Nearly 60 policy breaches found in Soleiman Faqiri's death, jail guard tells inquest

A jail guard directly involved in restraining Soleiman Faqiri on the day of his death says an internal investigation found guards carried out approximately 60 breaches of policy that day, adding policies were often followed only when "convenient."

Dave Surowiec told jurors he didn't notice any policies being breached while Faqiri was restrained at the Central East Correctional Centre but he later learned of dozens of breaches through aninternal investigation from theCorrectional Services Oversight and Investigations Office, which has not yet been made public.

"In my experience, policy and procedures are great things but operationally they're not always adhered to," Surowiec said jurors at the inquest into Faqiri's 2016 death.

"Isn't it a bit like the wild wild West then?" coroner's counsel Prabhu Rajan asked Surowiec.

"It's an enormous problem," Surowiec answered, citing staffing levels and operational demands as reasons why policies might not be followed.

Jurors heardSurowiecjoined in restraining Faqiri at the Central East Correctional Centre after an emergency call for all available officers, known as a code blue. Once there, someone called out for a spit hood. Surowiec went to find one and by the time he returned, was told guards already had one.

Surowiec said he was then asked to replace a guard who was exhausted from the restraint and he took charge of restraining Faqiri's right arm. By this point, Faqiri was face down, wearing a spit hood andleg irons, and had been pepper sprayed twice without being decontaminated.

A spit hood is a light-weight fabric covering placed over a person's head to stop them from spitting. Jurors have heard one of the managers involved in his death alleged Faqiri spat at him on his way to his cell and that the manager slapped Faqiri in response.

WATCH | Video shows final moments before Faqiri's deadly restraint:

Inquest into Soleiman Faqiri's death reveals how and when force was used on mentally-ill man

10 months ago

Duration 3:27

WARNING: This video contains violence and some viewers may find it disturbing. CBC News has annotated surveillance video of Soleiman Faqiri's final moments to document the extent of the force correctional officers used on him before he died in a jail cell on Dec. 15, 2016. The timeline is based on an agreed statement of facts entered at the Ontario inquest into Faqiri's death, which is currently underway.

Spit hood could 'increase' psychotic symptoms: manual

Surowiec testified he was trained that handcuffing a personbehind their back while face down could risk cutting off their air supply, but that he was instructed to do so and didn't question the move. Jurors also heard theSurowiec was trained on proper use of a spit hood, but could not recall the specifics of that training.

As CBC News previously reported, Ontario's use of force policy for jails states in part: "Staff must ensure that an inmate is not placed on his/her stomach or in any position that could result in positional asphyxia while wearing the spit hood."

It also says an inmate must be "properly decontaminated" when pepper spray is used, and staff must ensure an inmate "is never left unattended while wearing the spit hood."

Jurors have previously heard Faqiri was left inside the cell on this stomach with the spit hood still over his face after guards exited his cell. He was reportedly being watched through the cell window, when a manager noticed he wasn't breathing.

The use of force manual also says using a spit hood on an inmate experiencing a "psychotic episode may increase the symptoms being experienced" and that staff must first attempt to use alternatives such as donning their own face masks or protective eyewear.

There is no indication the guards involved in Faqiri's death used such tools.

Further, a spit hood must be removed when there is "no longer an imminent threat of a person being spit on." It's unclear why Faqiri was left wearing a spit hood when there were no guards left in his cell.

Guard noticed Faqiri 'tick' at outset

Jurors heard Surowiec worked in the admissions and discharge area of the jail when Faqiri first arrived there on Dec. 5.

Surowiec processed Faqiri's paperwork and performed his strip search. Right from the beginning, he said,he could tell Faqiri may have some kind of mental health issue.

"I'd almost describe it as having a tick. He was jumpy. You could tell he was having trouble following my direction."

At no point over the next 11 dayswas Faqiri seen by a psychiatrist or taken to a hospital for treatment.

Jurors have previously heard that the jail's psychiatrist was on vacation at the time, that there was a fractured relationship with the nearby Ross Memorial Hospital, and that neither jail or health care staff believed they could send him to the emergency room, despite policy.

Rajan pressed Surowiec on what the guards restraining Faqiri were looking for in moving his handcuffs to his rear. Jurors heard Faqiri's hands were momentarily free while guards removed his handcuffs to reposition them behind his back and that he didn't use the opportunity to jump up or fight back.

Surowiec responded that guards were seeking "compliance."

Asked if guards' use of force training distinguishes between someone withe mental illness or without, he said, "The training doesn't differentiate."

Surowiecalso said he was never taught that a person with a mental health issue might not understand instructions to them.

Asked if that was a problem, he replied: "It would be like trying to speak English to someone who doesn't speak English."

In the aftermath of Faqiri's death, Surowiec was suspended from his position with pay for 22 months but was later reinstated. Surowiec Speaking to the jury Monday, he said he suffered greatly following Faqiri's death, experiencing depression and post-traumatic stress disorder, and that he is currently off the job.

Surowiec told jurors his mental health was impacted not only by what happened to Faqiri, but the "vilification" by his employer, noting Ontario's correctional ministry, now the Ministry of the Solicitor General offered little to no support.

Manager testifies sheknew risk of position

Surowiec's testimony echoed that of manager Dawn Roselle, who testified at the inquest Friday.

Roselle, who was fired in the aftermath of Faqiri's death, told jurors placing an inmate face down with handcuffs behind their back is "a higher risk" position as it can affect their breathing.

Still, Roselle said, she authorized the move in an attempt to "safely disengage the staff, to reassess and to provide inmate Faqiri care."

Roselle testified she arrived at the incident while it was already underway and wasn't told Faqiri had been covered with as spit hood or that he had been pepper sprayed.

During a lawsuit following Faqiri's death, Roselle acknowledged the combination of tactics used on him that day posed a "triple threat" for asphyxia.

The union representing correctional staff said in a statement to CBC News on Monday that it supports the inquest process and hopes it will bring answers and recommendations to prevent future such deaths.

"The dismantling of the social safety net in Ontario has led to an increase in incarceration for people with complex physical and mental health needs that the correctional system is not equipped to address," the statement said in part.

The statement went on to say the union has recommended dedicated mental health units at all Ontario jails and upgrading their infrastructure to better meet health care needs. So far, it says, it has had "virtually no" consultation with the province on the recommendations.

At the time of his death, Faqiri, who suffered from schizoaffective disorder a combination of schizophrenic and bipolar symptoms 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.

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.

• Deadly Restraint: The Fifth Estate investigates the jail death ofSoleimanFaqiri