A 30-year-old Ontario man suffered at least 50 injuries before dying in a provincial solitary confinement cell last December, the culmination of an hours-long confrontation with prison officers.
Details of Soleiman Faqiri's death at Central East Correctional Centre in Lindsay, Ont. are contained in an extensive coroner's report released to the man's family in recent days. It describes the final hours of an inmate suffering from schizophrenia and in deteriorating mental health who endured pepper spray and multiple blows shortly before his demise.
But despite the report taking nearly seven months to assemble, coroner Eric Ready was unable to determine a cause of death, calling it "unascertained."
Kawartha Lakes police were called in to investigate immediately after the death. Fourteen officers and one manager have been on suspension pending results of the police investigation, according to the correctional union.
Multiple sources told The Globe and Mail a criminal investigation by the Kawartha Lakes Police Service now sits with the Crown attorney's office to determine whether charges are warranted.
The lawyer representing the Faqiri family, Nader Hasan, told The Globe that although there is no medical explanation for Mr. Faqiri's death, he believes there is a legal explanation. "We count 50 injuries here," he said, "so there were multiple assaults taking place."
The president of the local union representing correctional officer at Central East hadn't seen the coroner's report as of Thursday night, but rejected allegations of wrongdoing by his members. "From what I know of what happened, staff acted professionally to subdue a rebellious inmate," Chris Butsch said. "I don't know the exact cause of death and it sounds like neither does anybody. I do know that a lot of staff advocated for him to go to a mental-health unit, to get extra help."
A spokesperson for Marie-France Lalonde, the minister responsible for Ontario prisons, said her office also has yet to see the coroner's report and therefore could not comment.
On Dec. 4, 2016, Mr. Faqiri was charged with one count of aggravated assault, one count of assault and one count of uttering a death threat. Authorities transported him to Central East soon after.
At the time, his family was desperate to reach jail staff to provide background on Mr. Faqiri's schizophrenia diagnosis. They travelled to Lindsay several times from their home in Ajax, an hour's drive, but were turned away, according to Yusuf Faqiri, Soleiman's brother.
Shortly after his admission, Soleiman Faqiri was placed in a segregation unit, where he displayed a variety of "behavioural problems," according to the coroner's report, which draws on photographs, witness interviews, closed circuit video and a variety of other sources to create a narrative of Mr. Faqiri's final hours.
On Dec. 12, a judge ordered Mr. Faqiri be transferred to a psychiatric facility for a mental-fitness assessment.
Three days later, while prison officials waited for a psychiatric bed to become available, Mr. Faqiri was led to a shower at 1:15 p.m. He remained there for nearly two hours, resisting all attempts to remove him by throwing shampoo bottles and splashing officers.
Eventually, he settled down and five or six guards led him to solitary cell B-10. The report describes closed-circuit video of Mr. Faqiri hunching forward as he walked down the hallway with his hands and legs cuffed.
At his cell, he refused to enter and a staff member doused him with pepper spray. Once inside the cell, guards tried to wrestle him to the ground and yelled, "Stop resisting." One of them hit him with a second round of pepper spray.
Mr. Faqiri, who was an avid weight-lifter according to his family, continued to raise himself off the floor, prompting staff to issue a "code blue," a facilitywide request indicating an officer in need of immediate assistance.
Moments later, several more officers ran into the cell to relieve their colleagues, who were exhausted from struggling with Mr. Faqiri. The second shift of guards placed a hood over his head to prevent him from biting or spitting and restrained his legs with leg-irons. At some point, the report states that a correctional officer "struck out at the inmate."
When they told Mr. Faqiri his hands would have to be switched from in front of his stomach to behind his back, he "appeared to calm down and co-operate." The cuffs in place, guards began leaving his cell when "onlookers noted that Soleiman was no longer moving and had stopped breathing. A medical emergency was called."
He was pronounced dead at 3:45 p.m.
The report notes a lengthy list of injuries to Mr. Faqiri's body, including a bruised laceration on the forehead, multiple bruises about the nose, neck and ears, along with dozens of bruises and abrasions on his torso and limbs.
The reports states the physical injuries were caused by blunt-force trauma, but were "insufficient to explain death." In summarizing, the coroner could not rule out asphyxiation or an irregular heartbeat as possible causes of death. The arrhythmia, the report states, could have been triggered by the combination of a physical struggle, emotional agitation, pain and the presence of an antipsychotic medication called olanzapine in his system.
"The Faqiris have waited way too long," Mr. Hasan said. "They are troubled, very troubled. They continue to grieve the loss of their son and brother. This report confirms their worst fears. Soleiman died a violent, unnecessary death."