A convicted murderer from Greater Manchester died of Covid just days after testing positive for the virus. The family of Trevor Ferguson questioned whether he didn't report his symptoms because of 'bullying' from other inmates in prison, a new report reveals.
Staff at HMP Garth 'heard' some prisoners hid signs of Covid 'so they would not be responsible for lockdown of the whole unit', said a fatal incident report now published by the Prisons and Probation Ombudsman (PPO), which carries out independent investigations into complaints and deaths in custody.
"To avoid detection, they sent other people to collect their meals," the report said. "This is the kind of dynamic that can exist between prisoners and does not strike us as implausible."
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It went on to say a wing officer recorded at the time Ferguson told her he had delayed reporting symptoms 'due to peer pressure'. The Category B prison in Lancashire has 'implemented a new policy' as a result, revealed the report, where staff conduct physical welfare checks on prisoners who fail to personally collect food.
"We are therefore satisfied that the prison addressed this issue promptly and make no further comment," said the PPO.
Ferguson from Sale, Trafford, was found guilty after trial in 2009 of the murder in north Wales of his ex-partner, Karen McGraw. Working at the time as a concrete layer, he stabbed the 50-year-old three times with a fish filleting knife in her garden as she tried to escape him. A court heard he couldn't accept their brief relationship was over.
They met over an internet dating site but Ms McGraw, a mother-of-four from Connah's Quay, north Wales, had called police after previous violence and domestic abuse, leading to criticism of North Wales Police for failing to do more for her. Ferguson, then of Gawsworth Road in Sale, was 49 when he was jailed. He denied murder, claiming the death of Ms McGraw was manslaughter on the grounds of diminished responsibility, but a jury found him guilty and he was jailed for a minimum of 17 years.
He died aged 60 from Covid pneumonia on December 9, 2020, while a prisoner.
The PPO investigation found Ferguson 'almost certainly' caught the virus at HMP Garth, but singled out the prison and its healthcare provider, the NHS, for a degree of criticism in the report. In response, the Prison Service told the Manchester Evening News prison staff have received 'additional emergency training' after concerns that an ambulance wasn't immediately requested in response to a medical emergency code issued after Ferguson was found in his cell.
The PPO said in its report an NHS England independent clinical reviewer commissioned to review the circumstances concluded his care at HMP Garth was just 'partly equivalent to that he could have expected to receive in the community'.
There were concerns over his clinical management after he contracted Covid as no care plan was in place, no clinical observations were taken and, despite his medical vulnerability, there were no healthcare checks between him reporting symptoms and his admission to hospital, added the report.
It also highlighted 'weaknesses in care' before Ferguson contracted the virus. "There is a lack of clarity as to whether Mr Ferguson had been assessed as vulnerable to complications from COVID-19 and offered the opportunity to shield," said the report.
"We were unable to resolve this and therefore cannot be satisfied that his risk was appropriately managed. We are also concerned that an ambulance was not requested immediately in response to a medical emergency code and information was not passed promptly to the Ambulance Service call handler."
A number of recommendations have been made, the report revealed. It said that due to Ferguson's 'long-term health conditions' he had been identified as being at 'high-risk' for Covid. He was also told by the prison governor of the risks and given advice but none of that information was in his records, together with no evidence of discussions about shielding.
Concerns about his health first surfaced on November 25, 2020, with a cough, sweating and shivering, but he 'had not reported this sooner due to pressure from other prisoners on his spur', the report said.
He was told to self-isolate in his cell and tested positive for Covid a day later. Staff on his wing completed welfare checks three times a day, but 'no further clinical checks were conducted'. On November 29, Ferguson was found in his cell short of breath and confused. He was taken to hospital but died on December 9.
"An entry in the wing observation book on 25 November, noted that there were prisoners on every spur who had not reported symptoms of Covid-19, for fear of a prison lockdown," added the report. "Previous entries also had brief references to peer pressure, aggression, agitation and threats to staff from several prisoners about the prospect of a lockdown."
"Given the discrepancy between the personal and medical records, we are not satisfied that Mr Ferguson's risk was managed appropriately, although we recognise that the differences might be due to inadequate record keeping," said the report. "During the pandemic, prison managers at Garth introduced two additional welfare checks, so each prisoner was checked in the morning, after lunch and during evening lock-up.
"Our investigation found that healthcare staff did not put in place a care plan to manage Mr Ferguson's health needs after he contracted Covid-19. We were told this was an oversight. Additionally, no monitoring or clinical observations were completed in the four days between his positive test and admission to hospital. We are concerned that as a patient at high risk of complications from Covid-19, Mr Ferguson received no clinical monitoring of his symptoms."
It also found 'there was a considerable delay in both calling an ambulance and providing details of the emergency', but that didn't 'affect the outcome' for Ferguson.
A Prison Service spokesperson said: "We have implemented all of the Ombudsman's recommendations and staff at HMP Garth have received additional emergency training."
Public Health England predicted up to 2,700 prisoners could die from Covid. There have been 157 Covid-related prisoner deaths to date. The Manchester Evening News has contacted the NHS for comment on the clinical findings of the report.
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