Coroner's report reveals numerous injuries before mentally ill inmate's death

Almost seven months to the day his family learned Soleiman Faqiri died inside a small Ontario prison cell, a coroner's report has been released listing a litany ofinjuries the 30-year-old suffered in the final minutes of his life.

Until now, his grief-stricken family has known little about how their son and brother, who had a history of schizophrenia and was awaiting a bed at a mental health facility, according to their lawyer, died in the province's custody.

The long-awaited report, released July 11, says it's highly likely that an inquest will be called to probe just what happened on the afternoon that Faqiri died.

And while it reveals no clear cause of death, it sheds light on the moments before Faqiri diedafter guards entered his cell at the Central East Correctional Centre in Lindsay, Ont., on Dec.15 11 days after he was arrested on charges of assault and uttering threats.

What is clear, says the report, is that all of the more than 50 signs of recent injury identifiedon Faqiri's bodywere caused by "blunt impact trauma."

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"We will forever have nightmares about that moment regarding my brother's life," his brother Yusuf Faqiri told CBC Toronto Thursday evening.

"There's so much pain and agony as we were reading the report and tears just kept dropping from our eyes as we were finding out what happened to our beloved Soleiman," he said, addingsome of the family couldn't bring themselves to read about the circumstances.

Guards reportedly exhausted

Faqiri, according tothe report, displayed behaviour problems while in custody and had been placed in segregation.

At about 1:15 p.m. on the day that would be his last, Faqiri was taken to the shower, where he remained for almost two hours, refusing to come out and spraying water and throwing shampoo bottles at the guards, the reportsays.

Eventually guards escorted Faqiri down a hallway to his cell while he resisted, according to the report, which citessurveillance footage.

"There appeared to be an episode when one of the correctional officers seemed to strike out at the inmate," saysthe report.

There is no video of what transpired inside Faqiri's jail cell. But he was pepper sprayed two separate times as he was told repeatedly to "stop resisting," the report states.

A few minutes later, a "code blue" was called, which indicates that staff are either in trouble, or inmates arefighting or being aggressive, and several more guards entered the cell.

"Several of the guards describe exhaustion after attempting to restrain Soleiman," the report says. With guards holding down his limbs, a spit hood was placed over his head and leg irons put on his legs. Soon after, his arms were cuffed behind his back and the guards began to leave.

The second shift of guards lasted approximately five to 10 minutes. Shortly after,Faqiri was seen no longer moving and had stopped breathing.

He was pronounced dead at about 3:45 p.m.

Blows 'cannot be excluded'

None of the injuries listed in the report are deemed by the coroner to be a sufficient cause of death.

Theyinclude several bruises to the upper and lower extremities, posterior shoulders, posterior head, neck, left back, abrasions throughout the body, ligature marks around theankles and wrists, and a mild enlargement of the heart.

"Many of the injuries would be in keeping with the story of attempts to restrain this man, but falls, or blows or other impacts to these regions cannot be excluded," the report states.

Neither a genetic mutation affecting Faqiri's heart and blood vessels nor any disease was determined to be the cause of death. However, the coroner couldn't rule out asphyxia, which may or may not have resulted from the use of thespit hood.

"It is clear from the history that this man was involved in a physical struggle with probable emotional agitation and pain prior to death which may have promoted a pro-arrhythmic state," the report states.

The report also says the coroner found a quantity of the antipsychotic drug olanzapinein Faqiri's system. That drug can lead to fatal arrhythmia, but the investigation found the levels weren't high enough to have caused death.

But for all the detail contained in the report's 56 pages, the family has many more unanswered questions.

"Why did the government take my brother's dignity away? Why weren't we able to see him in those 11 days that he was in custody? Why did he have to die? Why was he cut off from his family?" Yusuf Faqiriasked.

While the report doesn't say who was responsible for the injuries Faqiri suffered, the family's lawyers say that for them, it confirms their worst suspicions. Nader Hasan believesthat the death was the result of a beating.

What the family and their lawyers want to see now, says Hasan, is accountability.

"In my respectful view, there is certainly more than reasonable, probable grounds that serious criminal offences have been committed. And I am hopeful that the police and the Crown attorney's office will take a similar view and hopeful that if they do, that they will lay charges," Hasan told CBC Toronto.

'Unspeakable tragedy'

Kawartha Lakes Police Service told CBC News on Friday it will not release any further information until its investigation is complete.

Ministry of Community Safety and Correctional Services spokesperson Andrew Morrison said that with Faqiri's case under police investigationit would be inappropriate to comment, and that the ministry does not publicly discuss human resource matters such disciplinary action.

Last December, Morrison said that "should the coroner's investigation determine that the death was anything other than natural causes, a mandatory inquest will be held."

Meanwhile, in an email to CBC News, a spokesperson for Ontario's ombudsman said the Central East Correctional Centre remains one of the "top sources of complaints to our office for the past few years," and was the most complained about facility in 2016-17, with some 545 complaints spanning issues such asmedical care, assault, lockdowns, the facilities themselves and other issues.

Speaking to CBC News on Friday,MonteVieselmeyer, a representative for correctional workerswith the Ontario Public Service Employees Union,said he could not comment on whether criminal charges would beappropriate, saying that would have to be determined by police.

But on the need for better training for correctional officers and managerial staff to deal with inmates with mental illnesses,Vieselmeyer didn't hold back, saying correctional officers have virtually no access mental health crisis training beyond their initial training.

"Unfortunately, right now one of the few tools we have right now is segregation," he said, adding there are simply not enough alternatives forstaff to use "so that we're not putting individuals with mental health issues into these situations that most experts will tell you are not appropriate for their needs."

Meanwhile,Faqiri'sfamily and their lawyers say they're hoping for justice and that no other Canadians will have to experience a loss like theirs.

"We would like to see swift and decisive action since the Faqiri family has suffered an unspeakable tragedy and it adds insult to injury to make them wait any longer," Hasan said.

Soleiman's brotherYusufagrees.

"I want everyone to remember: This could have happened to anybody but it happened to my beloved brother," he said.

"This was a man with a mental illness who needed help, instead he lost his life."