Two Ohio Nurses Suspended After Failing to Care for Dying Inmate

Nearly four months ago, Aaron Ferguson, 29, died while under the care of Lucas County Corrections Center in Toledo, Ohio. He was booked just after midnight on September 11th on charges of burglary and aggravated theft. 24 hours later, he was found unresponsive in his cell.

New details are emerging regarding Ferguson’s death in prison. Several employees of the Lucas County Sheriff’s Office are facing disciplinary actions, including two nurses who denied care to the inmate when he needed it most, leaving his loved ones to wonder whether this tragedy could have been avoided.

The Night of the Arrest

Officials have been reviewing evidence to find out exactly what happened to Ferguson while he was in the facility. In the body camera footage of his arrest, he tells the arresting officers that he has been losing his bowels. As they transported him to the Lucas County Corrections Center, he can also be heard saying that he couldn’t breathe and that he needed water.

According to the sheriff’s office report, when Ferguson arrived at the corrections center, Nurse Denise Luettke asked him a few questions before clearing him to be booked. During this exchange, Ferguson reportedly told the nurse that he had recently been exposed to someone with COVID-19. He also told her that he had used heroin and fentanyl a day or two previously.

Luettke put the inmate on a COVID-19 precaution, while adding the note to his medical intake form “Pt. (Patient) reluctant to answer any questions related to using a large amt (amount) of heroin/fentanyl “yesterday,” and it made Pt. very tired.)”

She also noted that Ferguson defecated and urinated on himself and that he was having trouble keeping his eyes open.

Once he was in his cell, Corrections Officer Ishmael Shine observed that his breathing sounded abnormal, yet he never reached for the emergency button or called for help.

Shine told Luettke that Ferguson “looked dead” and asked her to check on him in his cell.

According to the report, “Nurse Luettke replies, ‘He (Ferguson) didn’t look good sitting there. I mean, whether it’s Fentanyl or whatever he had is making him sleepy.’”

“Shine then says, ‘He is breathing really fast.’”

“Nurse Luettke then asks, ‘Does he have water?’”

“Shine states, ‘No, should I give him some?’”

“Nurse Luettke answers, ‘Yes, because he may be dehydrated,'” the report read.

Five hours after he was arrested, the medical records show Luettke gave Ferguson some Tylenol and water. He also had to change out of his prison uniform several times because he kept urinating on himself. Around 7 PM the next day, he was transferred to a different cell.

Close to 9 PM, Corrections Officer Kimyatta Owensby called the nurses station saying Ferguson needed help.

This time, Nurse Tammy Willoughby answered the call. According to the report, she outright denied Owensby’s request for help, adding that “medical staff had seen Ferguson earlier and he wasn’t complaining about anything.”

About 45 minutes later, Owensby called for medical back-up. Nurse Jenifer Upperco responded and performed CPR on Ferguson, who appeared unresponsive. Toledo Fire and Rescue Department crews quickly responded, as well. They performed another round of CPR and medical aid before transferring the inmate to a local hospital, where he later died.

What Went Wrong?

An internal affairs investigation is putting the blame on both nurses on staff that day.

• Nurse Denise Luettke

For Nurse Luettke, officials agree that she should’ve gone and checked on Ferguson when Corrections Officer Shine first reported that he was having trouble breathing.

In her defense, Luettke says she initially associated his condition with COVID-19, but then went on to say she thought it was related to his gastrointestinal discomfort.

When asked, “Is it important that anytime an inmate or anyone in this corrections center complains about not being able to breathe to check on them?” Luettke answered, “Absolutely.”

Upon reviewing the evidence, Director of Medical Services Anissa Floure says the fact that Ferguson came in complaining of shortness of breath and that he had recently used drugs should have been a red flag that he needed additional medical attention.

The official report concludes, “In summary, Nurse Denise Luettke’s failure to act when asked to do so by C/O Shine, is clearly supported by the evidence presented. The evidence presented exceeds the standard of preponderance of the evidence.”

• Nurse Tammy Willoughby

As for Nurse Willoughby, the report also found that she should have checked on Ferguson when Corrections Officer Owensby asked her to do so.

All the nurses interviewed were asked the same question: “Is it important, even though you have checked on an inmate’s breathing complaint, that if the same inmate complains later about a difficulty with breathing, is it imperative to check on them again?” To which they all answered, yes.

“Eighty-four minutes after C/O Owensby called the Nurse station and spoke with Nurse Tammy Willoughby, Mr. Ferguson was found unresponsive in his cell,” the report reads.

Overall, several calls were made to the nurses’ station regarding Ferguson’s condition, and nearly all of them went unanswered.

Both nurses have been placed on unpaid leave for 45 days.