Source · Prevention of Future Deaths

Clare Dupree

Ref: 2026-0181 Date: 18 Mar 2026 Coroner: M Vision Area: Avon Responses identified: 1 / 2 View PDF

In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number of prisons in the wider prison estate; the current use of domestic smoke detectors only mitigates the risks from an in-cell fire.

Date 18 Mar 2026
56-day deadline 19 May 2026
Responses identified 1 of 2
State Custody related deaths

Coroner's concerns

AI summary
In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number of prisons in the wider prison estate; the current use of domestic smoke detectors only mitigates the risks from an in-cell fire.
View full coroner's concerns
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 HMPPPS - 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 is 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.

Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com

Responses

1 respondent
HM Prison Probation Service Central Government
18 Mar 2026 PDF
Action Taken

HMPPS fully accepts the importance of in-cell Automatic Fire Detection and has a national programme in place, with over 40,000 prison places already equipped since 2009. They are continuously seeking to accelerate programme delivery, including adopting an "AFD-first" approach in some prisons. (AI summary)

View full response
Dear Ms Voisin REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: Ms CLARE DUPREE Thank you for your Regulation 28 Report dated 18th March 2026 concerning the tragic death of Ms. Clare Louise Dupree at HMP Eastwood Park. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS). We would first like to express sincere condolences to Ms. Dupree’s family and have carefully considered the findings of the inquest and the concerns identified by the Court. We acknowledge the jury’s conclusion that delayed detection of the fire possibly contributed to Ms Dupree’s death. We also recognise the Coroner’s concern that the absence of in-cell Automatic Fire Detection (AFD) caused a delay in alerting staff to the fire, and that the use of battery-powered Smoke Detectors (DSD) located outside cells provides a less effective form of protection. HMPPS accepts that in-cell AFD represents the most effective means of detecting fires within prison cells and minimising the risk of harm. 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. 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.

[Page 2] Prisons are prioritised for fire safety works through a structured, risk-based national process that draws on multiple data sources. Fire Risk Assessments identify hazards and remedial actions, which are then consolidated into Prison Information Cards that assign risk scores to key safety factors at each site. These scores inform a national dataset and feed into a Fire Safety Improvement List, which ranks prisons according to overall risk and need. This enables HMPPS to plan and sequence works strategically across the estate, ensuring that the highest-risk sites and most critical issues are addressed first, whilst balancing practical constraints such as prison capacity, decant availability, and the complexity of delivering infrastructure works safely and efficiently. 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. 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. These arrangements are supported by a wider framework of controls designed to reduce risk as far as reasonably practicable. Fire Risk Assessments are conducted at least annually and inform a nationally coordinated prioritisation process for capital works. Operational measures, including staff training, emergency procedures and arson reduction strategies, are embedded across all establishments. Other examples of important developments, which are the result of HMPPS constantly exploring ways to accelerate works which achieve the maximum possible impact on fire safety risks in the shortest time, include: Tier 2 Fire Detection Devices A project to implement a new technology involving Integrated Smoke Detectors (ISDs). This is a custom project developed by HMPPS in collaboration with Hispec (a leading provider of life safety systems) to address the particular challenges with the installation of AFD in the estate. The challenge with the installation of AFD is that it requires cells to be vacated and the installation of infrastructure within the cell. ISDs, by contrast, can be installed outside of cells and rely on Wi-Fi to work, thereby avoiding the need for hard wiring. The ISD system operates so that where one ISD is triggered, that will be relayed to a remote control panel and all other alarms which are simultaneously triggered, so that staff are visually and audibly aware of an incident and then can quickly identify which ISD was originally activated. It is hoped that ISDs will reduce substantially one of the drawbacks of DSDs, namely that they are less likely to be heard by prison staff, thus reducing response times. ISDs have been trialled at one prison (HMP Wymott), and HMPPS intend to further evaluate the application of this technology through trials at HMP Whatton and The Mount. Following evaluation, HMP Eastwood Park is one of the prisons likely to have Tier 2 Integrated Smoke Detectors (ISDs) installed. This would be to cover areas where some prisoners who are

