Soleiman Faqiri's death was a homicide, inquest hears, amid dozens of mental health care recommendations

Lawyers at a coroner's inquest say the death of a mentally ill man in an Ontario prison should be deemed a homicide, as they made dozens of recommendations that, if implemented, would broadly reshape psychiatric care behind bars.

The death of Soleiman Faqiri was a preventable tragedy borne from a lack of understanding of mental health issues among corrections employees, ignored alarm bells raised by front-line staff and systemic flaws in the prison system that prevented mentally ill patients from accessing health care resources, said commission counsel Prabhu Rajan.

All of that set the stage for how Faqiri was left in a cell covered in his own feces for days and was the background for the frustration that rose in the prison guards who slapped him while moving him to another cell in segregation, then killed him in a struggle involving pepper spray, repeated strikes, and restraining him in a prone position in a spit hood.

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“Inquest counsel is proposing homicide as the appropriate manner of death in this case,” Rajan said. “We know that Soleiman should never have been in the cell that day. He should have been in the hospital many days before.”

“I have two questions: why wasn’t Soleiman taken to the hospital and why did they just leave him in his cell? I’m resigned to never having those questions properly or fully answered,” he said.

In a coroner's inquest, a homicide is defined as an act by another person that resulted in a death. The other options include natural causes, an accident, suicide or undetermined. No charges were laid in the death, and this designation does not confer criminal liability.

It will be up to the coroner's jury to determine whether to adopt the recommendations put forward by the commission counsel jointly with several other parties at the inquest.

Faqiri had been taken into custody after he allegedly stabbed a neighbour in December 2016. A court suggested that he should be given an examination for his fitness to stand trial – a sign that Faqiri may have been having a psychotic episode, where he would not have been aware of his surroundings at the time.

Once in prison, corrections staff did understand that Faqiri was having an acute mental health crisis, but missed repeated opportunities to send him to a hospital, the inquest heard. He was never seen by the jail psychiatrist. As days went on, his condition worsened. He was left in a cell alone with garbage and feces.

One guard wrote an e-mail to management that appeared to be ignored. Another guard took a video of Faqiri’s condition as he moved him peacefully to a shower, breaking policy to do so, in an attempt to show how he was not simply an individual misbehaving, but needed psychiatric care.

Prison management demanded that he be moved to another segregation cell without the assistance of a specialized use of force team. One guard, the inquest heard, said, “F*** it, I’ll move him myself.” In that move, guards used force to subdue Faqiri, and repeatedly struck him, used pepper spray, and restrained him on the ground – something the inquest heard could result in asphyxiation.

Among the more than 50 recommendations is the creation of a new agency to oversee mental health care in prisons and ensure that people with mental health issues can be dealt with in a hospital setting.

The Ontario government should also establish a “Correctional Inspectorate” to investigate problems in correctional systems and make recommendations on operations and policy, the proposed recommendations say.

Prisons should establish partnerships with hospitals and community mental health services, fund them appropriately and, within prisons, correctional staff should be trained regularly to recognize mental illness and how to deal with it before using force.

The inquest heard that the guards in the segregation unit of Central East Correctional Centre, even in 2023, had not received any extra training since Faqiri's death. One former Sergeant, Clark Moss, said he and his staff were often subjected to unrealistic demands, pointing to a requirement to do 77 reviews of inmates in segregation in a day, while doing his regular job.

Prisons should eliminate unnecessary barriers to family isolation and find opportunities to allow families to visit in cases where mental health may be an issue, the proposed recommendations say. In Faqiri’s case, attempts by his family to visit were rebuffed.

“The current status quo cannot continue. This is not something that should take years. This should happen soon,” Rajan said.