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

Postby Thomas » Fri Nov 24, 2023 7:26 am

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.

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Inmate across from Soleiman Faqiri says 'beating started' af

Postby Thomas » Thu Dec 07, 2023 2:33 am

Inmate across from Soleiman Faqiri says 'beating started' after guards were out of camera's sight

Jurors shown police interview of John Thibeault, who spoke exclusively to The Fifth Estate in 2018

An inmate housed directly across from Soleiman Faqiri the day he died said guards started beating Faqiri "as hard as they could" as soon as they were out of view of the hallway camera.

John Thibeault made that statement to Ontario Provincial Police in the months after he spoke exclusively to CBC's The Fifth Estate, saying he felt compelled to come forward in the hope of justice for Faqiri's family.

"That's when the beating started," Thibeault told the investigator in the interview room. "They all started laying into him as hard as they could and it was vicious.

"I've never seen nothing like that before."

Police later described Thibeault as "candid and credible," in an email from OPP Inspector Brad Collins, obtained by CBC News.

Jurors at the inquest into Faqiri's death were shown video of Thibeault's statement on Tuesday, and were told Thibeault chose not to appear in person because of "safety concerns." The details of his statement line up with what Thibeault told The Fifth Estate less than a year earlier.

In his police interview in August 2019, Thibeault said under oath that he had not seen the video of Faqiri's final moments leading up to his restraint by guards. That video was made public for the first time earlier this month at the inquest into Faqiri's death at the Central East Correctional Centre in Lindsay, Ont.

Thibeault told the officer he watched from his cell window as six guards transferred Faqiri down the hallway to what was supposed to be new his new cell, B10.

'He's not fighting back'

Along the way, he saw one guard whisper something into Faqiri's ear, causing him to begin pulling back.

"They got him agitated," Thibeault told the investigator. "He wasn't fighting, he just didn't want to go into that cell."

A guard then pepper-sprayed Faqiri and guards pushed him into the cell, Thibeault said.

All the while, Thibeault said his window shutter was left open, leaving him with a direct line of sight into Faqiri's cell. Inside, he said four of the guards "started beating the shit out of him." During the restraint, Faqiri stood and ran smack into the back of the cell multiple times, he added.

Meanwhile, the inmates nearby started kicking at the doors and yelling for the guards to leave Faqiri alone, Thibeault said.

Around that time, the guard with his knee on Faqiri's neck yelled, "Stop resisting," Thibeault said. "I don't know why he was yelling that because buddy wasn't moving anymore."

'What happened that day is not right'

"I knew something was shady there," Thibeault told the officer, adding he believed the guard yelled that command not because Faqiri was actually resisting but perhaps because other inmates were piping up.

Thibeault said he then kicked at his own door and a guard took notice, running from Faqiri's cell and slamming Thibeault's shutter closed. After that, he couldn't see anything.

"He's not fighting back, he's just trying to get away from them," Thibeault said.

Thibeault said a female guard was standing on the bed looking "petrified," while another guard threw items from the cell into the hall.

During the 13-minute encounter, Thibeault told the officer, Faqiri was pepper-sprayed a second time, guards kicked at his head and one guard placed his knee on the back of Faqiri's neck.

Thibeault also made reference to guards "stomping" Faqiri's head on the ground and kicking his head off the bunk — something he also told The Fifth Estate. Asked if Faqiri's injuries reflected those particular actions, Ontario's chief forensic pathologist, Dr. Michael Pollanen, testified Tuesday that they did not.

Faqiri died at 3:47 p.m. that day after being repeatedly struck by guards, pepper sprayed twice, covered with a spit hood and placed on his stomach on the floor of a segregation cell.

Thibeault said he only learned of Faqiri's death later that night when he was asked to speak with police.

At the time, Thibeault refused to speak to investigators. He told CBC's The Fifth Estate he kept quiet about what he saw for nearly two years, fearing what might happen to him in custody if guards knew he'd spoken out about them.

"Call me a snitch, call it whatever you want. So be it," he said at the time. "The last thing I want is my face on the news, on TV. But what happened that day is not right."

Police said 'insufficient evidence' for charges

At the time of his death, Faqiri, who suffered from schizoaffective disorder — a combination of schizophrenic and bipolar symptoms — was awaiting a medical evaluation at the Ontario Shores Centre for Mental Health Sciences. He had been charged with aggravated assault, assault, and uttering threats following an altercation with a neighbour, but had not been convicted of any crime.

