Christian Hinkley

The Chief Inspector of the Crown Premises’ Fire Safety Inspectorate (“CPFSI”), , conducted an investigation and provided me with a report dated 30 September 2021. In that report he explained that:

• The cellular accommodation on Christian’s wing was served by an automatic “in-duct” fire detection system. Domestic smoke detectors were installed outside each cell and automatic fire detectors were located along the centre line of the ceiling in the corridor outside the cells.

• This arrangement could not reliably detect a cell fire within a known and predictable timescale from ignition or at a given point of fire development because: o The in-duct system is not designed to save life and is not regarded by HMPPS as a reliable fire detection system; and o The devices in the corridor rely on smoke exiting the cell which is variable and unpredictable because it depends on a number of factors (eg, size of gaps around the cell door, presence of service ducts in the cell, whether the window of the cell is open or not).

• The fire risk assessment for the houseblocks of this type at HMP Swaleside says that the current system “does not provide an acceptable permanent standard of fire detection.”

The Team Leader of the CPFSI investigation, , attended the inquest and gave live evidence. He told the me that:

• The Ministry of Justice (“MOJ”) conducted a test on the survivability of cell fires (in 2007) and concluded that: o Personal injury to a person in the cell would be expected within 6 minutes of ignition of the fire o Unconsciousness would be expected within 7 minutes of ignition o Death would be expected within 8 minutes of ignition

• In 2015 the CPFSI carried out an inspection at HMP Swaleside and concluded that the system in place there was not capable of detecting fires sufficiently early. A Notice was issued advising the prison to take action to address this problem.

• Four years later, in April 2019, the CPFSI carried out a further inspection at HMP Swaleside and concluded that the system in place at HMP Swaleside was still not capable of detecting fires sufficiently early. Yet again, a Notice was issued advising the prison to take action to address this problem.
• The only effective way to address this problem is to install in-cell automatic fire detectors.

• To date in-cell automatic fire detectors have not been installed at HMP Swaleside (or in most other prisons).

, the National Fire Lead at HM Prison and Probation Service (“HMPPS”) gave live evidence. He told the me that there is a plan to install in-cell automatic fire detection systems in all prisons in England and Wales. This programme is currently in the development stage. Given the enormity of the undertaking and the logistical challenges this will take some years to complete.

In answer to a number of written questions by me on this topic the MOJ told me that:

• “Fire safety systems are complex in nature and can take between two and three years to deliver at a single establishment. We currently are developing projects at 35 sites across the estate which we expect – with sustained funding – can be delivered within the next five to seven years. Accommodation which requires fire remedial work beyond this period will rely on availability of funding through the Spending Review process. The start date for construction works at HMP Swaleside is scheduled for December 2022.”

The Chief Inspector of the CPFSI has also advised me in writing on 4 November 2021 that:

• “Fire deaths in prison over the last decade have almost exclusively involved prisoners who are on or have recently been on an Assessment, Care in Custody Teamwork Programme or who have a history of barricading and fire-setting in prison or a conviction for arson, or all of these. This information is collected in prisons and is recognised as fire risk information by prison staff but they often cannot act on it to address the risk because there are no fire-safer cells (i.e. fitted with suitable in-cell automatic fire detection) in the wing (or in another wing at the prison) to which the prisoner can be moved.”

• “Every prison wing is already fitted with an automatic fire detection system for spaces other than for cells. Whilst it may not be technically possible to add fire detectors to every cell from the existing system, it may well be possible for in-cell fire detectors to be added to a small number of cells in each wing, and for prisoners on ACCT or with a history of barricading prison fire-setting and arson to be placed in those fire-safer cells. This should be considered by HMPPS and MoJ.”

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 to 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.