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A mentally ill man died in an Ontario jail because he was beaten and restrained by guards while clearly in crisis, the province’s chief forensic pathologist has found.

In a report released Tuesday, Dr. Michael Pollanen said Soleiman Faqiri died on Dec. 15, 2016, after being beaten, pepper sprayed and restrained face-down in a segregation cell at the Central East Correctional Facility in Lindsay, Ont.

The coroner’s office had previously concluded Faqiri’s cause of death was “unascertainable” but Pollanen re-examined what happened to help inform an upcoming inquest.

“The eyewitness accounts and the numerous injuries present on the body at autopsy indicate a violent struggle occurred in the segregation cell,” Pollanen wrote.

“The injuries were a significant contributing factor in death.”

Faqiri lived with schizophrenia and his symptoms worsened significantly during his 11 days in the jail, the report said, noting that the 30-year-old was set to be moved to a psychiatric facility for help.

He never made it there.

His family, who has been seeking answers for five years, said Pollaen’s findings now leave no doubt about what happened.

“It’s an extremely mixed day of emotions, my late brother was a beautiful man,” Yusuf Faqiri told The Canadian Press. “It’s a day that we relive his pain, his tragedy, but it’s also a day – dare I say – where some hope has started.”

Pollanen found a combination of factors contributed to Soleiman Faqiri’s death.

Faqiri had an enlarged heart, Pollanen said. That and the man’s exhausting “violent struggle” with jail guards were key factors in his death, Pollanen found.

Faqiri was remanded to jail on Dec. 5, 2016, in the midst of a schizophrenic episode.

“A review of the available documents and video footage show a steep and relentless deterioration in his psychiatric symptoms during his incarceration,” Pollanen wrote.

“This decline culminated in an episode of bizarre behaviour that was documented by video footage in the hours before his death. The video footage shows Soleiman Faqiri nude and in a disorganized and agitated state.”

Pollanen said the decline was obvious not only to a physician who examined him, but also to his family, other inmates and correctional officers.

Just prior to his death, guards had taken Faqiri for a shower. Video footages shows him lying naked on the floor. Then he is escorted back to his cell, where there is no video footage of what happened next.

“All the available information reveals that the altercation included: an exhausting struggle, prone position restraint, blunt injuries, pepper spray deployment, hand cuffing, shackling, and application of a spit hood,” Pollanen wrote.

The guards struck him in the body and head multiple times and held him face down on the floor of the cell, the report said. They also shackled his legs and handcuffed his wrists behind his back while keeping him in the prone position.

The violent struggle began at 3:04 p.m. and ended at 3:14 p.m., when the guards tried to resuscitate Faqiri, Pollanen said.

Pollenen said there were three “reasonable mechanisms of death.”

One was anoxia, “a lack of oxygen in his blood, starving his brain of the oxygen it needed to function,” he wrote.

The second was arrhythmia, “an abnormal heart beat causing his heart to stop beating.”

Or, third, a combination of the two led to his death, Pollanen wrote.

“This struggle and exertion would have contributed to a catecholamine surge, affecting his heart,” said Pollanen, noting the multiple blunt-trauma injuries all over Faqiri’s body.

Forcing Faqiri to the prone position was also a contributing factor, Pollenen said.

Ontario Provincial Police and Kawartha Lakes police have both conducted investigations into the case, but no charges have been laid.

The family said the case has now been referred back to the OPP for an investigation.

“We have absolutely no confidence in the OPP to do what is right,” Yusuf Faqiri said. “There needs to be criminal charges against the guards who killed my brother, that is the ultimate hope.”

The OPP did not immediately respond to a request for comment.

The family has also launched a civil suit in the matter.

A spokesman for the Ministry of the Solicitor General, which is responsible for provincial jails, said it would not be appropriate to comment given the civil suit and the upcoming coroner’s inquest, which is mandatory for all deaths in custody.

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