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

Nearly 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 the injuries the 30-year-old suffered in the final minutes of his life.

Long-awaited report gives no clear cause of death for Soleiman Faqiri as family, lawyers demand charges

Soleiman Faqiri, 30, died while in segregation at Central East Correctional Centre in December. A coroner's report reveals no clear cause of death, but says arrhythmia from a physical and emotional struggle may have played a role. (Submitted by Yusuf Faqiri)

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 of injuries 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 died after 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 identified on Faqiri's body were caused by "blunt impact trauma."

"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, adding some of the family couldn't bring themselves to read about the circumstances.

Guards reportedly exhausted

Faqiri, according to the 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 report says.

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

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

The Central East Correction Centre in Lindsay, Ont., is one of the top sources of complaints, says the province's ombudsman. (Google Streetview)

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 are fighting 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. 

They include several bruises to the upper and lower extremities, posterior shoulders, posterior head, neck, left back, abrasions throughout the body, ligature marks around the ankles 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 the spit hood.

Yusuf Faqiri says his family is grieving the loss of his younger brother Soleiman, who they say was suffering from schizophrenia before he was found dead in his segregation cell. (Nick Boisvert/CBC)

"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 olanzapine in 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 Faqiri asked.

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 believes that 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 investigation it 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."

Soleiman Faqiri, left, is pictured here with older brother Yusuf, right, and younger brother Ali, the two still mourning his loss. (Nick Boisvert/CBC)

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 as medical care, assault, lockdowns, the facilities themselves and other issues.

Speaking to CBC News on Friday, Monte Vieselmeyer, a representative for correctional workers with the Ontario Public Service Employees Union, said he could not comment on whether criminal charges would be appropriate, 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 for staff 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's family 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 brother Yusuf agrees.

"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."


Shanifa Nasser is a journalist with CBC Toronto interested in national security, the justice system and stories with a heartbeat. Her reporting on Canada's spy agency earned a 2020 Amnesty International award and an RTDNA, and her investigative work has led to two documentaries at The Fifth Estate. Reach her at: