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

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 yearssince 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 itrepresents 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. "Mybrother 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."

WATCH | What we learned at the inquest into Soleiman Faqiri's death:

What we learned at the inquest into Soleiman Faqiri's death

9 months ago

Duration 7:35

WARNING: This video contains graphic footage. Soleiman Faqiri died at the Central East Correctional Centre in Lindsay, Ont., after he was repeatedly struck by guards, pepper-sprayed twice, covered with a spit hood and placed on his stomach on the floor of a segregation cell. Shanifa Nasser explains what jurors were told at an inquest into the 30-year-olds death.

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 thatFaqiri'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 describedbroken 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 alack 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.

WATCH | Video shows final moments before Faqiri's deadly restraint:

Inquest into Soleiman Faqiri's death reveals how and when force was used on mentally-ill man

10 months ago

Duration 3:27

WARNING: This video contains violence and some viewers may find it disturbing. CBC News has annotated surveillance video of Soleiman Faqiri's final moments to document the extent of the force correctional officers used on him before he died in a jail cell on Dec. 15, 2016. The timeline is based on an agreed statement of facts entered at the Ontario inquest into Faqiri's death, which is currently underway.

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 whobroke protocol to film Faqiri's declining statein 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 whoalerted some 60 supervising staffthat Faqiriwas languishing in his cell covered in feces for four straight days.

WATCH | Corrections officer coaxes Soleiman Faqiri from cell:

Corrections officer coaxes Soleiman Faqiri from cell

10 months ago

Duration 9:31

Sgt. Clark Moss had another corrections officer record this video of him helping Faqiri move from a cell to the shower in a bid to show the extent of Faqiri's declining mental health. CBC Toronto is opting to post nine minutes of the footage to show the dynamic between the corrections officer and Faqiri. While it contains some graphic content and shows Faqiri in an apparent mental health crisis, CBC Toronto believes it is relevant to understanding this story. You can find the full story at cbc.ca/1.7050838

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 ofhis 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 OPPtold themit wasimpossible 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 environmentfor 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 saidit endorses all of the recommendations. However anindependent inspectorate is particularly important because at present, correctional facilities are "not held accountable in any shape orform," 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."

See all 57 recommendations made at the inquest into the death of Soleiman Faqiri: