18 Mar 2026 Clare Louise Dupree · Prevention of Future Deaths report Avon
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Concerns raised 1
Failure to provide in-cell automatic fire detection across parts of the prison estate View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Clare Louise Dupree · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Clare Louise Dupree, aged 48, was taken into custody at HMP Eastwood Park and suffered smoke inhalation after a fire in her cell. The jury concluded that the lack of automatic in-cell fire detection delayed detection of the fire and resulted in her death; the use of external domestic smoke detectors possibly contributed to her death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide in-cell automatic fire detection across parts of the prison estate
Wider context from the report “At the start of the inquest the MOJ made an admission it said …
1. “The Ministry of Justice has determined that in-cell automatic fire detection (AFD) is necessary to minimise the risk of harm from fires.
2. As at 26ᵗʰ December 2022, cell 59 on Residential 6 was not and is not currently equipped with in-cell AFD
3. For those cells which do not have in-cell AFD, battery powered standalone domestic smoke detectors (DSD’s) are in place outside cell doors, including cell 59 on Residential 6. This was the position as at 26ᵗʰ December 2022. The use of DSD’s as a mitigatory measure was agreed in 2015, in consultation with the Crown Premises Fire Safety Inspectorate. The Ministry of Justice acknowledges that the use of DSD’s in this way is a less effective way of minimising fire risks than in-cell AFD but has adopted them after thorough consideration as being the most effective available means of reducing risk as far as practicable until the installation of in-cell AFD can be completed “
During the inquest evidence was heard from ████████ from HMPPS - that in cell AFD's are now planned for Eastwood Park with a start date of June 2026 . I also heard about the position in relation to the prioritisation list for others in the prison estate. That said I also heard the frustration of ████████ from the CPFSI about the time this is taking to implement .
The matter of concern therefore … that in cell AFD is still to be implemented/completed at EWP prison and in addition a number of prisons across the prison estate. That the current use of DSD's only seek to mitigate the risks from an in-cell fire.
” Source location Clare Louise Dupree · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the national programme installing in-cell automatic fire detection across prison cells, using phased and, where appropriate, AFD-first delivery.
Verbatim wording from the response “HMPPS’ national position is that in-cell AFD is necessary to minimise the risk of harm from fire and should be installed within all prison cells. A national resourced programme of work is in place to deliver this, and substantial progress has already been made, with more than 40,000 prison places equipped with in-cell AFD since 2009.” Source location Response from HM Prison & Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver Eastwood Park’s fire safety improvement programme, including in-cell automatic fire detection, smoke ventilation, fire compartmentation and fire-door upgrades.
Verbatim wording from the response “At HMP Eastwood Park, a full programme of Fire Safety Improvement works has been developed which includes the installation of in-cell AFD alongside wider upgrades to smoke ventilation, fire compartmentation and fire doors. The project has progressed through business case approval and procurement and is currently in its pre-construction phase. Works on site are scheduled to commence in June 2026, with completion expected in Winter 2028. The pace of delivery at this site, as elsewhere, is constrained by the need to safely decant prisoners, with capacity limitations in the women’s estate further restricting the scale and speed of the works.” Source location Response from HM Prison & Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain interim fire detection and physical airflow mitigations in cells without in-cell automatic fire detection.
Verbatim wording from the response “We recognise that risk remains while this estate wide programme is ongoing and HMPPS has therefore taken a number of steps to minimise that risk across the estate. In all cells where in-cell AFD has not yet been installed, battery-powered Smoke Detectors are positioned immediately outside the cell door, which is a mitigatory measure agreed in consultation with CPFSI. Physical mitigations have also been carried out such as ensuring there is sufficient airflow around cell doors to enable smoke to reach the detector in the event of a fire. While we acknowledge that these systems are far from perfect, they provide coverage across the estate during the transition period and have detected over 1,200 fires since their introduction.” Source location Response from HM Prison & Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver approximately 600 additional automatic-fire-detection-protected cells for the highest-risk fire setters across the prison estate.
Verbatim wording from the response “Mini - Fire Safety Improvement (FSI)” Source location Response from HM Prison & Probation Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prison capacity and decanting requirements prevent simultaneous or faster installation of in-cell automatic fire detection across the estate.
