he keeps going back to Court, and is not happy about that. He also complained that the medication makes him very drowsy and sick, so he doesn’t sleep well, and cannot get sunshine and play football with the other inmates. The Defendant stated that he was not working nor helping on the Unit where he is housed because the officers look after him. He admitted to smoking cigarettes, but not marijuana. He continues to be seen regularly by the visiting psychiatrist, with no indication of active symptoms of his illness, not any recent change in his medication regime. The nurse reported that she had suggested that he be switched to injectable antipsychotic medications, but that was not done, and no explanation was given for the reason for this decision. There were no behavioural issues from him reported by the staff.

[14]Mental Status Examination of Mr. Ephraim, carried out on 05/02/25: The Defendant was seen clean, dressed adequately, well groomed. He was restless with good eye contact, and was co-operative with the interview. When asked about his mood, he stated that he was “Sleepy”. His affect was blunted, at times a bit expansive. His speech was clear, mostly rational, and he spoke with a foreign accent at times. He exhibited circumstantiality of his thought process (spoke quite a bit before getting to his point). Continued to express grandiose ideas that did not reach delusional intensity. He was preoccupied with the judge being angry at him for something. He denied having homicidal or suicidal thoughts. He denied experiencing hallucinations. He was oriented to place, and to person, but disoriented to time. His memory was intact. His attention and concentration were intact. His abstract thought was intact. His judgement was impaired, and his insight into his illness was poor. He continued significantly impaired in his responses to the questions that assessed his psycholegal abilities. This impairment appears to be due to his low intellectual level, as it was mainly due to his difficulty understanding the words used and the nuances of the legal system.

Dr. Gilliard’s Opinion in that Report

[15]Using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) tool. He formed a diagnosis of: (i) Schizoaffective Disorder, bipolar type, currently in partial remission. (ii) Alcohol and Cannabis Use Disorder, severe, in a controlled environment. (iii) Intellectual Disability.

[16]The Defendant appears to be exhibiting residual symptoms of his illness, which normally would not affect his ability to interact adequately with the legal system. His difficulties appear to stem from his low intellectual level which likely impairs the adequate processing of information presented to him. This is not expected to change. The presence of an intellectual disability as well presents a challenge in that it suggests a high likelihood that the Defendant may return to substance use after he is released from prison, and an inevitable relapse of his primary illness if he does not continue to receive antipsychotic and mood stabilising medications.

[17]At the time of his interview on February 5, 2025, the Defendant was deemed to be unfit to plead in a Court of Law.

Dr. Gilliard’s Recommendation(s)

[18]Again, Dr. Gilliard highly recommends that the Defendant be started on regular long- acting injectable antipsychotics in order to lessen his risk for relapse when he returns to his community. The Report of Ms. Siona Huxley

[19]She assessed the Defendant on the 2nd of November 2023 and the 8th of November 2023. Her findings are as follows:

Behavioral observations

[20]The Defendant appeared to be calm and polite during the clinical interview. He remained respectful and answered all questions without issue. He was not orientated with the date and had difficulty estimating dates of important personal events. There was some minor evidence of memory problems. There were significant issues with his processing of information.

Personal History

[21]The Defendant grew up in Soufriere with his parents, one brother and one sister. He described his childhood as nice, but he did not go out a lot because his family was strict. His basic needs were met. He had enough food, clothing, and school supplies. He did well in school until primary school, when his parents split up. He took their separation hard. His father moved out of the home and moved into his grandmother’s house, which was in the neighbourhood. He regularly saw both parents. He reported that he had to sit his Common Entrance Exam twice and then went to Piaye Secondary School. He reported that he had no issues in secondary school and graduated. Once he graduated, he went to England to live with family. He did not have the proper documentation to work there. He got married and had two children in the UK. The Defendant described a tumultuous relationship with his wife and her family.

[22]The Defendant has experienced an unstable living environment, having resided in the homes of various family members, and lacks any consistent work history. According to his sister, the Defendant’s mental health began to deteriorate while he was residing in the United Kingdom. He was admitted to a mental health wellness centre in the UK, where he was treated and placed on psychiatric medication. His condition showed initial improvement, and he was eventually discharged. However, following his discharge, the Defendant became non-compliant with his medication regimen, asserting that he no longer required treatment. As a result, his psychiatric symptoms re-emerged. His wife reported feeling unsafe having him in the home with her and their children, leading her to request that the Defendant’s family assume responsibility for his care. Consequently, the Defendant was returned to Saint Lucia by his family. Since his return, the Defendant has had multiple admissions to the Wellness Centre and has again been prescribed medication. Despite this, he has maintained a pattern non-compliance with treatment. His mental health difficulties have led to disruptive behaviour in the community, and he has been the subject of multiple arrests.

Psychological/Psychiatric History

[23]The Defendant has a longstanding and significant history of mental illness. Prior to his return to Saint Lucia, he experienced multiple admissions to a mental health centre in the United Kingdom, where he received psychiatric treatment and was placed on medication. Upon his return to Saint Lucia, he reported being involuntarily admitted to the Wellness Centre on approximately three occasions. The Defendant expressed a belief that these admissions were not due to mental health needs, but rather because others were jealous of how well he was doing. The Defendant has been diagnosed with depression, and he reported that he is currently taking medication for this condition. However, he has a persistent history of non-compliance with his medication plans. According to clinical observations and family reports, whenever the Defendant discontinues his medication, his psychotic symptoms, including delusional thinking, recur. The Defendant’s wife and sister both reported that his use of marijuana significantly exacerbates his psychiatric symptoms. This, combined with his ongoing pattern of treatment non-compliance, has contributed to recurring mental health crises, disruptive behaviour within the community, and multiple arrests.

Assessment

[24]Ms. Huxley used the following assessment tools were used to gather the relevant information: 1. Clinical Interview 2. References for the Client 3. Wechsler Adult Intelligence Scale (WAIS) 4. Minnesota Multiphasic Personality Inventory (MMPI-2) 5. Historical Clinical Risk Management – 20 (HCR-20) Wechsler Adult Intelligence Scale (WAIS)

[25]The Defendant’s Full-Scale IQ (67) fell in the “Lower Extreme” range. His Working Memory (69) also fell in the “Lower Extreme” range. His Verbal Comprehension (76), Perceptual Reasoning (71), and Processing Speed (71) all fell in the “Well Below Average.” His results on the WAIS-IV indicate that the Defendant may have more difficulty in understanding information or questions. Simple a.nd clear language should be used, and he should be given additional time to process information. Repeating or rephrasing instructions or questions may help the client understand the information.

Minnesota Multiphasic Personality Inventory (MMPI-2)

[26]On the validity scales, the Defendant’s VRIN (T-score 50) and TRIN (T-score 65T) indicate that his MMPI profile is valid, and the client responded in a consistent manner. However, it is characterized by some acquiescence. His results on the F scale (T-score 76), Fb scale (T-score 55), K scale (T-score 43), and S scale (T- score 35) further indicate that the MMPI profile is likely valid. His Fp scale (T-score 94) indicates that his MMPI profile is likely exaggerated but may be valid. His results on the L scale (T-score 91) indicates that the MMPI profile is likely invalid due to “Faking Good.” This means that the client denied or minimized current mental health and behavioral difficulties. Overall, his validity scales indicate that the MMPI profile is likely invalid due to “Faking Good.” Therefore, the subscales will not be provided nor interpreted.

Historical Clinical Risk Management – 20 (HCR-20)

[27]On the HCR-20, the Defendant received “Low- Medium” likelihood of Future Violence. His has “Low” likelihood of Serious Physical Harm and Imminent Violence. The Defendant has a lack of past violence. However, when he is experiencing delusional thoughts, he does react aggressively and make threats. He reported that he has never been involved in any fights during his incarceration and before his incarceration.

