PFD report

Richard Charles HUNT · Prevention of Future Deaths report

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Issued 8 Oct 2025•Rutland and North Leicestershire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
16

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised3

  1. Failure to keep aspirating fire detection system fault buzzers operational
    Part of recurring concern: Failure of fire detection systems to reliably alert and trigger emergency responsePart of recurring concern: Unreliable prison fire detection systems
  2. Failure to protect aspirating fire detection system control panels from deliberate tampering
    Part of recurring concern: Failure of fire detection systems to reliably alert and trigger emergency responsePart of recurring concern: Unreliable prison fire detection systems
  3. Lack of central oversight of aspirating fire detection system faults
    Part of recurring concern: Failure of fire detection systems to reliably alert and trigger emergency responsePart of recurring concern: Unreliable prison fire detection systems
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 recipient says it has done, is doing, or plans to do in response to a concern raised.14

  1. 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.
  2. 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.
  3. 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.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Crown bodies cannot be prosecuted under the Fire Safety Order, although enforcement notices remain available where continued non-compliance creates significant safety risks.

    Stated by Crown Premises Fire Safety InspectorateUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Failure of fire detection systems to reliably alert and trigger emergency response; Unreliable prison fire detection systems.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Failure of fire detection systems to reliably alert and trigger emergency response; Unreliable prison fire detection systems.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Failure of fire detection systems to reliably alert and trigger emergency response; Unreliable prison fire detection systems.

Open source report

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
Page 3 · response
Published 9 October 2025

Open published response

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
Page 2 · response
Published 9 October 2025

Open published response

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

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
Page 2 · response
Published 9 October 2025

Open published response

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
Page 2 · response
Published 9 October 2025

Open published response

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
Page 2 · response
Published 9 October 2025

Open published response

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
Page 2 · response
Published 9 October 2025

Open published response

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

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
Page 2 · response
Published 9 October 2025

Open published response

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

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
Page 3 · response
Published 9 October 2025

Open published response

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
Page 3 · response
Published 9 October 2025

Open published response

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
Page 2 · response
Published 9 October 2025

Open published response

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
Page 6 · response
Published 9 October 2025

Open published response

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

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
Page 6 · response
Published 9 October 2025

Open published response

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
Page 4 · response
Published 9 October 2025

Open published response

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
Page 16 · response
Published 9 October 2025

Open published response

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
Page 16 · response
Published 9 October 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Provide fire-safety training to uniformed staff, with current coverage at 98%, and maintain up-to-date training for night-duty staff.

    Stated by HM Prison and Probation ServiceStatus at responseThe respondent said that this action was partly complete when they made their response on 9 October 2025.
  2. 2

    Continue applying consistent, transparent and risk-proportionate fire safety enforcement action.

    Stated by Crown Premises Fire Safety InspectorateStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing local fire safety arrangements are considered generally suitable and sufficient to identify risks and implement proportionate controls.

    Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Provide fire-safety training to uniformed staff, with current coverage at 98%, and maintain up-to-date training for night-duty staff.

Verbatim wording from the response

“In the aftermath of these devastating incidents, HMP Stocken fully recognise the responsibility to ensure that all staff are equipped with the necessary knowledge regarding fire safety and the regulations we are obligated to follow. Fire safety training for all uniform grades currently sits at 98% and all staff covering night duty have up to date training.”

Source location

Response from HM Prison and Probation Service
Page 3 · response
Published 9 October 2025

Open published response

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

Continue applying consistent, transparent and risk-proportionate fire safety enforcement action.

Verbatim wording from the response

“In accordance with its enforcement policy, CPFSI will continue to take consistent and transparent enforcement action which is proportional to the risk.”

Source location

Response from The Crown Premises Fire & Safety Inspectorate
Page 16 · response
Published 9 October 2025

Open published response

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

Existing local fire safety arrangements are considered generally suitable and sufficient to identify risks and implement proportionate controls.

Verbatim wording from the response

“A subsequent CPFSI inspection on 27 January 2026 returned a positive outcome, with the inspectorate judging the local fire safety arrangements to be “generally suitable and sufficient,” meaning the fire safety measures and management systems broadly meet legal requirements for identifying risks and implementing proportionate controls.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 9 October 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026