Toronto

Jail official felt Faqiri didn't meet bar for hospital, refused to watch video taken as he deteriorated

The top health care official at the jail where Soleiman Faqiri died didn't feel he met the bar for her to send him to hospital and refused to watch a video taken by a guard capturing his decline in segregation, a coroner's inquest heard Tuesday. That official had no medical background. 

WARNING: This story contains graphic details and images

Before the altercation with guards, Faqiri was being transferred to the jail's maximum segregation unit, known as "8-seg." At the farthest end of the hallway is cell B-10, where he was supposed to be housed until his mental health assessment.
Before the altercation with guards, Faqiri was being transferred to the jail's maximum segregation unit, known as "8-seg." At the farthest end of the hallway is cell B-10, where he was supposed to be housed until his mental health assessment. (Kawartha Lakes Police Service)

The top health care official at the jail where Soleiman Faqiri died didn't feel he met the bar for her to send him to hospital and refused to watch a video taken by a guard capturing his decline in segregation, a coroner's inquest heard Tuesday. That official had no medical background. 

Helen Hamblin told jurors that despite Faqiri behaving erratically and smearing feces on himself, she instructed staff to leave him be after they contacted her on Dec. 10 because she felt he wasn't in physical danger. 

"My concern would be if at some point he started to self-harm," Hamblin told jurors, noting while his mental condition was a concern, she didn't feel she could send him to the hospital on that basis. Hamblin said she believed she could only send Faqiri to the hospital if he was physically harming himself or if a nurse advised he be sent to hospital.

Hamblin was the director of programming at the Central East Correctional Centre during Faqiri's detention in December 2016 and oversaw health care at the jail. She was also the on-call deputy in charge on the weekend operational manager John Thompson sent an email alerting 60 supervising staff about Faqiri's condition.

"He has been naked, washing walls and rolling in his own feces for four days. The inmate needs to be showered and the cell disinfected," Thompson's email said in part.

Soleiman Faqiri
Soleiman Faqiri was the second of five children and came to Canada from Afghanistan with his family in 1993 at the age of eight. According to his family, he was a straight-A student, captain of his high school rugby team and had a close and loving relationship with his four siblings and parents. (Submitted by Yusuf Faqiri)

Jurors have previously heard jail staff, whether health care or correctional, could have sent Faqiri to the emergency room if he could not be given the care he needed at the facility.

Any doctor could have also sent Faqiri to hospital on a Form 1 — a tool to place a person experiencing severe mental health difficulty in a facility for up to 72 hours for psychiatric assessment. Jurors have heard the doctor at the jail opted not to do so and will hear from that doctor this week. 

Situation wasn't 'life or death': ex-deputy

Hamblin told the jury she hadn't seen the email to supervisors and only learned about Faqiri's condition later that day when Thompson phoned her to request a specialized crisis team to move Faqiri from his cell to the shower. Hamblin said she and a mental health nurse on duty that day agreed the crisis team would only make a bad situation worse.

Her decision: It wasn't a "life or death" scenario, so staff should monitor Faqiri and advise if things escalated. 

LISTEN | The latest on the inquest into the death of Soleiman Faqiri on The Current: 
In 2016, Soleiman Faqiri was being held at the Central East Correctional Centre in Lindsay, Ont., awaiting trial. But 11 days after he went into custody, Faqiri, who lived with schizophrenia, died in a violent confrontation with guards. An inquest into Soleiman Faqiri's death is underway. CBC’s Shanifa Nasser walks us through the details.

Faqiri died five days later on Dec. 15 after being repeatedly struck by guards, pepper sprayed twice, covered with a spit hood and placed on his stomach on the floor of a segregation cell. His cause of death, previously deemed unascertained, was later deemed to be restraint in a face-down position and injuries from his struggle with guards. 

At the time of his death, Faqiri, who suffered from schizoaffective disorder — a combination of schizophrenic and bipolar symptoms — was awaiting a medical evaluation at the Ontario Shores Centre for Mental Health Sciences. He had been charged with aggravated assault, assault, and uttering threats following an altercation with a neighbour, but had not been convicted of any crime.

No one was ever charged in his death.

At no point during his time at the jail was Faqiri taken to a hospital or seen by a psychiatrist. Jurors have heard while the doctor employed by the jail suggested Faqiri be seen, the psychiatrist was away on vacation without a backup.

Jurors heard Hamblin, despite overseeing health care as part of her portfolio, had no background in the area. Nor did she have access to inmates' health records or those on remand.

As a result, she said, she relied heavily on the health-care manager reporting to her as well as other health staff to alert her if there was an issue where she might be needed to "advocate."

A forensic psychiatrist previously told the jury Faqiri was clearly in the throes of a mental health "emergency" prior to his death, and should have been taken to a hospital. 

Deputy didn't visit Faqiri despite call from staff

The day after her exchange with Thompson, on Dec. 11, Hamblin went to the jail in person as part of her usual on-call tours.

Despite being alerted about Faqiri's situation only a day earlier, jurors heard that she didn't visit him directly, opting to visit those on suicide watch instead. Asked how long it would have taken to do so, Hamblin acknowledged it would have taken less than 30 minutes. 

With Hamblin on tour that day was Sgt. Clark Moss. As CBC News previously reported, it was Moss who took to filming Faqiri inside his cell in the days before his death, breaking protocol to raise attention about his condition.

The approximately 13-minute-long video captures in painful detail Faqiri's state four days before his death. In it, Faqiri is seen in a part of the jail called 2-seg, before his final transfer to maximum segregation.

WATCH | Jail guard filmed Faqiri to raise awarness about his condition: 

Soleiman Faqiri inquest: As his condition deteriorated, guards filmed inside his cell

1 year ago
Duration 1:25
WARNING: This video contains violence and some viewers may find it disturbing. The Ontario inquest into the jail cell death of Soleiman Faqiri in 2016 was shown video recorded by corrections officers showing the challenges of caring for the mentally-ill man.

Jurors heard Moss tried to show Hamblin the video, but she declined to view it because it would show Faqiri undressed.

"I don't see any need to video an offender in the shower naked," she told the inquest. "I did not want to see that."

Asked if she would do anything differently in hindsight, Hamblin told jurors, "I guess the the only thing really is I probably should have gone to see Mr. Faqiri."

"Maybe that would have been helpful."

ABOUT THE AUTHOR

Shanifa Nasser

Reporter-Editor

Shanifa Nasser is a journalist with CBC Toronto interested in the justice system, mental health, national security and stories with a heartbeat. Her reporting on Canada's spy agency earned a 2020 Amnesty International Award and an RTDNA. Her work has also been the basis of two investigative documentaries at The Fifth Estate. Reach her at: shanifa.nasser@cbc.ca