Siona Huxley’s Conclusions

[28]The Defendant is a 35-year-old male currently awaiting sentencing at the Bordelais Correctional Facility. He lives with his parents, one brother and one sister. He had a nice childhood, and all his basic needs were met. When his parents separated, he had difficulty adjusting to the change. His academics suffered. Once he graduated secondary school, he moved to the United Kingdom and got married and had two children. While in the UK, his mental health deteriorated. He was admitted several times to a mental health institute there and prescribed medication. He was non-compliant with the medication plan. Every time he stops taking his medication, his symptoms return. His wife was unable to support him, and she felt unsafe when he was suffering with his symptoms. She requested that his family take care of his needs. He returned to St. Lucia, and he was also admitted to the St. Lucia National Wellness Centre approximately three times. He was also prescribed medication, but he often refuses to take it. He has a history of becoming aggressive and threatening when he is experiencing delusional thoughts. For his medical history, he reported that he suffers from asthma. He has experienced a couple of head injuries in his lifetime that resulted in bleeding or loss of consciousness. The client reported that he does not have any legal history.

Siona Huxley’s Recommendations

[29]1. Due to the client’s strong psychological history, it is recommended that he receive regular assessments from a psychiatrist and follow the psychiatrist recommended treatment plan. 2. It is recommended that the client receive regular counselling sessions to help with the difficulties of dealing with his mental health issues and the challenges of being separated from his family. 3. It is recommended that the client never consume marijuana or alcohol, as this has been a trigger for his mental health issues. It is recommended that he attend a Drug Rehabilitation program to learn how to deal with cravings when he is no longer in a controlled environment. 4. Due to the client’s WAIS-IV score, simple and clear language should be used when communicating with the client. He needs additional time to process information and may need instructions or questions repeated or rephrased to fully understand their meaning. 5. The client does not believe he could benefit from any work or educational programs. He has a poor work history, and it is recommended that he gain some work experience and skills that can help him earn income in a prosocial manner. 6. Once he is released from Bordelais Correctional Facility, it is recommended that he be admitted for the long stay at the St. Lucia National Wellness Centre to ensure he has additional supervision and is compliant with his medication plan. For best results, the client needs a caregiver who can ensure he takes his medication as prescribed.

[30]Ms. Huxley was unavailable at trial and her report was tendered admitted and marked in evidence as SH1 and was considered by this court in coming to its considered.

Discussion

[31]Having regard to the findings of the Psychiatrist, Dr. Julius Gilliard, the Court is satisfied that the Defendant, Garfel Ephraim, is presently unable, due to mental impairment, to: 1. Understand the nature of the charge laid against him; 2. Understand the requirement to enter a plea and the legal effect of such a plea; 3. Comprehend the purpose of the trial or follow its course; 4. Understand the nature of the evidence that may be presented against him; and 5. Instruct or otherwise communicate meaningfully with legal counsel.

[32]The Court further notes the recommendations of Consultant Psychologist Ms. Siona Huxley, who assessed that the Defendant requires long-term psychiatric support at the Wellness Centre, given the chronic nature of his mental health condition and history of non- compliance.

Disposition

[33]The Court finds the Defendant unfit to stand trial at this time, on the basis that he is currently unable to: 1. Understand the nature of the charge laid against him; 2. Comprehend the requirement to enter a plea and the legal consequences of such a plea; 3. Appreciate the purpose of the trial or follow its proceedings; 4. Understand the nature of the evidence that may be presented against him; and 5. Instruct or otherwise communicate effectively with his legal representative.

[34]Dr. Julius Gilliard further opines that the Defendant’s condition is unlikely to improve while he remains symptomatic, even if medicated, within the environment of the Bordelais Correctional Facility.

[35]Pursuant to Section 892(4) of the Criminal Code of Saint Lucia Cap 3.01, as amended by Section 7 of the Criminal Code (Amendment) Act No. 6 of 2025, the Defendant is hereby ordered to be transferred forthwith to the Saint Lucia National Mental Wellness Centre. He is to be detained therein to access to necessary interventions and therapy necessary for his diagnosis of schizo-affective disorder.

[36]The Defendant is to next appear before this Honourable Court on the 27th of May 2026, for the Court to determine his fitness to plead in accordance with the law.

[37]It is further directed that the Defendant’s family members are to be invited to attend the said hearing.

[38]Ms. Alina Auguste is to assess the Defendant in 6-month intervals and she is to prepare report to assist the court in determining the Defendant’s fitness to plead.

[39]Dr. Julius Gilliard is to prepare reports in 6-month intervals, which reports are to be filed in the proceedings.

[40]This order is to be served on the Bordelais Correctional Facility, the SLNMWC, the Chief Medical Officer, and the Director of the Millennium Heights Medical Complex.

Justice V. Georgis Taylor-Alexander

High Court Judge

BY THE COURT

REGISTRAR

SAINT LUCIA THE EASTERN CARIBBEAN SUPREME COURT IN THE HIGH COURT OF JUSTICE (CRIMINAL) CASE NO. SLUCRD2022/0087A,0088A,0089A THE KING vs. GARFEL EPHRAIM Defendant Before: The Hon. Mde. V. Georgis Taylor-Alexander High Court Judge Appearances: Mr. Linton Robinson for the Crown The Defendant present via zoom from the Bordelais Correctional Facility and unrepresented ____________________________ 2025: May 28; _____________________________ Judgment Excerpt – Fitness Hearing Trial Pursuant to Sections 14 and 66 of the Evidence Act, Cap. 4.15 of the Revised Laws of Saint Lucia

[1]TAYLOR-ALEXANDER J: This matter comes before the court for a Fitness Hearing Trial in accordance with Sections 14 and 66 of the Evidence Act, Cap 4.15 of the Revised Laws of Saint Lucia (hereinafter referred to as ”the Act”). The Defendant stands indicted for the offence of Burglary and has a well-documented and prolonged history of mental illness.

[2]The Defendant is unrepresented by legal counsel; however, his sister was present during the proceedings on his behalf. The court received oral evidence from Dr. Julius Gilliard, who was deemed to possess specialist knowledge pursuant to Section 66 of the Act, based on his qualifications, training, and extensive experience. The Court relied on his expert opinion on in arriving at its judgment.

[3]The report of Ms. Siona Huxley, Consultant Psychologist, was tendered into evidence. Although she was not available to give oral testimony, her report was admitted as evidence. Ms. Huxley had conducted multiple interviews with the Defendant and prepared her findings for the assistance of the Court. Dr. Julius Gilliard

[4]He is a medical doctor specializing in Psychiatry. He was trained by the Instituto Superior De Ciencias Médicas De Villa Clara, Cuba, (2004), DM Psychiatry. He is trained with the University of the West Indies, St. Augustine Campus, Trinidad (2017) and has undertaken Expert Witness Training facilitated by the University of Toronto and the St. Lucia Forensic Science Services Laboratory (April 2018). He is licensed to practice in St. Lucia by the Medical and Dental Council. This license expires in 2026. Pursuant to Section 66 of the Act, he was deemed an expert in Psychiatry.

[5]Dr. Gilliard interviewed the Defendant on two occasions and subsequently prepared two reports based on his evaluations. The following is a summary of the contents of those reports, which were tendered into evidence and relied upon by the Court during the trial. JG1 (Report Dated the 4th of December 2023) Substance Use History

[7]the Defendant was admitted multiple times to a mental hospital in the United Kingdom (The UK). He was diagnosed with Schizoaffective Disorder, and was being treated with oral antipsychotic medications. He has a long history of non-adherence with medications whilst in the UK. He was first seen at the Outpatient Clinic of the St. Lucia National Mental Wellness Centre (SLNMWC) in July 2012, during one of his visits from the UK. At that time, he was noted to be treated with antidepressant medications from the UK. No note was made on the behaviour that he was exhibiting, but a prescription was written for antidepressants, and he was discharged. He was next seen at the SLNMWC on January 25, 2018, after he became very aggressive towards his mother. He was diagnosed with Schizoaffective Disorder, and started on oral antipsychotic medications. He was discharged four days after his admission. Since his first admission, he has been re-admitted to the SLNMWC six times, always with a history of non-adherence to medications, excessive marijuana use, and “strange” and aggressive behaviour in the community. He is always discharged on oral medications. He attends the Outpatient Clinic, and is usually brought in by his mother or sister. His sister reported variable adherence to prescribed medications. The Defendant has been seen regularly at the Bordelais Correctional Facility (The Facility) by the visiting Psychiatrist. He is continually managed with oral medications, and remains symptomatic. He remains symptomatic even on medication. This may be because he continues to use marijuana, and he may not be monitored at the Facility especially in the evening, when medication is to be taken. Dr. Gilliard opined that the stress he encounters at the Facility may cause him to be impatient, irritable and non-compliant with medication. Current Status