His cause of death, previously deemed unascertained, was later deemed to be: "Prone position restraint and musculocutaneous injuries sustained during struggle, exertion and pepper spray exposure in a person with an enlarged heart and worsening schizophrenia."

In other words, while none of his injuries on their own were fatal, his death was the result of being held face down on his stomach and the injuries he suffered while being restrained and repeatedly struck.

Whether a guard did in fact place a knee on Faqiri's neck is not clear in the agreed statements of facts. The statement says an officer "may" have done so. Pollanen testified Tuesday that his determination of Faqiri's cause of death did not depend on that action.

"If you remove the bruise from the neck, it does not change my conclusion," he said.

There were three successive police investigations into Faqiri's death, one by Kawartha Lakes Police Service, another by the Ontario Provincial Police, and then a reinvestigation by the OPP. In their last investigation, the OPP said there was "insufficient evidence" for charges to be laid.

At the time, lawyers for the family said told them it was impossible to know which of the six or more guards involved delivered the fatal blow.

Jurors heard Monday that guards broke a number of use of force policies the day Faqiri died. A jail guard directly involved in restraining Faqiri testified that an internal investigation found guards carried out approximately 60 breaches of policy that day. Dave Surowiec told jurors policies were often followed only when "convenient."

The inquest is expected to conclude Friday.

https://www.cbc.ca/news/canada/toronto/ ... -1.7049636
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Soleiman Faqiri's death should be deemed a homicide, Ontario

Postby Thomas » Sat Dec 09, 2023 5:50 pm

Soleiman Faqiri's death should be deemed a homicide, Ontario coroner's counsel says

Union representing jail guards opposes proposal, arguing death 'accidental'

Ontario's coroner's office is calling for Soleiman Faqiri's jail cell death to be deemed a homicide, with its counsel saying the evidence points in "one direction."

"Inquest counsel is proposing homicide as the appropriate manner of death in this case," coroner's counsel Prabhu Rajan told jurors at the inquest into Faqiri's death on Friday.

"In our view Soleiman's death was a tragedy, a preventable tragedy," Rajan said. "We don't take this position lightly, but we believe the evidence points in this one direction."

Speaking to jurors directly, presiding coroner Dr. David Cameron said, "It was no accident that he was restrained in the manner that he was."

Jurors at the inquest are tasked with determining the manner of Faqiri's death, choosing from one of five options: natural causes, an accident, homicide, suicide or they could find it undetermined. They may also make recommendations to prevent future deaths.

A verdict is expected early next week.

No one was ever charged criminally in connection with Faqiri's death at the Central East Correctional Centre (CECC) in Lindsay, Ont. on Dec. 15, 2016.

A homicide verdict does not mean automatic criminal charges. Police can choose to reopen their investigation into Faqiri's death, but are not obligated to do so.

What do the province and union think?

Ontario's Ministry of the Solicitor General did not take a position on Faqiri's manner of death but said it supports some of the recommendations put forward.

Ontario Public Service Employees Union, representing correctional and health-care staff in jails, opposed the proposal of homicide, saying Faqiri's death was not intentional and could not have been foreseen.

OPSEU lawyer Charlie Sinclair argued Faqiri's death should be deemed "accidental." Sinclair reminded jurors that jail staff have testified they didn't have the necessary skill-set or training to care for someone as ill as Faqiri was.

"In our submission, there is no evidence of any intention on anyone's part to kill Mr. Faqiri, nor was it forseeable or expected that death would follow given that they were using ministry-approved techniques," Sinclair said.

The inquest has previously heard guards carried out nearly 60 policy breaches in Faqiri's death.

Ontario's chief forensic pathologist has said the injuries Faqiri sustained in the restraint created "a perfect storm for his death."

The proposed verdict was endorsed by the Canadian Muslim Lawyers Association and The Empowerment Council, an advocacy organization for mental health and addiction service users.

Who was Soleiman Faqiri?

Faqiri was born in Afghanistan in 1986 and was the second of five children. The family came to Canada when he was eight and they settled in Pickering, east of Toronto.

