A coroner’s inquest into the death of a mentally ill man at an Ontario jail culminated Tuesday in dozens of recommendations aimed at increasing oversight of the province’s correctional system and access to mental-health care for those within it, as jurors ruled Soleiman Faqiri’s death a homicide.
The jury’s findings provided long-awaited validation to Faqiri’s family, who for years pushed for answers regarding his time in custody, and gave them comfort that he had finally been seen and heard, his brother Yusuf Faqiri said.
“They humanized my late brother ? they looked at my family to see that Soleiman was somebody. They heard and they saw Soli, and I’m not sure that Soli was heard and seen in those 11 days (he spent in jail),” Yusuf Faqiri said after the verdict was delivered.
“And this homicide verdict isn’t just vindication, but it’s an opportunity for corrections to be transformed and changed. This cannot continue the way it’s continuing.”
The jury issued a total of 57 recommendations focusing on the delivery of health care _ particularly mental-health services _ in corrections, training for correctional staff and management, and use-of-force practices, among other issues.
They include creating an independent “inspectorate” for corrections, which would have the authority to launch its own investigations into individual and systemic issues involving Ontario’s correctional and detention centres, and would report annually on its findings.
Jurors also proposed that the province add an independent rights advisor and prisoner advocate in all correctional facilities to support, advise and advocate for those in custody on matters related to segregation, use of force and access to health care.
Other recommendations include establishing a provincial agency to oversee and deliver health care in correctional facilities, creating formalized relationships between institutions and psychiatric hospitals, and ensuring people in custody who have acute mental health issues are assessed by a mental health professional within 24 hours of a court order or remand.
Jurors expressed their condolences to the Faqiri family after delivering their findings and recommendations, and said they hoped the inquest would lead to positive changes for others in Faqiri’s situation.
“At many times, it felt like watching a movie you had seen before, where there are so many instances when if one small action had been different, the ending would not have been the one we know,” they said in a statement read by one juror.
“But the movie always played out the same way, and we are left to reflect on our shortcomings instead of seeing a happy ending. Hopefully this will be the last time.”
Coroner’s counsel had urged jurors to rule Soleiman Faqiri’s death a homicide, calling it the result of human error and decision making.
In closing submissions last week, lawyer Julian Roy argued that correctional officers brought Faqiri to his segregation cell on purpose, sprayed him with pepper foam to subdue him on purpose, and repeatedly struck and kneed him on purpose. He said staff also intended to restrain the 30-year-old man in a face-down position, knowing there was a risk it could affect his breathing.
The Ontario Public Service Employees Union, which represents correctional staff, opposed that suggestion and instead called for Faqiri’s death to be deemed accidental.
In a statement Tuesday, the union said it would be reviewing the verdict and recommendations in the coming days.
“We believe that many of the recommendations, if implemented, would prevent further deaths in custody,” the union said, adding that it has been making many of the same recommendations to the Ministry of the Solicitor General for years.
The jurors’ finding on the cause of death carries no legal liability and any recommendations it issues are not binding. The office of the solicitor general did not immediately respond to a request for comment Tuesday.
No charges have been laid in Faqiri’s death.
Faqiri was arrested in early December 2016 after allegedly stabbing a neighbour while experiencing a mental health crisis.
He died on Dec. 15, 2016, after a violent struggle with correctional officers that broke out as they were escorting him from the shower to his segregation cell.
The inquest heard that Faqiri, who had schizophrenia, appeared increasingly unwell during his time at the Central East Correctional Centre in Lindsay, Ont. At various points, he was observed to be covering himself in feces, flooding his cell and yelling.
While many correctional and medical staff members voiced concerns about him, he wasn’t taken to hospital, nor did he see a psychiatrist, the inquest has heard.
The physician who saw Faqiri in jail testified he thought it was too risky to send the man to hospital when he would likely just receive medication and get sent back to the facility.
The court also ordered Faqiri undergo an assessment of his fitness to stand trial, but he was deemed too unwell to attend the appointment, the inquest heard.
His parents and siblings tried to visit him several times, but were told he was too ill to see visitors, it heard.
One of the jury’s recommendations calls for greater communication and more compassionate support for family members of prisoners with mental health issues, including the designation of a family liaison to keep them updated and act as a point of contact.
It also proposes to eliminate “unnecessary barriers” to visitation and create virtual options for situations where in-person visits are not possible or appropriate.