Clare Louise Dupree · Prevention of Future Deaths report

On 17ᵗʰ January 2023 I commenced an investigation into the death of Clare Louise Dupree. The investigation concluded at the end of the inquest 17ᵗʰ March 2026. The conclusion of the inquest, held before a jury, was a narrative.

Box 3 on the jury Record of Inquest stated…

“On the 26th December 2022 Clare Louise Dupree suffered sustained inhalation of smoke in Cell 59, Residential Unit 6, at HMP Eastwood Park. The lack of Automatic in-cell Fire Detection (AFD) caused a delay in detecting the fire, which resulted in her death on 28th December 2022.”

Of relevance to this report Box 4 on the jury Record of inquest stated …
“…The use of DSDs (domestic smoke detectors) instead of AFDs (automatic fire detection) possibly contributed to Clare's death. The lack of AFD's caused a delay in alerting staff to the fire in Clare's cell … Clare died from sustained inhalation of smoke due to a delay in detection of fire as a result of arson.”

Clare was a 48 yrs old female and was taken into custody at Eastwood Park Prison on 19ᵗʰ November 2022, she had a history of poor mental health.

On 26ᵗʰ November 2022 there was a fire in her cell, caused by a vape, staff were alerted by the DSD outside of her cell. She was removed from the cell after the fire service arrived, was taken to Southmead Hospital where she died from:

1a) Hypoxic-ischaemic brain injury, lower respiratory tract infection and multi-organ failure
1b) Inhalation of products of combustion

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.