His family has said he was a straight-A student, captain of his high school football team, and that he was especially close to his mother. When he graduated, his future looked bright. In 2005, he enrolled at the University of Waterloo, where he was studying environmental engineering. But his plans were cut short after a car crash when he was 19. Not long after, he was diagnosed with schizophrenia.

From that point on, his life took a turn. He couldn't continue with school and he would go days without sleeping. He started having run-ins with the law, being picked up several times under Ontario's Mental Health Act. When he wasn't consistent with his medications, his condition quickly deteriorated.

At the time of his death, Faqiri, who suffered from schizoaffective disorder — a combination of schizophrenic and bipolar symptoms — was awaiting a medical evaluation at the Ontario Shores Centre for Mental Health Sciences. He had been charged with aggravated assault, assault, and uttering threats following an altercation with a neighbour, but had not been convicted of any crime.

CBC News first spoke to Faqiri's family just days after his death. His case was subsequently investigated by The Fifth Estate.

How did he die?

Jurors have heard that Faqiri's condition went from bad to worse during his time at the jail.

Faqiri died after being repeatedly struck by guards, pepper sprayed twice, covered with a spit hood and left shackled face down on the floor of a segregation cell after being moved from a shower stall, where he allegedly squirted water and shampoo on guards. During the course of his transfer, one guard alleged Faqiri spat at him and slapped Faqiri twice in the face before other guards joined in restraining him.

His cause of death, previously deemed unascertained, was later deemed to be: "Prone position restraint and musculocutaneous injuries sustained during struggle, exertion and pepper spray exposure in a person with an enlarged heart and worsening schizophrenia."

In other words, while none of his injuries on their own were fatal, his death was the result of being held face down on his stomach and the injuries he suffered while being restrained and repeatedly struck.

Why wasn't he sent to a hospital?

By all accounts, Faqiri should not have been in jail but rather at a medical facility, jurors have heard.

"I'd like to say there should have been alarm bells going off when Soleiman entered CECC's doors, but we now know and you have heard that well-intentioned people effectively shouted from a rooftop that Soleiman need help," Rajan told jurors.

Those people included a guard who broke protocol to film Faqiri's declining state in the days before his death in the hope of getting him help, a nurse who pursued a Form 1 application to send Faqiri to the hospital for a mental health assessment, and a manager who alerted some 60 supervising staff that Faqiri was languishing in his cell covered in feces for four straight days.

The court itself ordered Faqiri be assessed for his fitness to stand trial. Faqiri never had that assessment "essentially because he was in the midst of a psychiatric emergency," Rajan told jurors at the outset of the inquest. "Let the irony of that sit with you for just a moment."

On top of that, Faqiri's own family attempted to visit him multiple times in jail, but were denied. They alerted jail staff about the need for him to be medicated, brought him a Qur'an from home to help comfort him, but were never allowed to see him for the 11 days until his death because he was deemed too unwell to be brought to a visitation area.

At no point was Faqiri seen by a psychiatrist or sent to a hospital for treatment.

As for why, several witnesses have described a fractured relationship with the nearby Ross Memorial Hospital, where inmates in crisis were sometimes taken to the emergency room, only to be quickly sent back, after receiving an antipsychotic injection, due to a lack of mental health beds.

Jurors also heard that neither jail staff or health care staff understood that they could send Faqiri to the hospital, despite policy to do so if a person cannot get the care they need inside. The jail's head of health care testified that she didn't believe Faqiri was in enough physical danger to warrant being sent — that his mental health crisis didn't pose the kinds of obvious physical concerns to meet the threshold.

Faqiri was referred to the jail's psychiatrist, but the inquest has heard how that psychiatrist was on vacation at the time.

Why was no one charged?

There were three successive police investigations into Faqiri's death, one by Kawartha Lakes Police Service, another by the Ontario Provincial Police, and then a reinvestigation by the OPP. In their last investigation, the OPP said there was "insufficient evidence" for charges to be laid.

At the time, lawyers for the family said the OPP told them it was impossible to know which of the six or more guards involved delivered the fatal blow.

As previously reported, two managers were fired in the wake of Faqiri's death. Another 13 correctional staff were suspended, but it's unclear how long those suspensions lasted and whether they were paid or unpaid. Ontario's Ministry of the Solicitor General has previously refused to comment, saying human resource matters are confidential.

How is the family feeling?

The family has said it's trusting the inquest process and allowing the evidence to speak for itself.

They did deliver a statement earlier, which was read aloud to jurors, giving them a chance to hear not only about how Faqiri died but how he lived and what his loss has meant for the family.

It says, in part: "For the last seven years, my family and I have had a deep, painful hole right in the centre of our lives. Soleiman was an anchor for us that was taken away and left us adrift ... His death has left us empty."

The statement ended by calling for the truth to come to light and for the jury to come up with recommendations to prevent deaths like Faqiri's from happening again.

Next week marks seven years since Faqiri's death. Friends and supporters will gather, as they have every year, at a vigil in his memory.

What's being recommended?

The coroner's office is proposing 56 recommendations for jurors to consider with the goal of preventing future deaths like Faqiri's — all addressed to the province.

Chief among them is to acknowledge that correctional facilities are not an appropriate environment for people in custody with significant mental health issues.

The recommendations also call for "immediate steps" so that anyone in crisis behind bars is admitted to hospital for assessment, and that those in custody receive an equal level of care to what they would receive in the community.

Jurors heard this "principle of equivalence" is something enshrined in the UN's Mandela Rules. Currently health care is administered to those in custody, not by the provincial health ministry, but rather by the Ministry of the Solicitor General, jurors heard.

They also call for the province to strike a committee immediately to ensure recommendations from Faqiri's inquest are considered and any responses fully reported.

"I simply do not want to do any more of these cases," Rajan told jurors.

https://www.cbc.ca/news/canada/toronto/ ... -1.7053159
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Coroner's counsel asks jurors to find Soleiman Faqiri died a

Postby Thomas » Sat Dec 09, 2023 5:53 pm

Coroner's counsel asks jurors to find Soleiman Faqiri died as a result of homicide

TORONTO — Human actions and decision making led to the death of a mentally ill man in an Ontario jail roughly seven years ago, coroner's counsel told inquest jurors Friday in urging them to rule the death a homicide.

Soleiman Faqiri's death wasn't an accident, Julian Roy told the coroner's inquest, noting correctional officers bundled the 30-year-old man down a hall and into his segregation cell on purpose, sprayed him with pepper foam to subdue him on purpose, and repeatedly struck and kneed him on purpose.

Correctional staff also intended to place Faqiri in a "vulnerable, face down position," hold him down, restrain him with handcuffs and shackles, and leave him there, Roy said. There is no evidence anyone meant to kill Faqiri, "but there is ample evidence that those involved in his restraint were well aware that their actions might result in his death," he said.

"My submission is that to tell the truth about how Mr. Faqiri died, that you should make a finding of homicide. In other words, that Mr. Faqiri didn't just die on Dec. 15, 2016, he was killed," Roy said.

Lawyers for the Ontario Public Service Employees Union, which represents correctional staff, said they oppose a finding of homicide as a cause of death, proposing instead that Faqiri's death be found accidental.

Charlie Sinclair, one of the lawyers for OPSEU, said none of the officers intended for Faqiri to die, and noted a manager who came to the cell partway during the struggle testified she only saw ministry-approved use of force. He argued jurors should reject the video statement of another inmate who said guards were beating Faqiri before the manager arrived, noting the man previously admitted there were inconsistencies in his account.

Establishing a cause of death is one of the findings jurors must make in a coroner's inquest, but it does not carry legal liability. No criminal charges have been laid in connection with Faqiri's death.

Jurors may also make recommendations aimed at preventing similar deaths, but they are not required to do so, and any they do issue are not binding.

The coroner presiding over the inquest, Dr. David Cameron, told jurors the five possible causes of death in such a proceeding are natural, accidental, suicide, homicide, and undetermined.

He instructed them to consider an autopsy report and a subsequent report by the province's chief forensic pathologist in reaching their verdict. Dr. Michael Pollanen found Faqiri died from an arrhythmia resulting from his enlarged heart in combination with a number of other factors. He listed as contributing factors the bruises and other injuries Faqiri sustained, the pepper foam, and the fact that Faqiri was left in a prone position.

Cameron told jurors that if they accept these factors as contributors, they can rule Faqiri's death an accident if they believe those things were done inadvertently. If they believe they were done on purpose -- even if not for the purpose of causing harm or injury or death -- they should choose homicide, he said.

