60 Ontario jail staff were alerted about Soleiman Faqiri’s state. Still, he wasn’t sent to hospital

In the days before Soleiman Faqiri’s death, an operational manager at the Lindsay, Ont., jail sent a note to some 60 corrections staff alerting them about his condition.

“He has been naked, washing walls and rolling in his own feces for four days. The inmate needs to be showered and the cell disinfected,” the email said in part.

Still, Faqiri was never sent to a hospital or seen by a psychiatrist. He died five days later.

The email, sent to dozens of staff by John Thompson, was shown at the inquest into Faqiri’s death on Monday. Jurors heard from two senior officials at the Ministry of the Solicitor General, Linda Ogilvie and Tracey Gunton, about the internal review undertaken after his 2016 death at the Central East Correctional Centre, as well as lessons learned since.

Ogilvie, director of corporate health care for the ministry, told jurors that upon reviewing Faqiri’s file, it was clear he was “very, very unwell.”

He was so unwell, jurors heard, that he was not brought for a video assessment for his fitness to stand trial.

As for the psychiatrist employed by the jail, he was on vacation at the time of Faqiri’s stay and there was no backup psychiatrist in place.

‘Life-saving lessons’ may not have been noticed for months, jury hears

Ogilvie noted the jail has been “chronically challenged” with retaining and securing health care staff, something the ministry is working to address. 

Ogilvie also said ministry policy requires that if a jail cannot provide the care someone would receive in a community health setting, they should be taken to a hospital. The jail’s doctor decided Faqiri did not need to be sent to a hospital, however jurors heard correctional staff did have the authority to transfer Faqiri there if he could not be properly cared for at the jail.

Jurors are expected to hear from the doctor who oversaw Faqiri’s care this week.

At the time of his death, Faqiri, who suffered from schizoaffective disorder, 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 restraint in a face-down position and injuries from his struggle with guards on Dec. 15, 2016. No one was ever charged in his death.

The review into Faqiri’s care began in November 2017. Jurors heard that the frontline healthcare providers, including the doctor overseeing Faqiri’s care behind bars, were not spoken to as part of the review.

“There may have been lessons learned, life-saving lessons learned, that were not noticed by the ministry for 11 months after Mr. Faqiri’s death?” coroner’s counsel Julian Roy asked Ogilvie.

“Fair,” she responded.

No direct oversight into jails by ministry’s health care unit

At the time of Faqiri’s death, Ogilvie told jurors, corporate health care had no direct oversight into the jails themselves and was staffed by only a three-person team. Nearly seven years on, the unit still does not directly oversee institutions when it comes to health care, she said.

Frontline health care staff report to a health care manager, but the chain of command then goes to non-health-care staff. The health care manager reports to the jail’s deputy superintendent, who reports to the superintendent — with decisions on an inmate’s care therefore left to administrators without a health care background.

Ogilvie said the ministry is working to change that reporting structure, so that health care managers report to provincial counterparts at head office, who report to an assistant deputy ministry with direct access to the minister of the solicitor general.

Jurors heard again about a fractured relationship between the jail and the nearby Ross Memorial Hospital in Kawartha Lakes. Since Faqiri’s death, Gunton said, the ministry has struck a working group and developed a more positive relationship between the jail and hospital. At this point, however, there is no formal arrangement in place between the two.

In the absence of that, Roy asserted, there remains no way for someone in Faqiri’s condition to get the care he would have needed.

“This is potentially life and death, for people like Mr. Faqiri to have access to care in a hospital when they’re in an acute psychiatric emergency, right?” Roy asked.

“Correct,” Gunton replied.

A ministry spokesperson previously told CBC News that officials have been working closely with Ontario’s coroner to review deaths in custody, and that the health and safety of inmates is “paramount.”

Soleiman an ‘anchor’ whose death left family ‘adrift’

The inquest, which began last Monday, is now in its second week. It’s expected to continue until Dec. 8.

On Friday, the Faqiri family delivered a statement at the inquest, in which jurors heard not only about Faqiri’s death, but about his life and what his loss has meant to his loved ones.

“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,” the statement began. “His death has left us empty.”

The family closed their statement by calling for the truth of what happened to Faqiri to come to light, and asking the jury to make recommendations to prevent deaths like his from happening again.