Verbatim wording from the response “The implementation of this programme presents significant practical challenges. Installing AFD within prison cells is not a straightforward equipment upgrade; it involves complex infrastructure works, particularly in older custodial buildings. It requires cells and adjacent areas to be decanted for sustained periods, alongside enabling works, construction activity, and subsequent reinstatement. These works cannot be undertaken safely without decanting prisoners, and the prison estate is currently operating close to full capacity. As a result, only a limited number of cells can be taken out of use at any given time, which requires a phased and sequential approach to delivery rather than simultaneous installation across multiple sites. The guiding principle is to do the works as quickly as possible taking out as much capacity as the system can safely spare.” Source location Response from HM Prison & Probation Service
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Concerns raised 3
Failure to keep aspirating fire detection system fault buzzers operational View source Failure to protect aspirating fire detection system control panels from deliberate tampering View source Lack of central oversight of aspirating fire detection system faults View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 14
Action
Complete 19 of the 26 fire-safety actions identified in the strategic action plan.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 October 2025. View source
Action
Install a replacement fire panel after discovering that the existing panel had been tampered with.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 October 2025. View source
Action
Issue a national instruction requiring prison maintenance teams to keep fire-safety equipment efficient and fully operational.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 October 2025. View source
Action
Use maintenance-response data to assure that fire-panel fault alerts are unsilenced and remaining issues are rectified.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025. View source
Action
Introduce a daily morning-meeting feedback system for discussing and reporting fire faults and tracking follow-up.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 October 2025. View source
Action
Conduct post-fire visits and inspections to identify fire safety and management failures at HMP Stocken.
Stated by Crown Premises Fire Safety InspectorateStated completedThe respondent said that this action was complete when they made their response on 9 October 2025. View source
Action
Serve enforcement action-plan notices on responsible duty holders addressing fire alarm faults, detector tampering, training, drills, maintenance, monitoring and spare components.
Stated by Crown Premises Fire Safety InspectorateStated completedThe respondent said that this action was complete when they made their response on 9 October 2025. View source
Action
Monitor compliance with served notices and conduct a follow-up visit to HMP Stocken in January 2026.
Stated by Crown Premises Fire Safety InspectorateStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025. View source
Action
Create and use a revised inspection aide memoire specifying detailed checks of fire detection, warning, maintenance and anti-tampering arrangements in prison residential wings.
Stated by Crown Premises Fire Safety InspectorateStated completedThe respondent said that this action was complete when they made their response on 9 October 2025. View source
Action
Restrict access to fire-alarm-panel keys to authorised maintenance and health-and-safety personnel.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025. View source
Action
Commission fact-finding investigations into possible staff involvement in fire-equipment tampering.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 October 2025. View source
Action
Mandate that tampering with fire equipment is a disciplinary offence and will be investigated.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 October 2025. View source
Action
Communicate staff fire-safety responsibilities, reporting requirements and disciplinary consequences through meetings, blogs, briefings and senior-team correspondence.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 October 2025. View source
Action
Replace fire-alarm systems on I and K wings and the Care and Separation Unit, with networking to the Control Room.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025. View source See 11 more actions
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AI-generated summary
Richard Charles HUNT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Charles HUNT was a serving prisoner at HMP Stocken who set fire to his cell on 11 July 2025, was taken to hospital, and died later that day from smoke inhalation. The report raises concerns that the aspirating fire detection system’s buzzer failed to sound because it had been deliberately disabled or tampered with, and that similar issues were found across the prison estate without central oversight of faults.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to keep aspirating fire detection system fault buzzers operational
Wider context from the report “On both occasions prior to setting fire to his cell, ████████ it is designed to trigger an alarm on a control panel which is housed in the Wing Office situated on each wing. The triggering of that alarm should not only display a light but also sound a buzzer to alert staff of a fault.
On the 19th March when Mr Hunt set fire to his cell on K Wing and on 11th July when he set fire to his cell on I Wing this buzzer did not sound.
On 19th March 2025, Mr Hunt himself raised the alarm by sounding his cell bell and was discovered. He required CPR and was hospitalised for 3 days. The aspirating fire alarm system did not sound an alarm in the K Wing office.
On 11th July the detection of Mr Hunt having set fire to his cell was fortuitous as an OSG was conducting an ACCT check on another prisoner in a nearby cell and smelt smoke. The alarm indication of a fault had been triggered 2 hours before this discovery and Mr Hunt’s cell had been smouldering for around this period of time undetected. Again, no buzzer was sounded.