The jury's verdict doesn't have to be unanimous, just agreed on by the majority of five, on a balance of probabilities, he said.

Faqiri, who had schizophrenia, died at the Central East Correctional Centre in Lindsay, Ont., on Dec. 15, 2016, after a violent struggle with correctional officers that broke out as he was being led from the shower to his segregation cell.

He had been taken to the jail after allegedly stabbing a neighbour while experiencing a mental health crisis, and the inquest heard his condition deteriorated significantly while in custody.

While many correctional and medical staff members voiced concerns about Faqiri, 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.

In his closing submissions, coroner's counsel Prabhu Rajan called Faqiri's death a "preventable tragedy" that highlights the "profoundly problematic" manner in which people experiencing mental illness are treated in Ontario's correctional system.

Rajan laid out 56 jointly proposed recommendations for jurors to review and potentially adopt, including the creation of an independent provincial oversight body for the correctional system that could look into complaints and launch its own investigations.

Other proposed recommendations include establishing a dedicated agency to deliver and oversee health care within the correctional system; creating special needs units with specialized staff within correctional facilities; setting up formalized relationships between correctional centres and psychiatric hospitals; and ensuring people with mental health issues undergo an assessment of their fitness to stand trial within 24 hours of entering the judicial system.

Others relate to mental-health and use-of-force training for correctional staff, increased staffing levels, greater co-ordination between corrections and health-care providers, and a family-centred approach to ensure relatives of those in custody are kept informed and given compassionate support.

"You have the power to send a message through your recommendations to tell those who themselves have the power to make change to do what it takes ... to ensure that what happened to Soleiman can never happen again, that this is an urgent and potentially fatal problem that absolutely needs immediate solutions," Rajan told jurors.

"Because, as we heard, there are others with serious mental health issues at this moment, who reside at CECC (the jail where Faqiri was held) and likely reside at other correctional facilities."

The proposed recommendations are endorsed by the Faqiri family; the Empowerment Council, a patient advocacy group for people using mental health or addiction services; the Canadian Mental Health Association; the Canadian Muslim Lawyers Association; and Dr. Brent MacMillan, all of whom have standing at the inquest.

Other parties support some, but not all, the proposed recommendations, and several suggested recommendations of their own.

This report by The Canadian Press was first published Dec. 8, 2023.

https://www.baytoday.ca/ontario-news/co ... de-7944288

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Soleiman Faqiri's death was a homicide, inquest hears, amid

Postby Thomas » Sat Dec 09, 2023 5:54 pm

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.

“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.

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'No longer any doubt,' says Soleiman Faqiri's family as inqu

Postby Thomas » Sat Dec 16, 2023 3:20 pm

'No longer any doubt,' says Soleiman Faqiri's family as inquest deems Ontario jail death a homicide

Verdict confirms what 30-year-old’s family has believed ever since his 2016 death

Soleiman Faqiri's deadly restraint by Ontario jail guards in 2016 has been deemed a homicide — words his family has waited to hear for nearly seven years since he died shackled, pepper sprayed and covered with a spit hood face down on a cell floor.

The verdict from the jury at the coroner's inquest carries no legal consequence, however it represents a major milestone in the family's fight for accountability in the 30-year-old's death.

"The jury has spoken and called this a homicide. There is no longer any doubt left that my brother Soleiman Faqiri was killed by correctional officers," Faqiri's older brother, Yusuf Faqiri, told CBC News.

"Hearing the verdict, that meant the world to my family," he added. "My brother was heard today and he was seen. I visit his grave every Friday and I tell him that I'm going to keep fighting. And that's what today was about."

Along with the homicide verdict, the jury made 57 recommendations aimed at preventing future deaths in provincial jails. You can find the full list below.

Following the verdict, the five-person jury delivered a poignant statement about the testimony they heard over the three-week inquest:

"At many times it felt like watching a movie you had seen before where there were so many instances where if one small action had been different, the ending would not have been the one we know. 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."

The Ontario Public Service Employees Union, which represents correctional and health-care staff in jails, said Friday that Faqiri's death should not be deemed a homicide but rather accidental, saying it was not intentional and could not have been foreseen.

Faqiri suffered from schizoaffective disorder — a combination of schizophrenic and bipolar symptoms. He was taken into custody on Dec. 4, 2016 after allegedly stabbing a neighbour during what his family has said was a psychotic episode. At the time of his death at the Central East Correctional Centre, he was awaiting a medical evaluation at the Ontario Shores Centre for Mental Health Sciences.

That assessment never happened.

Less than two weeks later, Faqiri was dead.

Injuries a 'perfect storm' for his death: pathologist

Faqiri died after being repeatedly struck by guards, pepper sprayed twice, covered with a spit hood and left shackled on his stomach on the floor of a segregation cell after being moved from a shower stall, where he allegedly squirted water and shampoo on guards. The inquest revealed guards carried out 60 policy breaches in his death.

Ontario's chief forensic pathologist has said the injuries Faqiri sustained during that restraint created "a perfect storm for his death."

A straight-A student, Faqiri was captain of his high school football team and was especially close to his mother, his family has said. When he graduated, his future looked bright. He enrolled at the University of Waterloo in 2005, where he was studying environmental engineering.

But his plans were cut short after a car crash when he was 19. Not long after, he was diagnosed with schizophrenia.

From that point on, his life took a turn. He couldn't continue with school and was picked up several times under Ontario's Mental Health Act. Over the years, his family has said it struggled to get him the help he needed and that he was on and off his medications, his condition deteriorating.

In his 11 days inside the Lindsay, Ont., jail, jurors heard his condition went from bad to worse.

Witnesses described broken system

The inquest pulled back the curtain on what was described to jurors as a broken system, where corrections staff, health-care staff and management all recognized Faqiri was in crisis — but never sent him to hospital despite ministry policy. Witnesses spoke of a lack of training and familiarity with policies as well as tensions inside the jail around when its tactical crisis team could be invoked.

Jurors also heard about a fractured relationship with the nearby hospital, where inmates in crisis were sometimes taken and sent right back after receiving medication — and about a lack of mental health beds.

Speaking to CBC News on Monday, Yusuf said the inquest shone a light on his brother as a young man in mental crisis "who needed support, who needed compassion and instead lost his life."

The inquest also made public for the first time video of Faqiri's final moments leading to his violent restraint — video CBC News had sought for years through access to information requests since his death.

And it revealed that multiple "well-intentioned people effectively shouted from a rooftop that Soleiman need help," as inquest counsel Prabhu Rajan put it — to no avail.

Those people included a guard who broke protocol to film Faqiri's declining state in the days before his death in the hope of getting him help, a nurse who pursued a Form 1 application to send Faqiri to the hospital for a mental health assessment, and a manager who alerted some 60 supervising staff that Faqiri was languishing in his cell covered in feces for four straight days.

CBC News first spoke to Faqiri's family just days after his death. His case was subsequently investigated by The Fifth Estate.

At the time of his first interview about his brother's death, Faqiri's brother Yusuf said: "We want to know why my brother died. Why did Soleiman die? How did Soleiman die? That's what we're looking for."

Police can re-open investigation, but not obligated

The homicide verdict comes after three successive police investigations into Faqiri's death ended with no criminal charges laid against any of the guards involved.

In their last investigation, the OPP said there was "insufficient evidence" for charges to be laid. At the time, lawyers for the family said the OPP told them it was impossible to know which of the six or more guards involved delivered the fatal blow.

While the verdict bears no criminal liability, police can choose to reopen their investigation into the case based on what the jury heard. They are not obligated to do so.

"This was a long road for Soleiman's family. For them, his case was always about a killing. In the end, five members of the public, after two days of deliberation, reached the same conclusion and declared Soleiman's death a homicide," one of the family's lawyers, Edward Marrocco told CBC News.

"The police who sought to explain this away as something less should reflect and reconsider."

CBC News has asked provincial police if they plan to reopen the investigation and is awaiting their response.

'Tragedy as a starting point' for change

All of the 57 recommendations made by coroner's jury are aimed at Ontario government. The recommendations are non-binding, but include accountability measures so the factors that led to Faqiri's death aren't repeated.

The top five recommendations include:

    Develop a public position statement within 60 days recognizing that jails are not the appropriate environment for those with significant mental health issues.
    Take immediate steps to make sure anyone suffering an acute mental health crisis in custody is admitted to hospital for assessment and, where appropriate, treatment.
    Adopt a principle of equivalence so that those in custody receive equal quality health care as they would outside.
    Develop a committee to ensure the inquest's recommendations are properly considered and any responses fully reported on.
    Establish an independent provincial corrections inspectorate with the power to investigate individual and systemic complaints in correctional facilities.

