Guards, nurses sounded alarm about mentally ill man's condition in Ontario jail days before his death: inquest

Jail guards recorded a video of a mentally ill man in an Ontario jail, against their own policy, in an attempt to draw their superiors' attention to his worsening condition days before he died, an inquest examining his death heard on Wednesday.

But jail management at Central East Correctional Centre in Lindsay, Ont., ignored their concerns, as well as the observations of other front-line workers. Rather than send Soleiman Faqiri to the hospital, they gave a direct order to move him into another segregation cell, where he would die in a struggle with the guards.

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The video, which shows a sergeant talking to Faqiri through his cell window as he stands naked amidst piles of garbage and debris, is difficult to watch but crucial to understanding Faqiri’s death, said presiding coroner Dr. David Cameron.

“We’re watching this video because we’ve determined it’s necessary for this inquest to fully understand the situation Mr. Faqiri is in. You’ll understand he was in some distress, and that’s what makes it upsetting,” Cameron told the inquest jurors, who are hearing evidence in the case to create recommendations to avoid future deaths.

Faqiri’s brother Yusuf told CTV News in an interview that it is clear from the evidence that the correctional staff missed multiple cues to send Faqiri to a psychiatric hospital where he could have gotten the help that he needed.

“My brother was crying for help. He wanted to be seen. In the end, he wasn’t seen. He was dead within days of arriving at that institution,” he said.

Yusuf Faqiri, Soleiman's brother, told CTV News in an interview that it is clear from the evidence that the correctional staff missed multiple cues to send Faqiri to a psychiatric hospital where he could have gotten the help that he needed.

Faqiri was a talented rugby player, a promising engineering student, and was loved by his family, Yusuf said. The inquest has heard that after a car crash, Faqiri lived with schizophrenia for a decade and was arrested after a psychotic episode turned violent on Dec. 4, 2016.

“He was a human being that deserved better. Not to be returned to his family in a body bag,” Yusuf Faqiri said.

At the inquest, forensic psychiatrist Dr. Gary Chaimowitz testified that it was clear from Soleiman Faqiri’s arrival that he was displaying signs of mental illness, from banging on the door of his cell, shouting through the night, and flooding his cell and clogging his toilet.

Faqiri had denied on an intake form that he had any mental illness, but it’s common for people with mental illness to deny or fail to understand their own condition, Dr. Chaimowitz said.

“This is a man who’s now got feces on his window. And he’s naked. He’s not talking. He’s not eating. He’s not sleeping. He’s agitated. The notes from that time on continue to describe an unwell man who is disconnected from reality… and knowing anything about clinical progress, this is not going to get better by itself. It will only get worse,” Dr. Chaimowitz testified.

“A hospital setting, in my view, would have been the right place for Mr. Faqiri to be treated,” he said.

But three days into Faqiri’s stay, a prison doctor concluded “it would not be beneficial to send Mr. Faqiri to a hospital,” according to records entered into the inquest. The prison psychiatrist was notified but never examined Faqiri. When his family visited, they were interviewed about his medical history but were not allowed to see him.

By Dec. 11, 2016, one prison guard decided to record a video against the jail’s policy to illustrate what Faqiri was going through, the inquest heard.

“Sgt. Moss wanted to demonstrate the significance of Mr. Faqiri’s mental illness, which he hoped would draw attention to Mr. Faqiri’s situation,” according to the agreed statement of facts in the inquest.

A mental health nurse also started the process of committing Faqiri and said she was concerned moving him would be “disruptive to his well-being,” the agreed statement of facts says.

However, by Dec. 15, prison officials had lost patience.

“After observing that Mr. Faqiri had not been moved to 8-Seg from 2-Seg notwithstanding her direction, [Deputy Superintendent of Segregation Tamara] Easto issued a direct order to Sgt. Thompson to move Mr. Faqiri to 8-Seg. In a correctional setting, the failure to comply with a direct order could lead to discipline,” the document says.

The correctional centre did not activate an Institution Crisis Intervention Team, the document says, which is to “assist in the peaceful resolution of an institutional crisis through a disciplined show of force.”

A video shows Sgt. Thompson striking Faqiri as a team drags him, apparently naked, down a prison hallway to the cell. Records show he was pepper sprayed and restrained face-down with a spit hood over his head, his legs shackled together, and his hands cuffed behind his back as guards took positions over various parts of his body.

An operations manager “formed a concern that Mr. Faqiri was not breathing and that cell B-10 be re-opened. Mr. Faqiri was turned over, and the spit hood was removed."

Faqiri was unresponsive, and a medical alert was called, the document says. A doctor pronounced Faqiri dead.

Yusuf Faqiri said in an interview that the procedures need to change so that someone with a mental health condition can be treated, not killed.

“Let the evidence do the talking. Let the facts do the talking. See what happened to this man so we can prevent another death. So a tragedy that befell this family does not happen to another family. That’s what this is about,” Yusuf Faqiri said.