[8]The Defendant has been housed at the Facility since May 25, 2022. The staff report no significant behavioural issues. He is most times suspicious of the other inmates, who are a bit impatient with him. He stated that he is being picked on by the other inmates, adding “They are jealous of me and trying to Use my name to move ahead in life”. The nurses claim that he is adherent with medications given. Mental Status Examination of Al Ephraim, carried out on 29/11/23:

[6]The Defendant stated that he started using alcohol since he was “little”. He did not give further information. He uses cigarettes daily, adding that “I smoking it more now”. He also stated that he has only “tried” marijuana on a few occasions, and that he has never used any other substances of abuse. Psychiatric History

[10]1. Using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) tool to conduct his assessment. The Defendant was diagnosed with:  Schizoaffective Disorder, bipolar type.  Alcohol and Cannabis Use Disorder, severe, in a controlled environment.

[10]The symptoms of this disorder can be exacerbated by concurrent substance abuse. Mental deterioration is likely if the individual experiences multiple relapses which are concurrent with chronic substance use.

[12]1. The Defendant has a long history of non-adherence or variable adherence with oral antipsychotic medications, resulting in multiple relapses, violent behaviour in his community and towards his family, and a deterioration in his quality of life. In addition, there are no systems in place at the Facility to ensure that he is adherent with oral medications when given on an evening. This may be the reason that his symptoms have persisted whilst he is incarcerated. It is recommended that he be started on regular long-acting injectable antipsychotics, which would help mitigate this issue.

[9]The Defendant was seen clean, but unshaven, and adequately dressed. He was calm with fair eye contact, and was a bit indifferent towards the interview. When asked about his mood, he stated that he was “Depressed because I need to go home”. His affect was blunted, although at times a bit expansive. His speech was clear, but disorganised at times. He exhibited tangentiality of his thought process. He expressed grandiose ideas that did not reach delusional intensity. He denied having homicidal or suicidal thoughts. He denied experiencing hallucinations. He was oriented to place, and to person, but disoriented to time. His memory was intact. His attention and concentration were intact. His abstract thought was intact. His judgement was impaired, and his insight into his illness was poor. He was significantly impaired in his responses to the questions that assessed his psycholegal abilities. Dr. Gilliard’s Opinion

2.Dr. Gilliard found that although the Defendant is in partial remission, he is unable to say if he will ever be symptom free. His cognitive impairment may improve, but not significantly. He needs to be in a location where he can be on medication regularly, and where his symptoms can improve. He is not likely to become a symptomatic while at the Facility. His ability to interact with the legal system will not change while he remains symptomatic and at the Facility. Exhibit JG-2 (Report Dated the 8th of April 2025

[11]When he was interviewed on November 29, 2023, the Defendant was deemed to be unfit to plead in a Court of Law as at that time, he was unable to: (i) understand the nature of the charges, (ii) decide whether to plead guilty or not, (iii) exercise his right to challenge, (iv) instruct counsel, (v) follow the course of Court proceedings, and (vi) give evidence in his own defence. Dr. Gilliard’s Recommendation(s)

[15]Using the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) tool. He formed a diagnosis of: (i) Schizoaffective Disorder, bipolar type, currently in partial remission. (ii) Alcohol and Cannabis Use Disorder, severe, in a controlled environment. (iii) Intellectual Disability.

[17]At the time of his interview on February 5, 2025 the Defendant was deemed to be unfit to plead in a Court of Law. Dr. Gilliard’s Recommendation(s)

[13]The Defendant was interviewed in the presence of Nurse Natasha Bissette at the Facility. Before the interview started, he was told of the purpose of the interview and that a report would be submitted afterwards to the High Court for use in his case. The Defendant stated that his case was dismissed already but that he keeps going back to Court, and is not happy about that. He also complained that the medication makes him very drowsy and sick, so he doesn’t sleep well, and cannot get sunshine and play football with the other inmates. The Defendant stated that he was not working nor helping on the Unit where he is housed because the officers look after him. He admitted to smoking cigarettes, but not marijuana. He continues to be seen regularly by the visiting psychiatrist, with no indication of active symptoms of his illness, not any recent change in his medication regime. The nurse reported that she had suggested that he be switched to injectable antipsychotic medications, but that was not done, and no explanation was given for the reason for this decision. There were no behavioural issues from him reported by the staff.

