Anthony Ferris

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Independent investigation
into the death of
Mr Anthony Ferris,
a prisoner at HMP Haverigg,
on 18 September 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
3. On 28 March 2017, Mr Anthony Ferris was sentenced to 13 years in prison for
sexual offences. He died of end stage congestive heart failure and acute kidney
injury on 18 September 2024, at HMP Haverigg. He was 75 years old. We offer our
condolences to Mr Ferris’ family and friends.
4. The Ombudsman’s office wrote to Mr Ferris’ next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not
respond.
5. NHS England commissioned an independent clinical reviewer, to review Mr Ferris’
clinical care at Haverigg.
6. The clinical reviewer concluded that the clinical care Mr Ferris received at Haverigg
was predominantly equivalent to what he could have expected to receive in the
community. There was one area of care she found was not equivalent but noted this
was not related to his cause of death.
7. She found that Mr Ferris’ medical records contained evidence of good
communication and partnership working between healthcare and prison staff, and
appropriate monitoring and assessment processes were in place to manage Mr
Ferris’ condition. He was added to the complex case register which would have
positively impacted on care co-ordination.
8. The clinical reviewer made recommendations not related to Mr Ferris’ death that the
Head of Healthcare will wish to address.
9. The PPO investigator investigated the non-clinical issues relating to Mr Ferris’ care.
10. We did not find any non-clinical issues of concern. We make no recommendations.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Adrian Usher February 2025
Prisons and Probation Ombudsman
At the inquest held on 4 April 2025 the coroner concluded Mr Athony Ferris died of natural
causes.
Prisons and Probation Ombudsman 1
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE