Faqiri should have been taken to hospital

A coroner’s inquest into the death of a mentally ill man at an Ontario jail is hearing it was government policy that anyone whose health-care needs couldn’t be met within an institution be sent to a community hospital.

The inquest into the December 2016 death of Soleiman Faqiri is hearing from two senior officials with the Ministry of the Solicitor General, though neither had direct oversight of the case at the time.

Linda Ogilvie, who worked at the ministry’s corporate health-care unit and reviewed Faqiri’s file as part of an internal investigation, says it was the “expectation” even before December 2016 that institutions transfer people to community care if their health-care needs couldn’t be met on site.

She says those decisions are left to staff at the facility, a process that “does rely on the practitioners to certainly recognize that that care exceeds their ability.”

The inquest has heard Faqiri was arrested in early December 2016 after allegedly stabbing a neighbour while experiencing a mental-health crisis.

Health-care and correctional staff at the Central East Correctional Centre in Lindsay, Ont., noted increasingly concerning behaviours over time, and one witness, a forensic psychiatrist, told the inquest Faqiri looked as though he was in the middle of a severe psychotic episode.

Faqiri died after a violent struggle with corrections officers on Dec. 15, 2016.

Ogilvie told the inquest her team did not have direct oversight over the jail but could provide support and act as consultants if an institution reached out.

She said that did not happen during Faqiri’s time in custody.

The ministry launched an internal review in November 2017 but front-line healthcare workers weren’t spoken to as part of process, jurors heard. Ogilvie agreed that was too long.

“There may have been lessons learned, life-saving lessons learned, that were not noticed by the ministry for 11 months after Mr. Faqiri’s death?” coroner’s counsel Julian Roy asked her. “Fair,” she replied. Coroner’s counsel asked Ogilvie if the review, or any additional steps taken following that, had shed light on why Faqiri wasn’t sent to hospital, as would have been expected.

Ogilvie said she had only “anecdotal information” based on conversations with management at the jail.

“My understanding is that when patients were sent to the local hospital, they were often turned back at the emergency department and not provided a pathway for admission,” she said.