Following the fire on the 19th March 2025, investigation revealed that the aspirating fire detection system buzzer with the Wing Office had been ‘disabled’ and it was believed to have been deliberately silenced for 12 months prior to the incident.
Following the fire and Mr Hunt’s death on the 11th July 2025, the aspirating fire detection system was inspected and reviewed across the HMP Stocken Estate by ADT alarms, who are contracted to maintain the system. That inspection revealed that the reason the alarm on I wing, which was triggered but did not sound the buzzer, was because the control panel in the Wing Office (and in which the buzzer was housed) had been deliberately tampered with, by the insertion of a rubber glove between the connectors thereby disabling the buzzer.
Further inspection of the aspirating fire detection system panels across the HMP Stocken Estate found for example the control panel on L Wing had been vandalised ████████ and that control panel units in other Wings including segregation had been deliberately forced open to gain access.
I further understand that the aspirating fire detection system panels on the Wings do not link with the main Control Room, meaning there is no central oversight of faults (whether deliberate coverd or indicating a fire) for action to be immediately taken.
Whilst HMP Stocken may have a system of maintenance of the aspirating fire detection system within the prison, that maintenance system is futile if staff are going to deliberately tamper with that system to disable the buzzer which is designed to alert them as to risk. This is not an isolated occurrence and is systemic across the HMP Stocken Estate.
” Source location Richard Charles HUNT · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to protect aspirating fire detection system control panels from deliberate tampering
Wider context from the report “On both occasions prior to setting fire to his cell, ████████ it is designed to trigger an alarm on a control panel which is housed in the Wing Office situated on each wing. The triggering of that alarm should not only display a light but also sound a buzzer to alert staff of a fault.
On the 19th March when Mr Hunt set fire to his cell on K Wing and on 11th July when he set fire to his cell on I Wing this buzzer did not sound.
On 19th March 2025, Mr Hunt himself raised the alarm by sounding his cell bell and was discovered. He required CPR and was hospitalised for 3 days. The aspirating fire alarm system did not sound an alarm in the K Wing office.
On 11th July the detection of Mr Hunt having set fire to his cell was fortuitous as an OSG was conducting an ACCT check on another prisoner in a nearby cell and smelt smoke. The alarm indication of a fault had been triggered 2 hours before this discovery and Mr Hunt’s cell had been smouldering for around this period of time undetected. Again, no buzzer was sounded.
Following the fire on the 19th March 2025, investigation revealed that the aspirating fire detection system buzzer with the Wing Office had been ‘disabled’ and it was believed to have been deliberately silenced for 12 months prior to the incident.
Following the fire and Mr Hunt’s death on the 11th July 2025, the aspirating fire detection system was inspected and reviewed across the HMP Stocken Estate by ADT alarms, who are contracted to maintain the system. That inspection revealed that the reason the alarm on I wing, which was triggered but did not sound the buzzer, was because the control panel in the Wing Office (and in which the buzzer was housed) had been deliberately tampered with, by the insertion of a rubber glove between the connectors thereby disabling the buzzer.
Further inspection of the aspirating fire detection system panels across the HMP Stocken Estate found for example the control panel on L Wing had been vandalised ████████ and that control panel units in other Wings including segregation had been deliberately forced open to gain access.
I further understand that the aspirating fire detection system panels on the Wings do not link with the main Control Room, meaning there is no central oversight of faults (whether deliberate coverd or indicating a fire) for action to be immediately taken.
Whilst HMP Stocken may have a system of maintenance of the aspirating fire detection system within the prison, that maintenance system is futile if staff are going to deliberately tamper with that system to disable the buzzer which is designed to alert them as to risk. This is not an isolated occurrence and is systemic across the HMP Stocken Estate.
” Source location Richard Charles HUNT · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of central oversight of aspirating fire detection system faults
Wider context from the report “On both occasions prior to setting fire to his cell, ████████ it is designed to trigger an alarm on a control panel which is housed in the Wing Office situated on each wing. The triggering of that alarm should not only display a light but also sound a buzzer to alert staff of a fault.
On the 19th March when Mr Hunt set fire to his cell on K Wing and on 11th July when he set fire to his cell on I Wing this buzzer did not sound.
On 19th March 2025, Mr Hunt himself raised the alarm by sounding his cell bell and was discovered. He required CPR and was hospitalised for 3 days. The aspirating fire alarm system did not sound an alarm in the K Wing office.
