Why wasn’t inmate sent to hospital?

Testimony reveals a chain of jailhouse dysfunction ahead of mentally ill man’s death in 2016

Why wasn’t Soleiman Faqiri sent to hospital despite his rapid mental health decline over 11 days inside an Ontario jail?

That question was the driving focus of week two in the ongoing coroner’s inquest into his death following a violent struggle with guards at the Central East Correctional Centre, near Lindsay.

Faqiri, 30, had diagnosed schizophrenia and was arrested on Dec. 4, 2016, for assault following an altercation with a neighbour. During his stay in segregation, Faqiri suffered a psychiatric emergency, noticed by numerous staff inside the jail. On the day he died, he allegedly spit at one of the guards escorting him from a shower to a cell, leading to the struggle that resulted in his death.

At the inquest, multiple jail staff have testified Faqiri should have been in a psychiatric facility — but he never saw a psychiatrist and he was never taken to a hospital. The inquest has heard staff describe how decisions leading to his death were influenced by internal conflicts, frustration with the local hospital and key gaps in knowledge about who had authority over Faqiri’s care.

Here’s what we learned at the inquest’s second week:

Jail staff said the situation wasn’t ‘life or death’

Testifying on Tuesday, Helen Hamblin, the jail’s now-retired deputy superintendent of programs, described learning about Faqiri’s decline through a phone call with operational manager John Thompson, who’d earlier sent an email to 60 managerial staff — including Hamblin — warning about Faqiri’s deteriorating condition, including “rolling in his own feces for four days.”

She testified she doesn’t remember receiving that email, but after speaking about Faqiri’s state with Thompson on the phone, she said she didn’t think it was “going to be a life or death situation.”

She also testified she had refused to watch a video — taken by a jail guard in breach of protocol — detailing the extent of Faqiri’s distress on Dec. 11, 2016, four days before his death. The video showed him naked inside a cell with the floor and himself covered in feces, urine and vomit. A forensic psychiatrist has previously testified that Faqiri’s mental state was a clear “psychiatric emergency.”

Hamblin said she didn’t watch it at the time “for personal reasons,” without further clarification.

She further testified she believed at the time that the only individuals who had authority to send an inmate to a hospital because of mental health challenges were the jail’s physician, the psychiatrist — who was on vacation at the time — or nurses.

At the time, Hamblin said she thought she only had that authority when there was a risk of self-harm — a misunderstanding that wasn’t cleared up for three years after Faqiri’s death.

The jail’s doctor believed the local hospital wouldn’t admit Faqiri

Dr. Brent McMillan, a part-time physician at the Lindsay superjail, testified Wednesday that although he noticed Faqiri’s acute crisis, he felt the risks of a hospital transfer outweighed the benefits.

“The risk associated with trying to corral a man who’s frightened and vulnerable with a team of men who are trained to deal with potentially violent situations — I was quite concerned that would instigate a reaction … that would cause him mental or physical harm,” McMillan said.

The doctor defended his decision to not send Faqiri to a hospital, noting his frustrations with the local hospital, Ross Memorial, where he also works.

According to McMillan and other staff, the hospital has a history of sending inmates back after administering medication, but not admitting them. So, if Faqiri received an injection in jail, McMillan said, a transfer was not necessary.

McMillan said he decided to give Faqiri a long-lasting antipsychotic two days before he died; the medication would have taken up to two weeks for full effect.

“I think he should have been directed from the courts to a psychiatric facility. Anyone who has mental-health issues, man, they get worse when they’re in jail. I don’t have to tell you that,” McMillan testified.

On Thursday, Susan Grant, Ross Memorial Hospital’s director of risk, professional practice and patient relations, acknowledged that some patients in acute psychiatric crises were returned to jail. She explained: “There may not be a spot in the hospital that would provide that low stimulation, close monitoring.”

While communication between the two facilities has improved over the years, Grant said lack of funding, available beds and physical space remain the hospital’s biggest obstacles as to why they send some patients back to the jail.

A nurse created a care plan, but was at odds with guards

The inquest heard audio recordings from a 2017 internal investigation that involved two interviews with nurse and health-care manager Kathy Goard, and former operational manager John Thompson, both of whom were present the day Faqiri died. (Goard has not testified in person; Thompson died in 2021).

“My job isn’t to make decisions operationally, but my job is to advocate for the client,” Goard said in the audio clip.

Goard and her team created a three-part care plan for Faqiri: transfer him with officers from his first segregation cell to the shower, move him into a different segregation cell closer to the medical unit, then discuss a transfer with their local hospital.

The plan was communicated to Faqiri, who seemed to understand, but later in the shower he began throwing shampoo at officers and refused to get out.

Thompson requested the jail’s Institutional Crisis Intervention Team to help, but Goard and Hamblin advised against it.

“You would have had six to eight men dressed in black from head to toe (with) helmets and gas masks. They honestly look like alien ants from another world,” Hamblin explained.

“It’s very intimidating.” Thompson then proceeded to move Faqiri out of the shower without a wheelchair and without the other health care staff ready. After a violent struggle began in the hallway, Goard’s care plan was disregarded.

In the recording, Goard recalled her frustration and said the jail guards are “adversarial” toward health care staff.

“I’m sick and tired of this group. Why does it always have to be a fight,” she said.