[14]Mental Status Examination of Mr. Ephraim, carried out on 05/02/25: The Defendant was seen clean, dressed adequately, well groomed. He was restless with good eye contact, and was co-operative with the interview. When asked about his mood, he stated that he was “Sleepy”. His affect was blunted, at times a bit expansive. His speech was clear, mostly rational, and he spoke with a foreign accent at times. He exhibited circumstantiality of his thought process (spoke quite a bit before getting to his point). Continued to express grandiose ideas that did not reach delusional intensity. He was preoccupied with the judge being angry at him for something. He denied having homicidal or suicidal thoughts. He denied experiencing hallucinations. He was oriented to place, and to person, but disoriented to time. His memory was intact. His attention and concentration were intact. His abstract thought was intact. His judgement was impaired, and his insight into his illness was poor. He continued significantly impaired in his responses to the questions that assessed his psycholegal abilities. This impairment appears to be due to his low intellectual level, as it was mainly due to his difficulty understanding the words used and the nuances of the legal system. Dr. Gilliard’s Opinion in that Report

[20]The Defendant appeared to be calm and polite during the clinical interview. He remained respectful and answered all questions without issue. He was not orientated with the date and had difficulty estimating dates of important personal events. There was some minor evidence of memory problems. There were significant issues with his processing of information. Personal History

[16]The Defendant appears to be exhibiting residual symptoms of his illness, which normally would not affect his ability to interact adequately with the legal system. His difficulties appear to stem from his low intellectual level which likely impairs the adequate processing of information presented to him. This is not expected to change. The presence of an intellectual disability as well presents a challenge in that it suggests a high likelihood that the Defendant may return to substance use after he is released from prison, and an inevitable relapse of his primary illness if he does not continue to receive antipsychotic and mood stabilising medications.

[24]Ms. Huxley used the following assessment tools were used to gather the relevant information:

[18]Again, Dr. Gilliard highly recommends that the Defendant be started on regular long-acting injectable antipsychotics in order to lessen his risk for relapse when he returns to his community. The Report of Ms. Siona Huxley

[19]She assessed the Defendant on the 2nd of November 2023 and the 8th of November 2023. Her findings are as follows: Behavioral observations

3.Wechsler Adult Intelligence Scale (WAIS)

5.Historical Clinical Risk Management – 20 (HCR-20) Wechsler Adult Intelligence Scale (WAIS)

[21]The Defendant grew up in Soufriere with his parents, one brother and one sister. He described his childhood as nice, but he did not go out a lot because his family was strict. His basic needs were met. He had enough food, clothing, and school supplies. He did well in school until primary school, when his parents split up. He took their separation hard. His father moved out of the home and moved into his grandmother’s house, which was in the neighbourhood. He regularly saw both parents. He reported that he had to sit his Common Entrance Exam twice and then went to Piaye Secondary School. He reported that he had no issues in secondary school and graduated. Once he graduated, he went to England to live with family. He did not have the proper documentation to work there. He got married and had two children in the UK. The Defendant described a tumultuous relationship with his wife and her family.

[22]The Defendant has experienced an unstable living environment, having resided in the homes of various family members, and lacks any consistent work history. According to his sister, the Defendant’s mental health began to deteriorate while he was residing in the United Kingdom. He was admitted to a mental health wellness centre in the UK, where he was treated and placed on psychiatric medication. His condition showed initial improvement, and he was eventually discharged. However, following his discharge, the Defendant became non-compliant with his medication regimen, asserting that he no longer required treatment. As a result, his psychiatric symptoms re-emerged. His wife reported feeling unsafe having him in the home with her and their children, leading her to request that the Defendant’s family assume responsibility for his care. Consequently, the Defendant was returned to Saint Lucia by his family. Since his return, the Defendant has had multiple admissions to the Wellness Centre and has again been prescribed medication. Despite this, he has maintained a pattern non-compliance with treatment. His mental health difficulties have led to disruptive behaviour in the community, and he has been the subject of multiple arrests. Psychological/Psychiatric History

[27]On the HCR-20, the Defendant received “Low- Medium” likelihood of Future Violence. His has “Low” likelihood of Serious Physical Harm and Imminent Violence. The Defendant has a lack of past violence. However, when he is experiencing delusional thoughts, he does react aggressively and make threats. He reported that he has never been involved in any fights during his incarceration and before his incarceration. Siona Huxley’s Conclusions

[23]The Defendant has a longstanding and significant history of mental illness. Prior to his return to Saint Lucia, he experienced multiple admissions to a mental health centre in the United Kingdom, where he received psychiatric treatment and was placed on medication. Upon his return to Saint Lucia, he reported being involuntarily admitted to the Wellness Centre on approximately three occasions. The Defendant expressed a belief that these admissions were not due to mental health needs, but rather because others were jealous of how well he was doing. The Defendant has been diagnosed with depression, and he reported that he is currently taking medication for this condition. However, he has a persistent history of non-compliance with his medication plans. According to clinical observations and family reports, whenever the Defendant discontinues his medication, his psychotic symptoms, including delusional thinking, recur. The Defendant’s wife and sister both reported that his use of marijuana significantly exacerbates his psychiatric symptoms. This, combined with his ongoing pattern of treatment non-compliance, has contributed to recurring mental health crises, disruptive behaviour within the community, and multiple arrests. Assessment

[29]1. Due to the client’s strong psychological history, it is recommended that he receive regular assessments from a psychiatrist and follow the psychiatrist recommended treatment plan.

[25]The Defendant’s Full-Scale IQ (67) fell in the “Lower Extreme” range. His Working Memory (69) also fell in the “Lower Extreme” range. His Verbal Comprehension (76), Perceptual Reasoning (71), and Processing Speed (71) all fell in the “Well Below Average.” His results on the WAIS-IV indicate that the Defendant may have more difficulty in understanding information or questions. Simple a.nd clear language should be used, and he should be given additional time to process information. Repeating or rephrasing instructions or questions may help the client understand the information. Minnesota Multiphasic Personality Inventory (MMPI-2)

4.Due to the client’s WAIS-IV score, simple and clear language should be used when communicating with the client. He needs additional time to process information and may need instructions or questions repeated or rephrased to fully understand their meaning.

[26]On the validity scales, the Defendant’s VRIN (T-score 50) and TRIN (T-score 65T) indicate that his MMPI profile is valid, and the client responded in a consistent manner. However, it is characterized by some acquiescence. His results on the F scale (T-score 76), Fb scale (T-score 55), K scale (T-score 43), and S scale (T- score 35) further indicate that the MMPI profile is likely valid. His Fp scale (T-score 94) indicates that his MMPI profile is likely exaggerated but may be valid. His results on the L scale (T-score 91) indicates that the MMPI profile is likely invalid due to “Faking Good.” This means that the client denied or minimized current mental health and behavioral difficulties. Overall, his validity scales indicate that the MMPI profile is likely invalid due to “Faking Good.” Therefore, the subscales will not be provided nor interpreted. Historical Clinical Risk Management – 20 (HCR-20)

6.Once he is released from Bordelais Correctional Facility, it is recommended that he be admitted for the long stay at the St. Lucia National Wellness Centre to ensure he has additional supervision and is compliant with his medication plan. For best results, the client needs a caregiver who can ensure he takes his medication as prescribed.

[31]Having regard to the findings of the Psychiatrist, Dr. Julius Gilliard, the Court is satisfied that the Defendant, Garfel Ephraim, is presently unable, due to mental impairment, to:

[28]The Defendant is a 35-year-old male currently awaiting sentencing at the Bordelais Correctional Facility. He lives with his parents, one brother and one sister. He had a nice childhood, and all his basic needs were met. When his parents separated, he had difficulty adjusting to the change. His academics suffered. Once he graduated secondary school, he moved to the United Kingdom and got married and had two children. While in the UK, his mental health deteriorated. He was admitted several times to a mental health institute there and prescribed medication. He was non-compliant with the medication plan. Every time he stops taking his medication, his symptoms return. His wife was unable to support him, and she felt unsafe when he was suffering with his symptoms. She requested that his family take care of his needs. He returned to St. Lucia, and he was also admitted to the St. Lucia National Wellness Centre approximately three times. He was also prescribed medication, but he often refuses to take it. He has a history of becoming aggressive and threatening when he is experiencing delusional thoughts. For his medical history, he reported that he suffers from asthma. He has experienced a couple of head injuries in his lifetime that resulted in bleeding or loss of consciousness. The client reported that he does not have any legal history. Siona Huxley’s Recommendations

2.Understand the requirement to enter a plea and the legal effect of such a plea;

[30]Ms. Huxley was unavailable at trial and her report was tendered admitted and marked in evidence as SH1 and was considered by this court in coming to its considered. Discussion

5.Instruct or otherwise communicate meaningfully with legal counsel.

[32]The Court further notes the recommendations of Consultant Psychologist Ms. Siona Huxley, who assessed that the Defendant requires long-term psychiatric support at the Wellness Centre, given the chronic nature of his mental health condition and history of non-compliance. Disposition

1.Understand the nature of the charge laid against him;

[33]The Court finds the Defendant unfit to stand trial at this time, on the basis that he is currently unable to:

[34]Dr. Julius Gilliard further opines that the Defendant’s condition is unlikely to improve while he remains symptomatic, even if medicated, within the environment of the Bordelais Correctional Facility.

[35]Pursuant to Section 892(4) of the Criminal Code of Saint Lucia Cap 3.01, as amended by Section 7 of the Criminal Code (Amendment) Act No. 6 of 2025, the Defendant is hereby ordered to be transferred forthwith to the Saint Lucia National Mental Wellness Centre. He is to be detained therein to access to necessary interventions and therapy necessary for his diagnosis of schizo-affective disorder.

[36]The Defendant is to next appear before this Honourable Court on the 27th of May 2026, for the Court to determine his fitness to plead in accordance with the law.

[37]It is further directed that the Defendant’s family members are to be invited to attend the said hearing.

[38]Ms. Alina Auguste is to assess the Defendant in 6-month intervals and she is to prepare report to assist the court in determining the Defendant’s fitness to plead.

[39]Dr. Julius Gilliard is to prepare reports in 6-month intervals, which reports are to be filed in the proceedings.

[40]This order is to be served on the Bordelais Correctional Facility, the SLNMWC, the Chief Medical Officer, and the Director of the Millennium Heights Medical Complex. Justice V. Georgis Taylor-Alexander High Court Judge BY THE COURT REGISTRAR

1.It is Dr. Gilliard’s opinion with a reasonable degree of medical certainty, that the Defendant suffers from a disorder of the mind, Schizoaffective Disorder, Bipolar type. This disorder is diagnosed by the appearance of symptoms of Schizophrenia: delusions being fixed false beliefs, and/or hallucinations (a perception without a stimulus), and/or disorganized behaviour, and/or negative symptoms; (social withdrawal, alogia, flattening of affect, amotivation); in addition to symptoms of Bipolar Disorder; (elevated or expansive mood, increased energy, talkativeness or pressured speech, distractibility, decreased need for sleep, grandiosity, irritability, increased goal directed activity, increased risk taking).

1.In his present mental condition, the Defendant is not a candidate for drug rehabilitation, but this can be explored when the symptoms of his illness are better controlled.

1.Clinical Interview

2.References for the Client

4.Minnesota Multiphasic Personality Inventory (MMPI-2)

2.It is recommended that the client receive regular counselling sessions to help with the difficulties of dealing with his mental health issues and the challenges of being separated from his family.

3.It is recommended that the client never consume marijuana or alcohol, as this has been a trigger for his mental health issues. It is recommended that he attend a Drug Rehabilitation program to learn how to deal with cravings when he is no longer in a controlled environment.

5.The client does not believe he could benefit from any work or educational programs. He has a poor work history, and it is recommended that he gain some work experience and skills that can help him earn income in a prosocial manner.

1.Understand the nature of the charge laid against him;

3.Comprehend the purpose of the trial or follow its course;

4.Understand the nature of the evidence that may be presented against him; and

2.Comprehend the requirement to enter a plea and the legal consequences of such a plea;

3.Appreciate the purpose of the trial or follow its proceedings;

4.Understand the nature of the evidence that may be presented against him; and

5.Instruct or otherwise communicate effectively with his legal representative.