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TORONTO — People with mental illness can experience significant disruptions to their health care when they are taken into custody, Canada's former correctional investigator said Tuesday at a coroner's inquest for a mentally ill man who died in an Ontario jail.

Howard Sapers took the stand on the second day of the inquest examining the death of Soleiman Faqiri, who died in his cell on Dec. 15, 2016, after a violent struggle with correctional officers at the Central East Correctional Centre in Lindsay, Ont. 

The inquest has heard Faqiri was detained at the facility east of Toronto after he was charged with aggravated assault, assault and threatening death in an incident that occurred while he was experiencing a mental-health crisis. He died in his cell less than two weeks later.

When a person is detained in a provincial jail or federal penitentiary, they are no longer covered by the Canada Health Act during the period of custody, Sapers told the inquest jury Tuesday. 

The provision of health services falls, generally, on the correctional system, which can either create infirmaries, hospitals and the like inside institutions, or move inmates to community hospitals to receive health care it then has to pay for, he said.

"There's been a move in corrections really around the world to move away from corrections systems also acting as health-care systems and to try to move the provision of health outside of jail," Sapers said.

The government of Ontario committed to making that transition in 2018, and even convened an expert panel on the issue, but the shift hasn't happened yet, he said. The responsibility for health care in custody "resides squarely on the shoulders of the operators of the jails, and so you have correctional nurses and other clinicians who are employed by corrections to work on those jails," he said.

The switch from receiving care in the community and in jail can mean sudden and important changes, he noted.

"If you have a mental-health issue, and your mental-health condition has been stabilized through medications, and those medications are available to you at your local pharmacy and they've been prescribed by your doctor – all of that may change the moment you enter a prison or a provincial jail," he said.

"You no longer have access to your doctor, the medications that you were prescribed may not be considered appropriate for use inside a custody facility ... and so your health care can be very disrupted."

For many who have a history of taking psychotropic medication – a category that includes antidepressants, antipsychotics and mood stabilizers, among others – there usually is a period of trial and error before the right prescription is determined, he said. 

"But all of that, it may be disrupted as soon as you enter the admissions area of a jail," he added.

What's more, he said, health professionals within an institution, such as nurses and psychologists, are employees of the correctional system and may report to someone who is an administrator rather than a clinician, Sapers said. 

"Correctional staff, as I've said before, often lack accurate health information. It's difficult sometimes to share information," he said.

In the 12 years he served as correctional investigator, a type of specialized ombudsman dealing only with the federal correctional system, lack of access to health care was a top complaint, Sapers said. 

He noted there is no equivalent role at the provincial level in Ontario. While the provincial ombudsman can and has investigated issues related to the correctional system, that person has multiple files and topics to look into, he said.

The coroner's inquest began this week and is expected to last 15 days, ending shortly before the seventh anniversary of Faqiri's death. 

On Monday, the inquest heard an agreed statement of facts laying out some key events that took place in the lead up to Faqiri's death.

In that time, the inquest heard, Faqiri saw the institution's physician and was referred to a psychiatrist, but never saw a psychiatrist, nor did he take all the doses of the medication he was prescribed. The physician also decided not to send Faqiri to a hospital for a psychiatric assessment or as an emergency patient, it heard.

His condition worsened, and his behaviour grew increasingly concerning, the inquest heard. At one point, he was smearing feces on himself. 

His brother and a nurse testified in court to support an order that he undergo an assessment to determine his fitness to stand trial, the statement said. A video assessment was scheduled, but Faqiri was deemed too unwell to attend, it said.

On the day he died, Faqiri was transferred to a new cell and taken to a secure shower, the inquest heard. As he was being led, handcuffed and in his boxers, from the shower to his cell, several corrections officers said he spat at the sergeant who was holding his handcuffs, according to the statement.

The sergeant responded by slapping Faqiri, who then hunched in a ball, the statement said. He was then subjected to "various incidents of use of force" as the officers pushed him to his cell, including being struck in the head area, sprayed in the face with pepper spray foam and restrained face down on the ground, it said.

At some point, his legs were shackled and officers put a spit hood, a covering meant to prevent someone from spitting, on him, the statement said.

He was found to be unresponsive when officers removed the spit hood, the statement said.

His brother, Yusuf Faqiri, said his family has long called for an inquest, but the evidence remains difficult to hear and watch.

"We loved him," he said.

"This fight is for Solei but it's for so many other Canadians ... because I truly in my heart don't want another mother or brother to go through what we went through."

This report by The Canadian Press was first published Nov. 21, 2023.

Paola Loriggio, The Canadian Press

Note to readers: This is a corrected story. A previous version referred to the Central East Correctional Centre by the incorrect name.