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, a jail guardsent a note to some 60 corrections staff alerting them about his condition inside.

Still, he was never sent to a hospital or seen by a psychiatrist.

"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 from operational manager John Thompson said in part.

Faqiri died fivedays later on Dec. 15, 2016after being violently restrained by guards.

The email, sent to dozens of staff, was shown at the inquest into Faqiri's death on Monday.Jurors have previously heard Thompson was questioned abouttaking a swing at Faqiriwhile escorting him to his cell. That, and the fact that Faqiri was punched multiple times in the head, was left out of his own report.

Jurors alsoheard Monday from two senior officials at the Ministry of the Solicitor General, Linda Ogilvie and Tracey Gunton, about the internal review undertaken after his death at the Central East Correctional Centre in Lindsay, Ont., 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."

LISTEN | The latest on the inquest into the death of Soleiman Faqiri on The Current:

The Current17:56Inquest looks into the death of Soleiman Faqiri

In 2016, Soleiman Faqiri was being held at the Central East Correctional Centre in Lindsay, Ont., awaiting trial. But 11 days after he went into custody, Faqiri, who lived with schizophrenia, died in a violent confrontation with guards. An inquest into Soleiman Faqiri's death is underway. CBCs Shanifa Nasser walks us through the details.

Faqiri 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.

'Life-saving lessons' may not have been noticed for months, jury hears

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 thereif he could not be properly cared for at the facility.

"A nurse or even an operational manager could send him to hospital at any time, given that his decompensating behaviour did not not appear to be manageable in a correctional setting," a medical manager later said in the review.

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

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

11 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.

At the time of his death, Faqiri, who suffered from schizoaffective disorder a combination of schizophrenic and bipolar symptoms and was awaiting a medical evaluation at the Ontario Shores Centre for Mental Health Sciences. He hadbeen charged with aggravated assault, assault, and uttering threats following an altercation with a neighbour, buthad not been convicted of any crime.

He died 11 days after arrivingat the jail 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.

"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 Ogilvie.

"Fair," she responded.

No direct oversight into jails by ministry's health-care unit

At the time of Faqiri's death, Ogilvie told jurors,corporate health care had no direct oversight into the jails themselves and was staffed by only a three-person team. Nearly seven years on, the unit still does not directly oversee institutions when it comes to health care, she said.

Frontline health-care staff report to a health-care manager, but the chain of command then goes to non-health-care staff. The health-care manager reports to the jail's deputy superintendent, who reports to the superintendent with decisions on an inmate's care therefore left to administrators without a health-care background.

Ogilvie said the ministry is working to change that reporting structure, so that health-care managers report to provincial counterparts at head office, who report to an assistant deputy ministry with direct access to the minister of the solicitor general.

Jurors heard again about a fractured relationship between the jail and the nearby Ross Memorial Hospital in Kawartha Lakes. Since Faqiri's death, the ministry has struck a working group and developed a more positive relationship between the jail and hospital, said Gunton, a regional director with the ministry.At this point, however, there is no formal arrangement in place between the two.

In the absence of that, Roy asserted, there remains no way for someone in Faqiri's condition to get the care he would have needed.

"This is potentially life and death, for people like Mr. Faqiri to have access to care in a hospital when they're in an acute psychiatric emergency, right?" Roy asked.

"Correct," Gunton replied.

Jurors also heard jail staff have an obligation under ministry policy to report and intervene when excessive force is used.

A ministry spokesperson previously told CBC News that officials have been working closely with Ontario's coroner to review deaths in custody, and that the health and safety of inmates is "paramount."

Soleiman an 'anchor' whose death left family 'adrift'

The inquest, which began last Monday, is now in its second week and is expected to continue until Dec. 8.

On Friday, the Faqiri family delivered a statement,in which jurors heard not only about Faqiri's death, but about his life and what his loss has meant to his loved ones.

"For the last seven years, my family and I have had a deep, painful, hole right in the centre of our lives. Soleiman was an anchor for us that was taken away and left us adrift," the statement began. "His death has left us empty."

The family closed their statement by calling for the truth of what happened to Faqiri to come to light, and askingthe jury to make recommendations to prevent deaths like his from happening again.

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