John Chambers

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Independent investigation into
the death of Mr John Chambers,
a prisoner at HMP Hull,
on 17 June 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, 2024
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. Mr John Chambers was recalled to prison in January 2021. He had previously been
sentenced to life imprisonment for sexual offences and served 14 years. He died of
cancer on 17 June 2024, at HMP Hull. He was 70 years old. We offer our
condolences to those who knew him.
4. Mr Chambers had no nominated next of kin, so the Ombudsman’s office did not
contact anyone about this investigation.
5. The PPO investigator investigated the non-clinical issues relating to Mr Chambers’
care. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Mr
Chambers’ clinical care at HMP Hull.
7. The clinical reviewer concluded that the care Mr Chambers received at Hull was
variable. Some aspects of care were equivalent to that which he could have
expected to receive in the community and some not. The clinical reviewer found
that Mr Chambers’ unexplained weight loss was not escalated to a GP to assess
whether a referral to specialists was needed. The clinical reviewer made five other
recommendations on issues not directly related to Mr Chambers’ death, which the
Head of Healthcare will wish to address. We recommend:
The Head of Healthcare should ensure that the healthcare team adhere to
NICE guideline: Suspected cancer: recognition and referral, by escalating
changes in a patient’s weight to the GP who can then decide on the most
appropriate plan of care.
8. We shared our initial report with HMPPS and with the prison’s healthcare provider,
Spectrum Community Health CIC. They found no factual inaccuracies. Spectrum
Community Health CIC provided an action plan which is annexed to this report.
Adrian Usher
Prisons and Probation Ombudsman September 2024
The inquest, held on 13 December 2024, concluded that Mr Chambers died from
natural causes.
Prisons and Probation Ombudsman 1
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OFFICIAL - FOR PUBLIC RELEASE
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