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Soleiman Faqiri is shown in this undated family handout photo.Yusuf Faqiri/The Canadian Press

A coroner’s jury called for significant changes to how people with mental illness are treated within the corrections system as it ruled that the death of a man who was in a severe psychotic crisis when he had a fatal altercation with guards at an Ontario jail was a homicide.

Soleiman Faqiri’s death at the Central East Correctional Centre in Lindsay, Ont., in December, 2016, sparked outrage from mental-health advocates and calls to reform how the correctional system treats people in crisis.

Mr. Faqiri’s brother said Tuesday the family felt vindicated by the three-week inquest and the jury’s findings.

“They humanized my late brother. They looked at my family to see that Soleiman was somebody. They heard and they saw Soli, and I’m not sure that Soli was heard and seen in those 11 days [he spent in jail],” Yusuf Faqiri said after the verdict was delivered.

“This homicide verdict isn’t just vindication, but it’s an opportunity for corrections to be transformed and changed. This cannot continue the way it’s continuing.”

The jury made 57 recommendations including a new oversight body for provincial jails, better support for family members with mental health issues and banning people with severe mental illness from being held in segregation.

Though the jury concluded his death was a homicide, that is not a criminal finding and carries no legal liability. The goal of an inquest is not to lay blame, but rather to come up with recommendations to prevent similar deaths in the future.

Andrew Morrison, a spokesperson for the Ministry of the Solicitor-General, said the government thanked the jury for its recommendations and would review them before responding to the coroner.

Over the course of the three-week inquest, the five-member civilian jury heard Mr. Faqiri, a onetime University of Waterloo engineering student diagnosed with schizoaffective disorder after a 2005 car accident, had spent 11 days in a severe psychotic crisis before he died.

That afternoon, a group of correctional officers had forced him into a segregation cell, where he was sprayed twice with pepper spray and shackled by his wrists and ankles. A spit hood was placed over his head, and he was left lying stomach-down on the floor of the cell.

He stopped breathing and was declared dead minutes later. He was 30 years old.

No jail staff were charged in Mr. Faqiri’s death, despite earlier probes that found Mr. Faqiri had sustained at least 50 injuries during his fatal scuffle with correctional staff.

The Ontario Public Service Employees Union, which represents correctional staff, called for the inquest jury to deem Mr. Faqiri’s death accidental.

The bulk of the inquest testimony centred largely on the treatment of inmates with mental illnesses in Ontario jails.

The first recommendation from the jury is to “develop and issue a public position statement within 60 days of this verdict recognizing that correctional facilities are not an appropriate environment for persons in custody experiencing significant mental health issues.”

Another was to ensure that court-ordered mental fitness assessments of inmates be turned around within 24 hours.

In Mr. Faqiri’s case, the jury heard that he suffered from schizoaffective disorder, which was flagged at his first court appearance, on Dec. 5, 2016, where he appeared on charges related to stabbing a neighbour. But he was deemed too ill to participate in subsequent court proceedings, as well as a court-ordered mental fitness assessment that was supposed to have been completed by Dec. 19, four days after his death.

In an interview after the verdict, inquest counsel Prabhu Rajan said the case highlights the need for systemic change within corrections, particularly when it comes to mental health care.

“This case, I would hope, draws attention to the systemic problems that exist in the health care of such individuals in our correctional system. It is not, unfortunately, a one-off situation, as we heard in the evidence. There are other people in similar situations,” he said. “What is clear is that I don’t think that the Ministry of the Solicitor-General is best placed to be responsible for the health care of people in their facilities.”

The jury recommended placing health care functions within provincial jails under the Ministry of Health instead of the Ministry of the Solicitor-General – a change that the jury heard British Columbia recently made, with immediate benefits.

Other recommendations included banning severely mentally ill prisoners from being held in segregation, creating special needs units, improving recruitment and retention of health care staff, establishing mandatory mental-health training for correctional staff and clarifying when jail staff should call in specially trained tactical squads, called Institutional Crisis Intervention Teams.

Witnesses testified that correctional officers and health staff had clashed over whether to use these teams to move Mr. Faqiri throughout the building.

In addition to accountability mechanisms to ensure the consideration and implementation of these recommendations, the jury also recommended the broader creation of an Independent Provincial Correctional Inspectorate that would have the power to investigate and review jail operations across Ontario.

The jury also expressed their condolences to the Faqiri family in a statement read out Tuesday by one juror.

“At many times, it felt like watching a movie you had seen before, where there are so many instances when if one small action had been different, the ending would not have been the one we know,” the juror said. “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.”

With a report from The Canadian Press

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