Colin Cambray

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Colin Cambray,
a prisoner at HMP Haverigg,
on 19 January 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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© Crown copyright, 2024
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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. In October 2020, Mr Colin Cambray received an extended determinate sentence of
nine years for sexual offences. He died from a hypoxic brain injury on 19 January
2024, while a prisoner at HMP Haverigg. This was caused by a cardiac arrest which
was in turn caused by spontaneous pneumothorax (the presence of air or gas in the
cavity between the lungs and chest wall). He was 55 years old. We offer our
condolences to Mr Cambray’s family and friends.
4. The Ombudsman’s office wrote to Mr Cambray’s next of kin, his wife, to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond to our letter.
5. NHS England commissioned an independent clinical reviewer to review Mr
Cambray’s clinical care at Haverigg.
6. The clinical reviewer concluded that the clinical care Mr Cambray received at
Haverigg was of a good standard and equivalent to that which he could have
expected to receive in the community. She found that appropriate reviews were
held when Mr Cambray’s physical health deteriorated, staff responded appropriately
to the emergency code and transferred him to hospital when it was clinically
indicated. The clinical reviewer made no recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Cambray’s
care. We did not find any significant non-clinical issues of concern related to his
death and we make no recommendations.
Governor to note
8. Prison staff did not activate their body-worn cameras when the general alarm
sounded on 2 January 2024, as required by Haverigg’s local policy.
Good practice
9. The family liaison log for Mr Cambray was detailed, and the Governor approved a
one-off payment to help his family with travel costs to visit him in hospital.
10. Haverigg provided the information needed for this case, including 15 detailed staff
statements, in a timely and organised manner.
Prisons and Probation Ombudsman 1
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11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
12. At the inquest held on the 2 July 2024, the coroner concluded that Mr Cambray died
of natural causes.
Adrian Usher June 2024
Prisons and Probation Ombudsman
2 Prisons and Probation Ombudsman
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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
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