What the death of a mentally ill inmate tells us about Canadian justice

The coroner's report on Soleiman Faqiri's death in an Ontario prison has finally arrived. It's long on gruesome detail and short on accountability.

A small group of family and friends of Soleiman Faqiri, hold a vigil at Nathan Phillips Square, for the mentally ill man who died during an altercation with guards in jail in Lindsay. (Rick Madonik/Toronto Star/Getty Images)

A small group of family and friends of Soleiman Faqiri hold a vigil at Nathan Phillips Square for the mentally ill man who died during an altercation with guards in a jail in Lindsay, Ont. (Rick Madonik/Toronto Star/Getty Images)

Seven months.

Seven months of waiting for answers, seven months of agonizing silence. That’s how long Yusuf Faqiri and his family waited for the coroner’s report that was supposed to tell them how their beloved brother and son Soleiman died. It didn’t. Instead, the report, which arrived last week and which Maclean’s has obtained, has raised more questions than answers. How did Soli, as they called him, die? Who was involved? Will charges be laid against anyone? The family still don’t know any of this. Soli fell down a black hole in the justice system, and the Faqiri family have been dragged down it as well. They are still falling.

On Dec. 4, 2016, Soleiman Faqiri was incarcerated for aggravated assault at the Central East Correctional Centre in Lindsay, Ont. The prison administration knew he was mentally ill, diagnosed with schizophrenia. Still, they put him in segregation, otherwise known as solitary confinement. Eleven days later, Soli was dead.

I first wrote about the tragic death of Faqiri in this magazine back in March, as this was another example of how badly mentally ill inmates are treated by our system. Back then, all the Faqiri family knew was that Soli had been in a confrontation with some guards. Months kept passing. Last week, at last, the coroner’s report arrived and the family got the details about Soli’s death. “It’s horrible,” Yusuf told me. “I could barely get through the report. He never had an easy life, but this was a horrible end. It is 2017 and this happened to a mentally ill person in the government’s care.”

It is horrible. On Dec. 15, Soli was in the prison shower. The staff wanted him to go back to his cell, but he refused, throwing shampoo bottles at the guards. Eventually, according to the coroner’s report, Soli “calmed down” and got out. Video evidence from the prison shows Soli being escorted down a cellblock hallway by five or six guards at 3 p.m. “There appeared to be some resistance on the part of the inmate to be returned to the cell and there appeared to be an episode when one of the correctional officers seemed to strike out at the inmate,” the report says, describing the video footage. It goes on. “His ankles and wrists were cuffed and he [Soli] was hunched forward as he walked. He was smacked after spitting on a guard. Upon arrival to his cell, he resists entering, and pepper spray was deployed.”

So, at this point, we know that Soli had cuffs on his ankles and wrists, had been hit by a guard and been pepper sprayed. But according to the report, Soli kept resisting and he was pepper sprayed a second time. After more struggles the guards call a “code blue,” which indicates that a staff member is in trouble or an inmate is being aggressive. “Numerous guards are seen running toward the cell.”

At this point the video stops being helpful. Like the missing minutes of the Nixon tape, there is no video of the critical events that transpired inside Soli’s cell, where they had pushed him. “After the code blue was called, several more staff entered the cell to relieve those who had already been inside struggling with the decedent. Several of the guards describe exhaustion after attempting to restrain Soleiman.”

Soleiman’s lawyers told me they had heard that more than 20 guards were involved, but they could not confirm that number. No one knows, but the report confirms that after the code blue was called, more guards came to help the original five or six deal with a man already cuffed and restrained.

Things escalated, according the report. “A spit hood was placed over his [Soli’s] head and leg irons were placed on his legs.” Soli then had his hands cuffed behind his back and the report says he “appeared to calm down and co-operate.” That is an odd but critical addition. Was Soli now co-operating after all that struggling? Obviously something doesn’t make sense because within minutes, Soli was in mortal crisis. “Shortly thereafter, onlookers noted Soleiman was no longer moving and had stopped breathing. A medical emergency was called.” CPR was performed. By 3:15 p.m., Soleiman Faqiri was pronounced dead.

So, what happened? A day later, an autopsy was performed and the details of Soli’s injuries become clear. He had a deep laceration across his forehead, and 50 different bruises and injuries all over his face, head, neck and upper and lower body. To an outsider it looks like Soli was the victim of a brutal beating. The wounds appear consistent with blunt force trauma, but the corner ended up with no solid conclusion. “The cause of death is unascertained and the manner of death was undetermined.”

READ MORE: The mental health crisis in Ontario prisons

There will likely be an inquest into the death, but for now none has been called. The Kawartha Lakes Police Service has still not brought any charges to any of the guards involved, but say they are consulting with a Crown attorney. No one knows when or if they will take action. Nader Hasan, the Faqiri family lawyer, believes the coroner’s report outlines reasonable and probable cause for a case of aggravated assault causing bodily harm or even homicide or manslaughter charges, but he has no names of the guards involved. Meanwhile, he is prepared to bring a lawsuit against the correctional facility and the government, but he’s waiting to see if charges will be laid first. And that’s the compounding factor to this tragedy. The waiting.

If justice delayed is justice denied, it does not apply to this case. There is no law that instructs the system on how quickly to write a coroner’s report, on how quickly a police service should lay charges or even inform the family of a deceased as to what happened. In 2016, the Supreme Court ruled in the R v. Jordan case that the trial for someone accused of a crime must take place within 18 months of charges being laid for provincial cases and 30 months for federal cases. But if someone dies in custody, like Soli, where is the law that forces the government to tell the family what happened in a timely manner? Where is the law that forces the government to act in a reasonable and timely manner in terms of accountability? It doesn’t exist.

I asked the minister of Community Safety and Correctional Services for some answers, and all I got was the standard reply: “We would like to extend our deepest condolences to the family and friends of this individual for their loss,” wrote Yanni Dagonas, the minister’s press secretary. “The safety and security of our inmates and staff is our top priority. As there are ongoing investigations into the matter, it would be inappropriate for the ministry to comment further and may be subject to a coroner’s inquest. Any questions about the coroner’s death investigation process and inquests should be directed to the office of the chief coroner. Any questions about criminal charges should be directed to the investigating police service.”

And so the clock keeps ticking. The Faqiri family and their lawyers still wait for any accountability in the death of Soleiman Faqiri, not just another mentally ill inmate who died behind bars, but an inmate whose death remains unexplained and blacked out. “We hope this doesn’t happen to anyone else,” says Yusuf Faqiri. “There has to be some accountability.”

Looking for more?

Get the Best of Maclean's sent straight to your inbox. Sign up for news, commentary and analysis.