[Page 3] higher-risk fire-setters must be housed outside the areas already covered by AFD due to their specific needs. Mini - Fire Safety Improvement (FSI) Advanced AFD works which are delivering c.600 AFD protected cells dispersed across the prison estate to be able to accommodate the highest risk fire setters. This is an important step in risk reduction whilst awaiting the full rollout of AFD. Virtual Reality fire extinguisher training HMMPS have also developed a Virtual Reality (VR) fire extinguisher training solution, which has been endorsed by CPFSI. Delivered by in-house Health and Safety trainers, VR training offers a cost-effective method for ensuring that staff across the estate continue to be trained to the standard required by the Regulatory Reform (Fire Safety) Order 2005. These technologies have been promoted by CPFSI for a range of reasons including due to their flexibility in delivery to meet demand, because it allows for several virtual locations and scenarios to be included in the training (e.g. fire ground, different types of bespoke prison accommodation etc), it provides an immersive experience for learners and there is no clean-up of extinguisher content required. These VR training packages can also be designed to be bespoke to particular prisons. Fire reduction measures In addition to the steps taken around fire detection, HMPPS has been moving ahead with important fire risk reduction measures. These include the Moja Safer Vape Pen (SVP) project and trials of Arc Fault Detection Devices. (a) Safer Vape Pen (SVP) project Vape pens are permitted as prisoner possession items in prisons having been introduced as a smoking cessation aid following the introduction of the smoke-free prisons project in 2017. Currently, over 2 million vape capsules are sold to prisoners per month through the ‘prison canteen’. Fire setting in prisons has always been prevalent with ignition sources traditionally being cigarette lighters, but with the prohibition of smoking in prisons in 2020, the primary ignition source became the heated coil of the vape pen. Typically, the vape pen is dismantled to expose the coil with a taper wick placed against the heated element until ignition temperature is reached. The taper is then used to light larger objects or heat illicit chemical substances. Deliberate fires set using vape pens accounted for the majority of fires set each year. Given these fire risks, HMPPS launched an initiative in January 2025 to introduce a “safer” vape pen product in prisons with the aim of cutting the number of deliberate fires set. This has been a significant success and since its introduction, vape-related fires have declined by 92%, with zero incidents attributed to the Moja SVP device. Overall, fires have reduced by 46% across the prison estate during this period. (b) Arc Fault Detention Devices While the Safer Vape Pen project has been highly successful in reducing the overall number of fires across the prison estate, there has been an increase in electrically set fires during this period and steps have been taken to try and mitigate that new development. HMPPS is currently trialling new technology – Arc Fault Detection Devices (AFDDs) – to address this fire risk. AFDDs protect electrical circuits from arcing-related fire (i.e. fires which start when an electrical arc produces enough heat to ignite surrounding materials).

[Page 4] HMPPS is working with Electrium (an electrical installation manufacturer) to adjust the detection algorithm so that it can identify tampering-induced sparking by prisoners interfering with equipment. Early trials of standard AFDDs are underway at HMP Werrington and HMP Wetherby. This will be followed by trials of a new prison-specific AFDD variant. In summary, HMPPS continues to work at pace to take forward plans to bring all prisons into compliance as soon as possible, whilst also exploring – and where appropriate implementing – interim measures to mitigate risks whilst this takes place. The matters identified by the Coroner in this case reflect a broader challenge rather than an isolated deficiency at a single establishment. The response to that challenge is national in scope and carefully sequenced to ensure that the available capacity within the estate is used to deliver the greatest possible reduction in risk. HMPPS continually looks for ways to accelerate programme delivery. This includes adopting a different approach in certain prisons, whereby AFD is installed first, with other infrastructure installed at a second phase, so as to expedite the installation of AFD, with other necessary works such as ventilation and suppression mechanisms to be installed subsequently, thereby delivering the most effective intervention as soon as possible, with limited effects on the installation of later projects. We continue to meet with CPFSI to review progress in this area, and engagement between the organisations remains ongoing. At a meeting in late February 2026 between the HMPPS CEO, , and the Chief Inspector, CPFSI expressed support for the change in approach to the delivery of AFD, including the move to an “AFD-first” programme where appropriate, and for the pace at which HMPPS is now working. In conclusion, HMPPS fully accepts the importance of early fire detection and the role of in- cell AFD in achieving that. We remain firmly committed to completing installation across the estate. The time required to do so reflects the complexity of delivering major infrastructure change within a live custodial environment, rather than any lack of recognition of the risk. Within those constraints, we want to assure you that we are working to ensure that we are doing everything that can be reasonably done to bring the estate into compliance with fire safety standards as quickly and effectively as possible.

Report sections

Investigation and inquest
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.”
Circumstances of the death
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.

Telephone 01275 461920 Email AvonCoronersTeam@bristol.gov.uk Website www.avon-coroner.com 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
Copies sent to
Ministry of JusticeHealthcarePractice Plus GroupMental healthcareCrown Premises Fire Safety InspectorateCardiff & Vale Health Board and to the following

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Report details

Reference
2026-0181
Date of report
18 March 2026
Coroner
M Vision
Coroner area
Avon

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 May 2026.

Sent to

Director General Operations
Ministry of Justice

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