On 11th July the detection of Mr Hunt having set fire to his cell was fortuitous as an OSG was conducting an ACCT check on another prisoner in a nearby cell and smelt smoke. The alarm indication of a fault had been triggered 2 hours before this discovery and Mr Hunt’s cell had been smouldering for around this period of time undetected. Again, no buzzer was sounded.
Following the fire on the 19th March 2025, investigation revealed that the aspirating fire detection system buzzer with the Wing Office had been ‘disabled’ and it was believed to have been deliberately silenced for 12 months prior to the incident.
Following the fire and Mr Hunt’s death on the 11th July 2025, the aspirating fire detection system was inspected and reviewed across the HMP Stocken Estate by ADT alarms, who are contracted to maintain the system. That inspection revealed that the reason the alarm on I wing, which was triggered but did not sound the buzzer, was because the control panel in the Wing Office (and in which the buzzer was housed) had been deliberately tampered with, by the insertion of a rubber glove between the connectors thereby disabling the buzzer.
Further inspection of the aspirating fire detection system panels across the HMP Stocken Estate found for example the control panel on L Wing had been vandalised ████████ and that control panel units in other Wings including segregation had been deliberately forced open to gain access.
I further understand that the aspirating fire detection system panels on the Wings do not link with the main Control Room, meaning there is no central oversight of faults (whether deliberate coverd or indicating a fire) for action to be immediately taken.
Whilst HMP Stocken may have a system of maintenance of the aspirating fire detection system within the prison, that maintenance system is futile if staff are going to deliberately tamper with that system to disable the buzzer which is designed to alert them as to risk. This is not an isolated occurrence and is systemic across the HMP Stocken Estate.
” Source location Richard Charles HUNT · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete 19 of the 26 fire-safety actions identified in the strategic action plan.
Verbatim wording from the response “identified 26 actions including high level requests for changes to fire safety and detection systems as well as tasks for immediate actions such as replacing sounders on the fire alarm panels. To date, 19 of these actions have been completed with most of the remaining actions awaiting approval of spending bids.” Source location Response from HM Prison and Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install a replacement fire panel after discovering that the existing panel had been tampered with.
Verbatim wording from the response “Following Mr Hunt’s death and the discovery that the fire panel located in the wing office had been tampered with, preventing the buzzer from sounding, immediate action was taken and a replacement fire panel installed. The prison’s Health and Safety team was further tasked with undertaking a review of the physical security of the fire alarm panels, which found that the panels could be accessed, posing a significant risk to operational safety. Work is ongoing to rectify this issue, with access to fire alarm panel keys to be restricted to authorised personnel only - namely ADT (the fire alarm installer and maintainer), Amey, and Health & Safety advisors, preventing further unauthorised access and ensuring compliance with safety protocols.” Source location Response from HM Prison and Probation Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a national instruction requiring prison maintenance teams to keep fire-safety equipment efficient and fully operational.
Verbatim wording from the response “Nationally, in response to the March incident, on 3 April 2025 a Service Managers Instruction (SMI) was issued to all prison maintenance teams, reiterating their responsibility to ensure that all fire safety equipment is maintained in an efficient and fully operational condition. Data from responses to this instruction is being used to provide assurance that panels’ fault alerts are un silenced, and that action is being taken to rectify any remaining issues.” Source location Response from HM Prison and Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use maintenance-response data to assure that fire-panel fault alerts are unsilenced and remaining issues are rectified.
Verbatim wording from the response “Nationally, in response to the March incident, on 3 April 2025 a Service Managers Instruction (SMI) was issued to all prison maintenance teams, reiterating their responsibility to ensure that all fire safety equipment is maintained in an efficient and fully operational condition. Data from responses to this instruction is being used to provide assurance that panels’ fault alerts are un silenced, and that action is being taken to rectify any remaining issues.” Source location Response from HM Prison and Probation Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a daily morning-meeting feedback system for discussing and reporting fire faults and tracking follow-up.
Verbatim wording from the response “Locally, the Governor has introduced a daily feedback system into the morning meeting he chairs whereby all fire faults are discussed and reported. There is a specific focus on any alarms which are not sounding when in fault, and alarms which are continually sounding. This is to ensure that follow-up actions are completed where appropriate by prison staff and also that the maintenance provider is made aware of faults which require attention.” Source location Response from HM Prison and Probation Service
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct post-fire visits and inspections to identify fire safety and management failures at HMP Stocken.
Verbatim wording from the response “• Carry out an initial post fire visit to quickly gather vital information to establish and understand the facts of the fire event that occurred on 11th July 2025 in preparation for a post fire inspection.” Source location Response from The Crown Premises Fire & Safety Inspectorate
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Serve enforcement action-plan notices on responsible duty holders addressing fire alarm faults, detector tampering, training, drills, maintenance, monitoring and spare components.
Verbatim wording from the response “Following the post fire inspection on 16th July 2025, CPFSI took enforcement action by serving 28-day action plan notices to each of the Governing Governor, MOJ Property Service, Amey FM and HMPPS Director General Operations.” Source location Response from The Crown Premises Fire & Safety Inspectorate
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor compliance with served notices and conduct a follow-up visit to HMP Stocken in January 2026.
Verbatim wording from the response “CPFSI continues to monitor progress with the actions being taken to comply with each Notice served and intends to conduct a follow up visit to HMP Stocken during January 2026.” Source location Response from The Crown Premises Fire & Safety Inspectorate
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and use a revised inspection aide memoire specifying detailed checks of fire detection, warning, maintenance and anti-tampering arrangements in prison residential wings.
Verbatim wording from the response “CPFSI has reviewed its business processes for inspecting residential wings in prisons. Specifically, by creating a revised aide memoire which provides inspectors with specific, detailed lines of enquiry to confirm that fire detection and warning systems can always provide effective detection performance. This is supported by: the provision of systems and components that are in accordance with the recommendations of relevant British Standards and expectations of MOJs own Technical Specifications; robust day-to-day management systems to deter tampering with life safety equipment and monitoring arrangements which ensure that specialist planned maintenance and remedial works are completed in a competent and timely fashion.” Source location Response from The Crown Premises Fire & Safety Inspectorate
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Restrict access to fire-alarm-panel keys to authorised maintenance and health-and-safety personnel.
Verbatim wording from the response “Following Mr Hunt’s death and the discovery that the fire panel located in the wing office had been tampered with, preventing the buzzer from sounding, immediate action was taken and a replacement fire panel installed. The prison’s Health and Safety team was further tasked with undertaking a review of the physical security of the fire alarm panels, which found that the panels could be accessed, posing a significant risk to operational safety. Work is ongoing to rectify this issue, with access to fire alarm panel keys to be restricted to authorised personnel only - namely ADT (the fire alarm installer and maintainer), Amey, and Health & Safety advisors, preventing further unauthorised access and ensuring compliance with safety protocols.” Source location Response from HM Prison and Probation Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission fact-finding investigations into possible staff involvement in fire-equipment tampering.
Verbatim wording from the response “Following the concerns regarding the tampering of fire alarm control panels the Governor of HMP Stocken commissioned two fact-finding investigations to determine if staff may have been involved with the tampering of fire safety equipment, and if so whether those staff could be identified. While it has not been possible to identify any individuals, the Governor has made clear to staff the seriousness of such action, and that anyone engaging in any tampering of the fire alarm system will be subject to formal disciplinary action.” Source location Response from HM Prison and Probation Service
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandate that tampering with fire equipment is a disciplinary offence and will be investigated.
Verbatim wording from the response “On 15 August 2025 a Governor’s Order was issued mandating that tampering with fire equipment is a disciplinary offence and will be investigated. This has been reiterated at a face to face, full staff meeting on 24th September 2025, in weekly blogs and in briefings to staff issued in April, July and August 2025. These set out clearly staff’s personal responsibility for fire safety, reminding staff of the need to ensure they understand the equipment in place and to report all faults and issues immediately, signposting how this is done and where support can be sought from. The Governor has also met with and written to the senior team outlining their responsibilities within their functions with regards to fire safety.” Source location Response from HM Prison and Probation Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate staff fire-safety responsibilities, reporting requirements and disciplinary consequences through meetings, blogs, briefings and senior-team correspondence.
Verbatim wording from the response “Following the concerns regarding the tampering of fire alarm control panels the Governor of HMP Stocken commissioned two fact-finding investigations to determine if staff may have been involved with the tampering of fire safety equipment, and if so whether those staff could be identified. While it has not been possible to identify any individuals, the Governor has made clear to staff the seriousness of such action, and that anyone engaging in any tampering of the fire alarm system will be subject to formal disciplinary action.” Source location Response from HM Prison and Probation Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace fire-alarm systems on I and K wings and the Care and Separation Unit, with networking to the Control Room.
Verbatim wording from the response “In regards to your concern regarding the link between the fault panels on the wings and the main Control Room, in November 2025 Ministry of Justice Property Directorate issued a mandate for the full replacement of the fire alarm systems on I and K wings and the Care and Separation Unit, with full networking back to the Control Room master fire alarm panel to allow any alarms or faults raised by the local fire alarm control panels on those wings to be visible in the Control Room. This is currently in the design and tendering stage with the intention that it will be rolled out as soon as practicable.” Source location Response from HM Prison and Probation Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Crown bodies cannot be prosecuted under the Fire Safety Order, although enforcement notices remain available where continued non-compliance creates significant safety risks.
Verbatim wording from the response “Crown bodies must comply with the provisions of the Order**, but they cannot be subject to prosecution**. Non-Crown Responsible Persons and others with duties under the Order in Crown premises can be prosecuted.” Source location Response from The Crown Premises Fire & Safety Inspectorate
Open published response
4 Nov 2021 Christian Gary HINKLEY · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 2
Lack of fire-safer cells for prisoners at increased risk of in-cell fire View source Failure of prison fire detection systems to reliably detect in-cell fires within a life-saving timescale View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christian Gary HINKLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christian Gary Hinkley, a prisoner at HMP Swaleside, died from smoke inhalation after a fire developed in his barricaded cell during the night of 28–29 July 2019. The report raises concerns that prison fire detection systems could not reliably detect cell fires early enough to allow life-saving action, particularly for prisoners at increased risk, and that installing in-cell detectors across prisons could take years.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of fire-safer cells for prisoners at increased risk of in-cell fire
Wider context from the report “I am concerned that:
(a) The system of fire detection in HM Prisons is currently inadequate and unsafe. This evidence came from MOJ and CPFSI witnesses and was undisputed.
(b) Whilst there is a plan to install in-cell automatic fire detectors in all prison cells the MOJ estimates that this may take up to 7 years to complete in 35 prisons across England and Wales (and perhaps longer for others).
(c) From the MOJ’s own study in 2007 it is expected that a prisoner in a cell will die within 8 minutes of ignition of an in-cell fire.
(d) There is no reasonable prospect of local Fire & Rescue Service firefighters attending the cell with breathing apparatus and firefighting equipment within that timescale.
(e) As it stands, and until in-cell fire detectors are installed at prisons, there is a significant risk of death from in-cell fires because the current fire detection systems cannot reliably detect a fire within a timescale that will enable life-saving steps to be taken in time.
(f) That risk is further increased for prisoners with a history of suicide/self-harm, barricading and/or arson.
(g) The Chief Inspector of the CPFSI tells us that simple measures could be taken to reduce the risk of death by fire in prison, namely adding in-cell fire detectors to a small number of cells in each wing for prisoners (a) on an ACCT, (b) with a history of barricading, (c) with a history of prison fire-setting or (d) with a history of arson, and placing such prisoners in those fire-safer cells.
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by cell fires in prisons (as an interim measure before in-cell detection systems are installed across the prison estate). In particular, the suggestion of the Chief Inspector of the CPFSI – highlighted in bold above – should be considered carefully.
” Source location Christian Gary HINKLEY · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of prison fire detection systems to reliably detect in-cell fires within a life-saving timescale
Wider context from the report “I am concerned that:
(a) The system of fire detection in HM Prisons is currently inadequate and unsafe . This evidence came from MOJ and CPFSI witnesses and was undisputed.
(b) Whilst there is a plan to install in-cell automatic fire detectors in all prison cells the MOJ estimates that this may take up to 7 years to complete in 35 prisons across England and Wales (and perhaps longer for others) .
(c) From the MOJ’s own study in 2007 it is expected that a prisoner in a cell will die within 8 minutes of ignition of an in-cell fire.
(d) There is no reasonable prospect of local Fire & Rescue Service firefighters attending the cell with breathing apparatus and firefighting equipment within that timescale.
(e) As it stands, and until in-cell fire detectors are installed at prisons, there is a significant risk of death from in-cell fires because the current fire detection systems cannot reliably detect a fire within a timescale that will enable life-saving steps to be taken in time .
(f) That risk is further increased for prisoners with a history of suicide/self-harm, barricading and/or arson.
