Mentally ill man should not have been in jail where he died, inquest hears

A handcuffed, mentally ill man was slapped, struck multiple times in the head area, sprayed twice in the face with a pepper spray foam and restrained face down on the ground as correctional officers took him from a shower to his cell at an Ontario jail, a coroner's inquest into his death heard Monday.

Soleiman Faqiri was subjected to "various incidents of use of force" in the moments leading up to his death on Dec. 15, 2016, at the Central East Correctional Facility in Lindsay, Ont., east of Toronto, according to an agreed statement of facts read at the inquest. 

He was then left alone, face down with his hands cuffed behind his back and a spit hood – a hood or mask meant to prevent someone from spitting – on his head, inside his cell for close to a minute until an operations manager became concerned that Faqiri wasn't breathing, the statement said.

When officers removed the spit hood, there was fluid inside and Faqiri was unresponsive, the statement said. A medical alert was issued, setting off several attempts to revive him by a nurse and, later, paramedics, it said. Faqiri, 30, was pronounced dead about half an hour later by a doctor consulted over the phone.

"Soleiman should not have died that day in his jail cell," coroner's counsel Prabhu Rajan said in his opening statement on Monday, the first day of the inquest.

"But more importantly, he should not have been there in a jail lacking adequate health-care resources within a broader system that doesn't effectively deal with individuals affected by significant psychiatric issues." 

Faqiri had a longstanding, major mental disorder: schizoaffective disorder, which combines features of schizophrenia and bipolar disorder, Rajan said.  

According to the statement of fact, which was agreed to by all inquest participants except the Ontario Public Service Employees Union, Faqiri was being held at the facility after his arrest in early December 2016 on allegations he had stabbed a neighbour during a mental-health crisis related to schizophrenia. He was charged with aggravated assault, threatening death and assault. 

While he saw a physician there and was prescribed antipsychotic medication, he did not take it regularly, the inquest heard. He was referred to the institution's psychiatrist, but did not see that psychiatrist or any other at any point while at the jail, it heard. 

As his condition worsened, an assessment was scheduled to determine whether he was fit to stand trial, a process that could have led to his transfer to a mental health facility, the statement said. But Faqiri was deemed too ill to attend, the inquest heard. 

Faqiri's relatives have previously said they hope the inquest will provide answers about his death and the 11 days he spent in jail leading up to it.

Ontario Provincial Police and Kawartha Lakes police both conducted investigations into the case, but no charges were laid.

On the day he died, Faqiri was transferred to a different cell, as his previous one had been filled with two inches of water due to a clogged toilet, it heard. He was then taken to a secure shower stall to clean himself.

While in the shower, Faqiri splashed water and squirted shampoo and soap at some officers, who then put up a shield between themselves and the shower stall, the statement said.  

There were disagreements between correctional staff on how to take Faqiri back to his cell, with some requesting a special escort, the statement said. Eventually, Faqiri agreed to be handcuffed and to return "peacefully" to his cell on the promise that he would get food and a copy of the Quran, it said.

The area was cold and, while he was waiting, Faqiri expressed he was uncomfortable, the statement said. A sergeant there said something suggesting he would move Faqiri himself, it said. 

Faqiri was wearing only boxer shorts with his hands cuffed in front of him as he was initially led, then pushed, toward his cell, the inquest heard. 

Several correctional officers said they saw him spit at the sergeant who was holding his handcuffs, it said. The sergeant responded by slapping Faqiri, who then hunched into a ball before the group pushed him toward the cell, the statement said. 

He was pepper sprayed in the doorway, then struck multiple times as officers brought him to the ground inside the cell, where he was pepper sprayed again, it said. An officer may have placed a knee on his neck, the statement said.

Faqiri's face was never decontaminated from the pepper spray, the inquest heard. Other correctional officers were called for assistance, with three coming inside the cell to help restrain Faqiri and others staying outside. Faqiri's legs were shackled and he was held face down on the ground as some officers inside traded places with those outside, the statement said.

Soon after, a spit hood was put on Faqiri while he remained pinned on the ground, the inquest heard. His hands were cuffed behind his back before the officers left the cell and closed the door, the statement said. 

A video of the hallway leading to Faqiri's cell was shown at the inquest, but did not show any of the events that took place inside the cell.

The inquest, conducted virtually, is expected to last 15 days and hear from roughly 20 witnesses. 

Coroner's inquests are held to look into the circumstances of someone's death. They are mandatory under certain circumstances, including when someone dies in custody.

The inquest jury may issue recommendations aimed at preventing similar deaths, but those recommendations are not binding.

This report by The Canadian Press was first published Nov. 20, 2023.