The fatal restraint of Suleiman Faqiri by Ontario prison guards in 2016 was considered a homicide, words his family had been waiting to hear for nearly seven years since his death, shackled, pepper-sprayed, and covered with a hood on the cell floor.

The coroner’s jury verdict carries no legal consequences but marks a milestone in the family’s fight for accountability in the death of the 30-year-old.

Youssef Faqiri, Suleiman’s older brother, told CBC News: “The jury has spoken and described this as a homicide. There is no longer any doubt that my brother Suleiman Faqiri was killed by correctional officers.”

“Although we will never get our beloved Suli back, my family feels relieved that the truth has come to light for Canadians to see — the facts speak for themselves.”

Alongside the homicide verdict, the jury made 57 recommendations aimed at preventing future deaths in provincial prisons.

After the verdict, the five-person jury issued an emotional statement about their experience hearing about 22 witnesses over a three-week investigation:

The statement said, “Many times, it felt like watching a movie you had seen before, where there were many instances where if a small event had been different, the ending would not have been what we know, but the movie always plays out the same way. And we were left to reflect on our flaws instead of seeing a happy ending. We hope this is the last time.”

Faqiri suffered from schizoaffective disorder, a combination of schizophrenia and bipolar symptoms. He was detained on December 4, 2016, after stabbing a neighbor during what his family described as a psychotic episode. At the time of his death in the East Correctional Centre, he was awaiting medical assessment at Ontario Shores Centre for Mental Health Sciences. That assessment never happened, and less than two weeks later, Faqiri died.

Faqiri died after being repeatedly beaten by guards, pepper-sprayed twice, covered with a spit hood, left shackled and face down on the segregation cell floor after being moved from the shower stall, where he allegedly sprayed water and shampoo on guards. The investigation revealed the guards committed 60 policy violations in his death.

Ontario’s chief forensic pathologist said the injuries Faqiri sustained during violent restraint by guards were “a perfect storm for his death.”

His family said Faqiri, a high-achieving student, was the captain of his high school football team and was particularly close to his mother. When he graduated, his future looked bright. In 2005, he enrolled at the University of Waterloo studying environmental engineering, but his plans stopped after a car accident at age 19. Shortly thereafter, he was diagnosed with schizophrenia.

From that moment on, his life took a different turn; he could not continue in school and was arrested several times under Ontario’s Mental Health Act. Over the years, his family said they struggled to get the help he needed, and he was on and off medications, and his condition deteriorated.

During the 11 days he spent inside Lindsay Prison, Ontario, jurors heard his condition worsened from bad to worse.

The investigation also released for the first time video footage of Faqiri’s final moments leading to the violent restraint, video CBC News sought for years via access to information requests since his death.

It also revealed that many “well-intentioned people effectively shouted from the rooftop saying Suleiman needed help,” according to inquiry lawyer Prabhu Rajan.

Among those people was a guard who broke protocol to film Faqiri’s deteriorating condition in the days before his death in hope of getting help; a nurse who filed a Form 1 application to send Faqiri to hospital for mental health evaluation; and a manager who alerted about 60 supervising staff that Faqiri had been in his cell covered in feces for four consecutive days.

The homicide verdict comes after three consecutive police investigations into Faqiri’s death without criminal charges against any guards involved.

In the last investigation, the Crown attorney’s office said there was “insufficient evidence” to lay charges. At that time, family lawyers said the Crown told them it was impossible to determine which of the six or more guards involved participated in the fatal blow.

While the verdict carries no criminal liability, police may choose to reopen their investigations based on what the jury heard. They are not obligated to do so.

Edward Maroko, the family’s lawyer, told CBC News: “This has been a long road for Suleiman’s family. For them, his case has always been about homicide. In the end, five members of the public, after two days of deliberations, came to the same conclusion and declared Suleiman’s death a homicide.” “The police who sought to interpret this as something less should reconsider.”

Recommendations

All 57 recommendations made by the coroner’s jury are addressed to the Ontario government. The recommendations are not binding but include accountability measures so the factors that led to Faqiri’s death are not repeated.

The top five recommendations include:

Prepare a public position statement within 60 days acknowledging that prisons are not a suitable environment for those with significant mental health issues.

Take immediate steps to ensure that anyone experiencing an acute mental health crisis while in custody is admitted to hospital for assessment and treatment as appropriate.

Adopt the principle of equivalency so that detainees receive health care of equal quality as that available outside custody.

Form a committee to ensure that investigation recommendations are properly considered and that any responses are fully reported.

Establish an independent provincial corrections watchdog with authority to investigate individual and systemic complaints in correctional facilities.