(g) The Chief Inspector of the CPFSI tells us that simple measures could be taken to reduce the risk of death by fire in prison, namely adding in-cell fire detectors to a small number of cells in each wing for prisoners (a) on an ACCT, (b) with a history of barricading, (c) with a history of prison fire-setting or (d) with a history of arson, and placing such prisoners in those fire-safer cells.
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by cell fires in prisons (as an interim measure before in-cell detection systems are installed across the prison estate). In particular, the suggestion of the Chief Inspector of the CPFSI – highlighted in bold above – should be considered carefully.
” Source location Christian Gary HINKLEY · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the national fire safety improvement programme, including rollout of in-cell fire detection systems across the prison estate.
Verbatim wording from the response “Her Majesty’s Prison and Probation Service (HMPPS) is committed to fire safety and ensuring that all prison accommodation complies with modern fire safety standards, this is currently being improved through an ambitious national fire safety improvement programme. In 2015/16 HMPPS committed to the Crown Premises Fire Safety Inspectorate that at least 15% of the annual capital maintenance budget would be allocated to fire safety improvement works across the prison estate. We have honoured this commitment each year since and in 2021 the Government agreed to invest £315m into the prison estate in order to tackle the most pressing maintenance issues, including that of the introduction of in-cell fire detection systems.” Source location 2021-0376-Response-from-HMPPS_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commence the scheduled HMP Swaleside fire safety assessment, including installation of in-cell fire detection systems.
Verbatim wording from the response “There are currently fire safety improvement programmes underway at 35 sites across the prison estate. The work begins with a full assessment of each establishment, many of which require the installation of a full and updated fire detection system before the in-cell fire detectors can be installed. The start date for the fire safety assessment to commence at HMP Swaleside, which will include the installation of the in-cell detections, is currently scheduled to be in December 2022.” Source location 2021-0376-Response-from-HMPPS_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install stand-alone portable fire detection devices in cells without automatic fire detection systems.
Verbatim wording from the response “Stand-alone portable fire detection devices are currently installed for all cells that do not have the automatic fire detection systems, including at HMP Swaleside. These provide an interim fire detection solution, in accordance with the fire safety regulation requirements. All prisons across the estate have also been provided with an increased number of water mist firefighting equipment and portable smoke ventilation fans to assist smoke disbursement during fire incidents. Access to fire ignition sources will remain prohibited with electrical items removed from possession when found to have been tampered with.” Source location 2021-0376-Response-from-HMPPS_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Interim installation in selected cells is not feasible because it would be costly, complex and delay the overall fire safety programme.
Verbatim wording from the response “While it has been reviewed whether in-cell fire detectors could be added to a small number of cells for prisoners that pose a higher risk of self-harm, barricading and fire setting, as an interim measure, this is unfortunately not feasible. Given that a complete new fire system will be required in many prisons across the estate before the in cell detectors can be installed, the workmanship and equipment required to install even a small number of cells for each prison would be significant. The work would then have to resume at a later date to complete the remaining cells and this would be costly and would delay the completion of the overall fire safety improvement programme.” Source location 2021-0376-Response-from-HMPPS_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Earlier national installation cannot be completed because complexity, investment, resources, disruption and security constraints require five to seven years.
Verbatim wording from the response “The rollout of the automatic fire safety systems nationally relies on a sustained level of investment and on the availability of resources to ensure that there is minimal disruption to the prison regimes. Fire safety systems are costly and complex to install and there can be delays in these works due to important measures to maintain the safety of staff and prison residents and also to maintain the overall security of the prison. It can therefore take a number of years to install the full system at a single establishment. Given the number of prisons nationally that require this work and the challenges in doing this, the overall” Source location 2021-0376-Response-from-HMPPS_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing interim fire measures, including portable detection devices, firefighting equipment, inspections and staff training, address risks pending automatic systems.
Verbatim wording from the response “For the prisons where the in-cell fire detection systems are not yet installed, there are a number of interim safety measures in place to reduce the risks of cell fires. In April 2021, annual risk based inspection programmes were introduced which are conducted by the HMPPS National Fire Safety Team who review fire safety measures in each prison. This includes reviewing the provision of fire safety equipment, staff training and compliance and the Arson Reduction Strategy of each prison to identify any fire safety risks and any protective measures that may be required to address those risks.” Source location 2021-0376-Response-from-HMPPS_Published
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Includes failures in prison fire-detection systems and their dedicated controls, including in-cell or external detection, alarm transmission, detection timing, interim mitigation and provision of fire-safer cells where these directly affect timely detection of in-cell fires.