A spokesperson for Ontario's Ministry of the Solicitor General said "the ministry will carefully review the inquest recommendations looking at potential ways to inform policies and procedures and will respond to the Office of the Chief Coroner."

For its part, the family said it endorses all of the recommendations. However an independent inspectorate is particularly important because at present, correctional facilities are "not held accountable in any shape or form," Yusuf said.

"I want people to remember this tragedy as a starting point for transformational change in the correctional system," he said. "I hope this can be the start."

https://www.cbc.ca/news/canada/toronto/ ... -1.7053473
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Faqiri inquest recommends corrections 'inspectorate,' rules

Postby Thomas » Sat Dec 16, 2023 3:21 pm

Faqiri inquest recommends corrections 'inspectorate,' rules death a homicide

Faqiri inquest recommends corrections 'inspectorate,' rules death a homicide

TORONTO - 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.

The jurors' finding on the cause of death carries no legal liability and any recommendations it issues are not binding. The union and 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.

This report by The Canadian Press was first published Dec. 12, 2023.

https://www.cp24.com/news/faqiri-inques ... -1.6683433
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Jurors deem Soleiman Faqiri’s death a homicide as inquest co

Postby Thomas » Sat Dec 16, 2023 3:22 pm

Jurors deem Soleiman Faqiri’s death a homicide as inquest concludes with 57 recommendations

Jurors have deemed the death of a mentally ill man at an Ontario jail a homicide and made 57 recommendations, including that the province create a designated “inspectorate” for corrections.

The jury examining the circumstances of Soleiman Faqiri’s death began deliberating Friday afternoon after hearing about three weeks of evidence.

Their conclusion came just before noon on Tuesday.

Faqiri’s brother, Yusuf Faqiri, said the jury’s verdict validated what his family knew: that his brother was killed.

“I believe this is an important statement, not just for Soli and my family, but for Canadians,” he said.

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.

Faqiri, who was 30, was arrested in early December 2016 after allegedly stabbing a neighbour while experiencing a mental health crisis.

The inquest has heard that Faqiri, who had schizophrenia, appeared increasingly unwell during his time at the Central East Correctional Centre in Lindsay, but did not see a psychiatrist, nor was he taken to hospital.

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.

Coroner’s counsel urged jurors to rule his death a homicide, a proposal that was opposed by the Ontario Public Service Employees Union, which represents correctional staff.

Lawyers for the union wanted his death to be ruled accidental.

Jurors at inquest are required to make a finding on the cause of death, but it carries no legal liability. No charges have been laid in Faqiri’s death.

In an interview with CityNews, Yusuf said he does feel some relief after seven years of fighting, asking for accountability and justice.

He said his hope was for people to see the facts of this case, to show “how people who are mentally ill are treated in the correctional system,” and provide an opportunity to change that system.

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 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.

“The ball is in the premier’s court right now to implement all of these recommendations, specifically this provincial watchdog to oversee corrections.”

He said the pain of losing his brother will never go away. “Soleiman paid with his life. We need to do better so we can prevent another family’s loved one who pays with their life.”

When asked if he thinks the OPP will reopen the case, Yusef said they don’t have the confidence that will happen.

“The facts speak for themselves, 60 policy breaches, 50 bruises, legs and hands were tied, pepper-sprayed twice and still no criminal accountability … no charges. That’s a question Canadians should ask, ‘Why didn’t the police press charges?’,” said Yusef. “We don’t have confidence in the OPP, frankly, ending up doing the right thing.”

CityNews has reached out to the OPP to ask if the police service was considering reopening the investigation, but have not received a response at this point.

Yusuf said they will be holding a vigil on Saturday in Dundas Square to mark the seven-year anniversary of Faqiri’s death.

https://toronto.citynews.ca/2023/12/12/ ... e-inquest/
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After a nearly 7 year fight for answers, Soleiman Faqiri's f

Postby Thomas » Thu Dec 21, 2023 5:50 am

After a nearly 7 year fight for answers, Soleiman Faqiri's family hosts a final vigil

Faqiri's family still hoping criminal charges will be laid after Faqiri's death ruled a homicide

After a coroner's inquest ruled Soleiman Faqiri's 2016 death at the hands of Ontario jail guards was a homicide, his family hopes to use a Saturday evening vigil to move forward from the nearly seven years they spent fighting for the truth.

Held at Toronto's Yonge-Dundas square Saturday, the seventh annual vigil for Soleiman will be the last, said his brother, Yusuf Faqiri.

Soleiman died shackled, pepper sprayed and covered with a spit hood while face down on a cell floor in the Central East Correctional Centre in Lindsay, Ont. He was also repeatedly struck by guards, who carried out 60 policy breaches in his death, as revealed during the inquest.

The homicide verdict reached by the inquest jury, which carries no legal consequence, is one Faqiri's family has been waiting years to hear.

"[The vigil] is an opportunity to, in many ways, close this chapter, to move forward in some ways. In the sense that, here we are, we fought, we got to the truth," Yusuf said.

Now that the search for answers has achieved some results, Yusuf says they're looking for criminal charges to be laid and recommendations from the inquest implemented. Despite the fact that the verdict bears no criminal liability, police can reopen their investigation into the case based on what the jury heard.

In an email to CBC Toronto, the Ontario Provincial Police said it would be too early to comment on the investigation or speculate on potential outcomes from the inquest recommendations.

The Ontario Public Service Employees Union, which represents correctional and health-care staff in jails, said Soleiman's death should not have been ruled a homicide and was accidental.

'We will have other tragedies'

The jury provided 57 recommendations meant to prevent similar deaths in custody, including steps to ensure anyone suffering from a mental health crisis in custody is taken to hospital for assessment and treatment.

Born in 1986, Soleiman came to Canada from Afghanistan when he was eight. In high school, he was captain of the rugby team and a straight-A student, which led him to enrol the University of Waterloo in 2005. Then, he got in a car crash at 19 and was diagnosed with schizophrenia not long after. He couldn't continue with school and was picked up several times under Ontario's Mental Health Act.

Soleiman suffered from schizoaffective disorder — a combination of schizophrenic and bipolar symptoms. He was taken into custody on Dec. 4, 2016 after allegedly stabbing a neighbour during what his family has said was a psychotic episode. At the time of his death at the Central East Correctional Centre, he was awaiting a medical evaluation at the Ontario Shores Centre for Mental Health Sciences.

That assessment never happened and he died less than two weeks later.

"We have an opportunity here," said Yusuf. "We have an opportunity to really turn a page and to transform corrections. Because if we don't, and if these recommendations are not implemented, then we will have other tragedies. Mark my word."

Howard Sapers, the former Correctional Investigator of Canada, says many of the recommendations have been made before but the government has been slow to respond.

Sapers says change in the justice system can be slow because there are competing voices who all need resources.

"But really, there can be nothing more important than making sure that everybody is safe, ensuring the preservation of life," he said.

He said he's seen similar situations before, but not always resulting in someone's death.

"What was really striking about this set of circumstances is that everyone who came in contact with Mr. Faqiri recognized his illness," Sapers said. "And even with that the system was incapable of getting him into safer circumstances."

He said in his time working in corrections he has seen change, but it's been incremental and uncertain.

For Yusuf, the seven year journey toward transparency began with a promise to his mother to find out what happened to his brother. Every Friday, Yusuf visited Soleiman's grave and promised him he would fight.

"We're able to breathe a little bit. [I can] look at Soleiman and say, 'Bro, the country now knows what happened to you."

https://www.cbc.ca/news/canada/toronto/ ... -1.7061895
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Soleiman Faqiri: A mother’s memories of the son she loved, b

Postby Thomas » Wed Jan 17, 2024 2:36 pm

Soleiman Faqiri: A mother’s memories of the son she loved, before he was killed by Ontario jail guards

There is no longer any question about how Soleiman Faqiri was killed. Now, Maryam Faqiri says she wants Canadians to understand that her son was more than his mental illness.

For almost a decade, Maryam Faqiri has endured daily reminders that she can no longer depend on her son Soleiman to do some chores around the house.

Every December is especially melancholic. Maryam knows that if the snow in the driveway of their Ajax home isn’t shovelled, she won’t see her family’s gentle giant taking the unprompted initiative.

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https://www.thestar.com/news/gta/soleim ... c6dab.html
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