60 Ontario jail staff were alerted about Soleiman Faqiri's state. Still, he wasn't sent to hospital

In the days before Soleiman Faqiri's death, an operational manager at the Lindsay, Ont., jail sent a note to some 60 corrections staff alerting them about his 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," the email said in part.

Still, Faqiri was never sent to a hospital or seen by a psychiatrist. He died five days later.

The email, sent to dozens of staff by John Thompson, was shown at the inquest into Faqiri's death on Monday. Jurors heard from two senior officials at the Ministry of the Solicitor General, Linda Ogilvie and Tracey Gunton, about the internal review undertaken after his 2016 death at the Central East Correctional Centre, as well as lessons learned since.

Ogilvie, director of corporate health care for the ministry, told jurors that upon reviewing Faqiri's file, it was clear he was "very, very unwell."

He was so unwell, jurors heard, that he was not brought for a video assessment for his fitness to stand trial.

As for the psychiatrist employed by the jail, he was on vacation at the time of Faqiri's stay and there was no backup psychiatrist in place.

Ogilvie noted the jail has been "chronically challenged" with retaining and securing health care staff, something the ministry is working to address. 

Ogilvie also said ministry policy requires that if a jail cannot provide the care someone would receive in a community health setting, they should be taken to a hospital. The jail's doctor decided Faqiri did not need to be sent to a hospital, however jurors heard correctional staff did have the authority to transfer Faqiri there if he could not be properly cared for at the jail.

Jurors are expected to hear from the doctor who oversaw Faqiri's care this week.

At the time of his death, Faqiri, who suffered from schizoaffective disorder, 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.

He died on Dec. 15, 2016 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. 

No one was ever charged in his death.

The review into Faqiri's care began in November 2017. Jurors heard that the frontline healthcare providers, including the doctor overseeing Faqiri's care behind bars, were not spoken to as part of the review.