Clare Dupree

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Independent investigation into
the death of Ms Clare Dupree,
a prisoner at
HMP/YOI Eastwood Park,
on 28 December 2022
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Ms Clare Dupree died in hospital of hypoxic brain injury, lower respiratory tract infection
and multi organ failure as a result of smoke inhalation produced by a fire she set in her
cell, on 28 December 2022 while a prisoner at HMP Eastwood Park. She was 48 years
old. I offer my condolences to Ms Dupree’s family and friends.
Ms Dupree had a history of suicide attempts, substance misuse and mental health issues
and after one day at Eastwood Park she made threats to harm herself. Staff appropriately
started ACCT procedures but failed to formulate any care plan actions or hold a post-
closure review.
HM Chief Inspector of Prisons and the Independent Monitoring Board found that Eastwood
Park had the highest rate of self-harm in the women’s estate, to the extent it was listed as
a prison of concern. We have raised issues about the management of ACCT procedures
at Eastwood Park before and are satisfied that HMPPS’ Director of the Women’s
Directorate has implemented a plan to improve practice.
When the fire was detected, an officer radioed for assistance but did not set out the nature
of the emergency. The fire panel in the gate house had malfunctioned earlier that day, so
staff in the control room were unaware there was a fire. There was a delay before control
room staff were alerted to the fire and called the emergency services.
Other regulatory bodies conducted their investigations and found that there were
deficiencies in the fire detection and warning system on Ms Dupree’s wing.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman November 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 15
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Summary
Events
1. On 19 November 2022, Ms Clare Dupree was sentenced to 52 weeks in prison for
assault and threatening behaviour and was sent to HMP Eastwood Park.
2. Ms Dupree had several mental health disorders, a history of substance misuse,
suicide attempts and mental health difficulties. She attempted suicide (by hanging)
twice in the community. In 2022, Ms Dupree made threats to the police that she
would burn a block of flats down, but she had no recorded history of fire setting or
arson.
3. On 21 November, a nurse started Prison Service suicide and self-harm prevention
procedures known as ACCT, after Ms Dupree said she planned to hang herself.
Staff did not formulate a care plan. Ms Dupree was assessed by a psychiatrist who
prescribed diazepam and, the following month, an antipsychotic.
4. On 23 November, another psychiatrist referred Ms Dupree to a Psychiatric Intensive
Care Unit for assessment. Her mental state deteriorated, but her assessment was
delayed because she contracted COVID-19.
5. On 14 December, Ms Dupree was assessed as not suitable for the Psychiatric
Intensive Care Unit. Mentally, she was doing much better, and the next day staff
stopped ACCT procedures. The decision to end ACCT monitoring should have
been reviewed within seven days but was not.
6. On 23 December, a member of the mental health team saw Ms Dupree after staff
said they were concerned about her mental state. She was still expressing bizarre
ideas but there were no concerns she would harm herself.
7. On the afternoon of 26 December, Ms Dupree was locked in her cell. Later that
afternoon, prisoners in nearby cells heard her shouting random abusive words.
8. At 4.39pm, an officer heard the smoke detector alarm outside Ms Dupree’s cell.
Another officer radioed for assistance but did not say that there was a fire. The fire
panel (which alerts the prison that there is a fire) in the gate house was not working
so staff did not call the emergency services.
9. Staff on the scene did not immediately tell Gate staff the emergency was a fire, but
afterwards followed the protocol to manage the situation. At 4.46pm, they told
control room staff that there was a cell fire, and they called the emergency services.
10. At 5.03pm, the fire service arrived at the cell and took over management of the fire.
At 5.09pm, paramedics arrived. Officers unlocked the cell and pulled Ms Dupree
out.
11. Healthcare staff and paramedics commenced live saving techniques and at 6.14pm,
Ms Dupree was taken to hospital, where she was moved to intensive care.
12. At 11.09am on 28 December, Ms Dupree died in hospital.
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13. The post-mortem report concluded Ms Dupree died as a result of smoke inhalation.
Findings
14. Ms Dupree had several risk factors for suicide and self-harm. We found
weaknesses in the management of ACCT procedures designed to identify her risks
and triggers and co-ordinate support for her. Staff did not formulate a care plan and
they did not hold a post-closure review.
15. We have raised concerns about ACCT management at Eastwood Park before. In
January 2023, we sought assurance from HMPPS’ Director of the Women’s
Directorate that the issues identified were being addressed. We are satisfied that
the Director has taken steps to improve the management of ACCT procedures.
16. The officer who detected the fire in Ms Dupree’s cell radioed for staff assistance but
did not specify that there was a fire and the fire panel in the gatehouse was faulty
which led to a delay in control room staff calling the emergency services.
17. The clinical reviewer concluded that the care Ms Dupree received at Eastwood Park
was good. However, Ms Dupree did not collect her medication on the morning of
the fire and there is no evidence that healthcare staff followed this up or alerted the
mental health team in line with local policy.
18. The Crown Premises’ Fire Safety Inspectorate conducted an investigation and
found deficiencies in Eastwood Park’s smoke detection system.
Recommendations
• The Governor should ensure staff are prepared and confident of their
responsibilities in the event of a fire, including raising the alarm correctly, by running
regular emergency planning exercises.
• The Principal Pharmacist should undertake regular clinical audits to ensure that the
policy for managing omitted doses of medication is complied with and prescribers
are alerted to any non-compliance.
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The Investigation Process
19. HMPPS notified us of Ms Dupree’s death on 28 December 2022.
20. The investigator issued notices to staff and prisoners at HMP Eastwood Park
informing them of the investigation and asking anyone with relevant information to
contact her. One prisoner responded citing her own experiences of Eastwood Park.
21. The investigator obtained copies of relevant extracts from Ms Dupree’s prison and
medical records. She obtained the HMPPS Early Learning Review. She was not
able to view the prison’s CCTV and body worn video camera (BWVC) footage due
to technical issues at the prison.
22. The investigator interviewed nine members of staff and one prisoner at Eastwood
Park in May and June 2023. The interviews were carried out in person and by video
conference.
23. NHS England commissioned a clinical reviewer to review Ms Dupree’s clinical care
at the prison. She conducted joint healthcare interviews with the investigator.
24. The investigator liaised with Avon Fire Service, Crown Premises’ Fire Safety
Inspectorate (CPFSI), who investigated the smoke detection system, and HMPPS
Fire Service. Our investigation was suspended between May 2023 and March 2024,
while we awaited the outcome of these investigations and the clinical review report.
CPFSI and HMPPS Fire Service sent us a copy of their investigation reports.
25. We informed HM Coroner for Avon of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
26. The Ombudsman’s office liaised with Ms Dupree’s family through their legal
representative. Ms Dupree’s family asked the following questions:
• The letters Ms Dupree sent showed a significant decline in her mental health
over her time at HMP Eastwood Park. How did Ms Dupree come to be in such a
desperate state? Was this picked up by staff and what was done to help her?
• Was she receiving her medication and the support she needed for her mental
health and substance misuse?
• Was there a delay in Ms Dupree’s letter to them being sent out by the prison?
• How was the fire started and what was done to put it out?
• Was there any delay in staff reaching Ms Dupree?
• What were the actions staff took once they were alerted to the fire and reached
Ms Dupree’s cell?
• Were the fire safety equipment and processes at the prison up to standard?
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We have answered Ms Dupree’s family’s questions in this report and in the clinical
review.
27. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS highlighted some minor factual inaccuracies, which have been amended.
28. Ms Dupree’s family received a copy of the initial report. The solicitor representing
them wrote to us pointing out some factual inaccuracies and omissions. The report
has been amended accordingly. They also raised a number of questions or matters
that do not impact on the factual accuracy of this report. We have provided
clarification by way of separate correspondence to the solicitor.
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Background Information
HMP/YOI Eastwood Park
29. HMP Eastwood Park is a closed prison for women in Gloucestershire. It has 10
residential wings, two of which provide specialist substance misuse services.
Practice Plus Group provides integrated healthcare services and Avon and Wiltshire
Mental Health Partnership NHS Trust provides psychosocial and mental health
services.
HM Inspectorate of Prisons
30. The most recent published inspection report of HMP Eastwood Park followed an
inspection in October 2022. Inspectors found that safety had declined considerably
and gave it their lowest judgment of ‘poor’.
31. Inspectors carried out a review in September 2023. They found that the prison had
the highest rate of self-harm in the women’s estate, but incidents were slowly
starting to reduce. There was some improvement in how ACCTs were carried out
(such as more consistent case management), but some women remained frustrated
at how difficult it was to get basic requests dealt with. Staffing levels on residential
units had improved giving women more time out of their cells with staff able to
deliver more regime.
Independent Monitoring Board
32. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to October 2023, the IMB reported
that compared to the last reporting year, self-harm had risen by 128%, with a small
number of prisoners contributing to a large proportion of incidents. A strategy to
identify drivers for self-harm was introduced and more support was offered. Staffing
levels at the beginning of the reporting period were low and considered to have
impacted staff-prisoner relationships and time out of cell.
33. The Board noted that prisoners awaiting transfer to a secure mental health hospital
had to wait far too long for placements, with the recommended target of 28 days
exceeded for 40% of prisoners. The Board was pleased to report that the complex
needs wing had been completely refurbished. The brighter environment and
dedicated therapeutic support had a positive impact on the women housed on the
wing.
Previous deaths at HMP/YOI Eastwood Park
34. Ms Dupree was the fourth prisoner to die at Eastwood Park since July 2021. Of the
previous deaths, two were self-inflicted and one was natural causes. Up to the end
of May 2024, there had been one (drug-related) death at the prison since Ms
Dupree’s.
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35. In January 2023, we made recommendations about poor ACCT processes at
Eastwood Park. The Director of the Women’s Directorate responded and set out a
number of improvement measures that had been implemented at Eastwood Park
and assurance that quality checks were being completed every 12 weeks.
Assessment, Care in Custody and Teamwork
36. ACCT is the care planning system the Prison Service uses to support prisoners at
risk of suicide or self-harm. The purpose of the ACCT is to try to determine the level
of risk posed, the steps that staff might take to reduce this and the extent to which
staff need to monitor and supervise the prisoner. Checks should be made at
irregular intervals to prevent the prisoner anticipating when they will occur.
37. Part of the ACCT process involves assessing immediate needs and drawing up a
support plan to identify the prisoner’s most urgent issues and how they will be met.
Staff should hold regular multidisciplinary reviews and should not close the ACCT
plan until all the actions of the caremap are completed. Guidance on ACCT
procedures is set out in Prison Service Instruction (PSI) 64/2011 on safer custody.
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Key Events
38. On 19 November 2022, Ms Clare Dupree was sentenced to 52 weeks in prison for
assault and threatening behaviour and was sent to HMP/YOI Eastwood Park. It was
not her first time in prison or at Eastwood Park.
39. Ms Dupree had a history of substance misuse, mental health difficulties, suicide
attempts and self-harm; she had attempted suicide by consuming weed killer and
said that she had attempted to hang herself from a tree in the community. Ms
Dupree had no history of arson, but it was recorded that in 2022, she told the police
she would set a block of flats on fire.
40. Ms Dupree had a diagnosis of bipolar disorder, paranoid psychosis, schizophrenia,
mixed personality disorder, anxiety and depression. She had contact with mental
health services in the community and her last admission to a psychiatric hospital
was in 2022, when she was detained under the Mental Health Act.
41. When Ms Dupree arrived at Eastwood Park, staff carried out the initial reception
screen. Ms Dupree was pleasant and compliant throughout the process. She was
provided with a vape pack and offered some phone credit to make a phone call, but
she declined.
42. A nurse carried out the first night screen. She noted Ms Dupree’s mental health
diagnoses and referred her to the prison’s mental health team. Ms Dupree’s clinical
observations were within the normal range, and she tested positive for cocaine,
amphetamine, buprenorphine (Subutex, an opiate substitute) and opiates. The
nurse considered Ms Dupree was mildly withdrawing from opiates, benzodiazepine
and alcohol. Ms Dupree declined to be referred to the prison’s substance misuse
service. Ms Dupree said that she did not have any thoughts of suicide or self-harm
and that she was not on any prescribed medication in the community.
43. Staff housed Ms Dupree on residential wing eight, an induction wing. Healthcare
staff saw her regularly and monitored her withdrawal symptoms. They did not
identify any clinical concerns or withdrawal problems.
44. On 20 November, a Recovery Support Worker noted that staff were concerned
about Ms Dupree’s behaviour as she was wandering into other people’s cells and
shouting at the medication hatch for treatment. She noted that Ms Dupree had
suffered with psychosis during her last time in prison and more information would
be obtained from the Community Mental Health Team. It was planned that the
prison’s Crisis Team would see her.
45. At around the same time, Ms Dupree wrote a letter to her mother. In it, she
apologised for a previous argument they had had and expressed hope that one day
she would be a good mother, daughter and sibling.
46. On 21 November, a nurse carried out a mental health assessment. She recorded
that Ms Dupree was distressed, frustrated and sad. She noted that she was
presenting with symptoms of psychosis with preoccupied thoughts about her family.
Ms Dupree said that the police had hurt her family, and as a result, she was suicidal
and planned to hang herself so that she could be reunited with them. She did not
want to take any medication or receive help from the mental health team. Ms
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Dupree said that she had stopped taking her prescribed medication in the
community because they gave her unwanted side effects. The nurse started Prison
Service suicide and self-harm prevention procedures (known as ACCT).
47. A Supervising Officer (SO) completed the Immediate Action Plan. Ms Dupree was
aware of the Listeners scheme (prisoners trained by the Samaritans to offer
support) but had no phone numbers on her prison phone account and said she did
not want to talk to anyone. An officer noted that Ms Dupree had been referred to the
mental health team for assessment, staff were not to remove any items from Ms
Dupree’s cell, and she was given distraction packs. The SO set hourly observations
with three conversations a day. Ms Dupree was to move to residential wing four
which was dedicated to providing increased mental health support (the team visited
daily).
48. On 22 November, an officer carried out the ACCT assessment. He described Ms
Dupree as having rapid mood swings and hearing voices telling her to kill herself.
She said that she wanted to develop her relationship with her four children, get
some education and leave prison without the need for probation supervision.
49. That day at 11.55am, a SO chaired the first case review. An officer, a student
psychosocial substance misuse worker and a nurse attended. Ms Dupree also
attended and engaged but her verbal contributions were not always relevant to the
questions being asked. She appeared mentally unwell and was unmedicated. It was
noted that she was due to see a psychiatrist that day. Ms Dupree said that she felt
better than she had the day before and that trying to kill herself in prison was
pointless. She said she would speak to staff if she felt like killing herself again. The
staff were concerned and raised her observations to two an hour and three
conversations a day.
50. The SO did not set a date for the next review because she was the only Induction
Unit SO. The Safer Custody Team was required to reallocate the case coordinator
role to someone else in the main prison and the new case coordinator would be
responsible for setting the next review date. The sources of support section of the
case review log listed Ms Dupree’s sister as an external source of support. The SO
did not formulate any care plan actions to reduce Ms Dupree’s risk. At interview, the
SO could not recall why.
51. Also, that day, a psychiatrist saw Ms Dupree. He recorded in the ACCT observation
log that Ms Dupree told him she had had suicidal thoughts since she was 18 but
was not suicidal currently. She denied any thoughts of self-harm but could not give
any guarantees about her safety. He recorded that another psychiatrist would
review Ms Dupree in the next couple of days.
52. The psychiatrist also noted in the medical record that Ms Dupree appeared to be
experiencing psychosis which was possibly drug induced given her positive results
when she first arrived in prison. She declined his offer of antipsychotic medication
but agreed to take Diazepam (a sedative).
53. On 23 November, the psychiatrist asked Alder Ward Psychiatric Intensive Care Unit
to assess Ms Dupree. She described her as psychotic and unwilling to take
antipsychotic medication. (Alder Ward is part of University Hospital Llandough and
provides short-term admission and treatment for patients in the most acutely
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disturbed phase of a serious mental disorder, supporting them in the early stages of
their recovery.)
54. On 24 November, a psychosocial substance misuse worker carried out a substance
misuse assessment. Ms Dupree gave inconsistent information about herself. He
was concerned she did not have the mental capacity to make decisions. He
discussed Ms Dupree with a mental health nurse, and they decided to add Ms
Dupree to the substance misuse treatment waiting list.
55. On 26 November, Ms Dupree’s allocated care coordinator (a mental health nurse
and Eastwood Park’s mental health lead) saw Ms Dupree. Ms Dupree was pleasant
but was rambling and expressing bizarre thoughts. The coordinator documented
that Ms Dupree did not express a risk to herself during the consultation.
56. On 28 November, the psychiatrist made an entry in the ACCT observation book. Ms
Dupree presented as very mentally unwell and acutely psychotic with muddled
speech. She said she had felt suicidal since she was 18. When asked if she had
any thoughts of self-harm she would act on, Ms Dupree questioned how she could
when she had not had her ‘money’ since August. This comment did not relate to
anything obvious, and the psychiatrist recorded that Ms Dupree had not answered
her question.
57. The psychiatrist also made an entry in the medical record and recorded that Ms
Dupree was now acutely psychotic with paranoid and persecutory beliefs and no
insight. His plan was to await the outcome of the Psychiatric Intensive Care Unit
assessment and continue with Diazepam. Ms Dupree continued to refuse
antipsychotic medication.
58. On 29 November, Ms Dupree was accepted for a move to residential wing four at
the prison and would move when a space became available.
59. The psychiatrist and the allocated care coordinator chased the referral to the
Psychiatric Intensive Care Unit as they considered Ms Dupree to be acutely
psychotic. Ms Dupree’s assessment was booked for 7 December.
60. On 2 December, a psychiatrist saw Ms Dupree and recorded in the ACCT
observation book that she had chronic thoughts of self-harm but no current plans to
hurt herself. He said she was erratic, thought disordered and her main risks were
towards others at that time. He also noted she was confrontational and paranoid,
having made threats to punch someone if she did not get an allegedly stolen vape
back. Ms Dupree was moved to a different landing on wing eight.
61. On 4 December, a health worker saw Ms Dupree and carried out an assessment of
needs. She described Ms Dupree’s presentation as very calm, rational and relaxed
and throughout the review she expressed no abnormal thoughts or delusional
content. Ms Dupree denied any thoughts of suicide or self-harm. The assessment
took place through the cell door observation panel as staff shortages meant staff
could not open the cell door.
62. On 5 December, Ms Dupree tested positive for COVID-19. Healthcare staff saw her
on 7 and 8 December and rebooked the Psychiatric Intensive Care Unit
assessment for 14 December.
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63. On 8 December, the allocated care coordinator made an entry in the medical record
and said that she had held an ACCT case review (the ACCT document contained
no record of the meeting). A SO attended, but Ms Dupree did not as she had been
diagnosed with COVID-19.
64. The SO told the allocated care coordinator that he had spoken to Ms Dupree that
day and she was feeling unwell but okay. He and the coordinator discussed closing
the ACCT, but the coordinator felt that as she had not seen Ms Dupree for a few
days and she was awaiting a psychiatric assessment, she did not want to close it.
The SO agreed and they decided to review the situation after Ms Dupree had been
assessed on 14 December.
65. At interview, the SO could not recall if he had completed the care plan, but he did
not add details of the psychiatric assessment to it. The prison lost the case review
paperwork, so there is no record of what decisions were made about the level of
observations. The ACCT observation book indicates that by 9 December,
observations had reduced to hourly with three conversations a day.
66. Ms Dupree’s family told us through their legal representative that around this time,
Ms Dupree’s sister received a letter from Ms Dupree. She enquired about the family
and asked for some money for vapes.
67. On 9 December, a psychiatrist carried out a psychiatric review and noted that Ms
Dupree was doing much better. He noted she appeared much less thought
disordered. She recognised she was mentally unwell and was willing to take
medication. She denied any thoughts of self-harm or harming others. He recorded
he had no acute concerns. They discussed her historical issues and various
medications and talked about prescribing Aripiprazole (an antipsychotic) which she
had not tried before. He provided Ms Dupree with a patient information leaflet about
this medication. They also discussed reducing her Diazepam and she agreed that
he could reduce the lunchtime dosage.
68. Overnight, Ms Dupree was disruptive and unsettled and had trashed her cell. She
said that her family had gone missing. Records indicate that she had been spitting
at staff during the ACCT checks while she was still COVID-19 positive.
69. On 12 December, a psychiatrist made an entry in the ACCT observation book
noting that he had been unable to review Ms Dupree because her wing was noisy,
and she was in COVID-19 isolation. He noticed she was reasonably well-kempt but
had smashed up her television. He recorded he would try and review her later on in
the week. In the medical record, he noted that officers said they found Ms Dupree a
little chaotic and she would often ask quite random questions, but they were not
concerned about her. He noted that it sounded as if her mental state had taken a
dip and wondered whether it might be better to defer the Psychiatric Intensive Care
Unit assessment until they had been able to fully assess her themselves, and
another psychiatrist was going to email a consultant from the Psychiatric Intensive
Care Unit about this. Ms Dupree’s medication at this point was 10mg of Aripiprazole
and 10mg of Diazepam. She was compliant with taking her medications.
70. On 14 December, the consultant assessed Ms Dupree. His early indications were
that he did not think she was suitable for transfer to their unit. Staff also concluded
she no longer met the criteria for a move to residential wing four at the prison.
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71. On 15 December, the SO and the allocated care coordinator held a case review
(the review paperwork is missing from the ACCT document). The coordinator said
Ms Dupree was presenting well and denied thoughts of suicide and self-harm. They
decided to close the ACCT. The SO set a post-closure review date for 23
December. In the meantime, staff were to keep a record of any notable
observations, but all formal observations would stop. Staff did not record any
notable observations over the following days.
72. On 19 December, the consultant formally told the prison he would not be offering
Ms Dupree a bed at his hospital as she seemed better, but that he was happy to
discuss this again if her presentation changed.
73. On 23 December, the allocated care coordinator recorded that the Nelson Trust (an
organisation dealing with resettlement issues) had met Ms Dupree and reported
concerns about her mental state. She went to see her in her cell and found her to
be reasonably kempt. She recorded that Ms Dupree was still expressing unusual
thoughts but felt better since taking Aripiprazole. They discussed her release plan
(Ms Dupree was due for release in May 2023), and she had no concerns about her.
74. That day, Ms Dupree moved to residential wing six. The ACCT post-closure review
did not take place.
75. On 24 and 25 December, staff did not record any concerns about Ms Dupree. Other
prisoners said that she was happy and dancing on Christmas Day, but that she was
still expressing bizarre thoughts.
76. On an unknown date, Ms Dupree wrote a letter to her mother and sister which they
received after Christmas. Ms Dupree seemed generally paranoid and described
herself as suicidal because of the lack of contact with her daughters. She felt she
should be in hospital not prison. On another unknown date, Ms Dupree sent a letter
to her sister. She expressed some unusual thoughts and said she was desperate
for vapes.A further letter, also sent to her sister and received in January, was
generally abusive, Ms Dupree asked for money and said she had COVID-19.
77. The prison told us that they only record letters being sent from prisoners who are
subject to public protection restrictions. Ms Dupree was not in this category so there
is no record of when her letters were posted. In December 2022, there was a series
of nationwide postal strikes.
Events of 26 December
78. As the investigator was unable to view CCTV footage for Ms Dupree’s unit on 26
December (due to technical issues at the prison), the following account is formed
from the police report, staff interviews and documentary evidence.
79. On the morning of 26 December, Ms Dupree did not attend the medication hatch to
collect her medication. There is no evidence that the pharmacist asked anyone to
get her or that the pharmacist alerted the mental health team in line with local
policy.
80. At 12.45pm, an OSG started his shift in the control room (which is co-located with
the gate house). He noticed that the fire panel in the gate house was lit up red
indicating that there was a fire on residential wing nine. He asked the staff already
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on duty in the control room what was happening. They told him that it was a fault
and that they had been unable to re-set it themselves. They had already called the
Works Department who had sent the maintenance person to deal with it, but he was
a plumber and had not been able to help. He believed that a maintenance person
would be coming back the next day to fix the fault.
81. At 3.47pm, Ms Dupree came out of her cell for her evening meal. An officer
accompanied her back to her cell. In his written statement, he said that it had been
quiet on the wing that day with no issues. Ms Dupree was with another prisoner
(Prisoner A) outside of her cell briefly before an officer locked them in their cells at
3.52pm. Prisoner A said Ms Dupree seemed quite happy but a little erratic.
82. Prisoner A told the police that at some point after being locked in their cell (the
exact timings have not been established), Ms Dupree was shouting the word
‘paedophile’. Around 15 minutes later, Ms Dupree was shouting that she was on
fire; smoke started to fill Prisoner A’s cell. Another prisoner (Prisoner B) was in the
cell below (downstairs) and could hear Ms Dupree shouting too. Prisoner A and
Prisoner B did not agree to be interviewed as part of this investigation.
83. Officer A had arrived at Ms Dupree’s wing to help with medication and to lock the
prisoners in their cells. At 4.39pm, the officer heard the smoke detector alarm
outside Ms Dupree’s cell on the second landing and went up the stairs to find out
which cell it related to. Officer B was by Ms Dupree’s cell door and told her there
was a fire. Officer A tried to raise the alarm using her radio, but the battery was
dead. Officer B made the radio call and asked for assistance on residential wing six.
She did not say that there was a fire. (Officer B was on extended leave from the
prison and we were unable to interview her.)
84. Because the fire panel was faulty and Officer B did not specify there was a fire, staff
in the control room did not call for the fire service. The OSG who was also in the
control room, said that the fire panel had beeped, but it still showed an issue on
residential wing nine which they knew was incorrect. He said that he and a
colleague decided to wait for a staff call confirming a fire before alerting the
emergency services.
85. Officer B started to inundate the cell with water through the inundation port (a hole
in the cell door which can be opened to insert a fire hose). When the officers called
Ms Dupree and kicked the cell door, she did not respond. The observation panel
was covered so they could not see in the cell.
86. At 4.40pm, Prisoner C activated the fire alarm and a Custodial Manager (CM)
arrived and took over the inundation. She told staff to collect Respiratory Protective
Equipment hoods. Because the fire panel was faulty, staff in the control room still
did not know that there was a fire on residential wing six.
87. At 4.42pm, Officer B and another officer put the hoods on and took over inundation.
A member of staff radioed for the senior manager in charge that day to attend the
wing.
88. At 4.46pm, an officer phoned the control room and confirmed that there was a cell
fire, and a prisoner was inside the cell.
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89. When control room staff received the call, they thought the fire was on residential
wing nine because that was what the fire panel was showing. They called the Fire
Service at 4.46pm followed by the ambulance service at 4.47pm. Another officer
came to the gate and told them that the fire was on residential wing six. Control
room staff informed the fire service and told them to go straight there.
90. At 4.50pm, the duty governor arrived on residential wing six. The CM told him the
fire was in Ms Dupree’s cell and that the observation panel was blocked. Two
officers put on smoke hoods and took over cell inundation.
91. Staff continued with inundation for 33 minutes until the fire service arrived on the
wing at 5.03pm and took over management of the fire.
92. At 5.09pm, paramedics arrived on the wing. At 5.12pm, once the fire was
considered to be under control, staff unlocked the cell door and fire-fighters pulled
Ms Dupree, who was lying unconscious on the floor near the cell door, out of the
cell. Medical staff and paramedics started CPR.
93. At 6.14pm, Ms Dupree was taken to hospital. She remained in intensive care,
where she died at 11.09am on 28 December.
Contact with Ms Dupree’s family
94. On 26 December, the prison appointed a family liaison officer (FLO). There were no
telephone numbers for Ms Dupree’s next of kin recorded anywhere on the prison
system. The FLO contacted the police for more information. The police provided
telephone numbers but when the FLO called the numbers, they did not connect.
The police attended the next of kin’s address and informed them that Ms Dupree
had been taken to hospital. On 27 December, the FLO met Ms Dupree’s family at
the hospital and offered her support. She remained at the hospital with them until
Ms Dupree’s death. She continued to offer support.
95. The prison contributed to the costs of the funeral in line with prison policy.
Support for prisoners and staff
96. After the incident, the duty manager debriefed the staff involved in the emergency
response to ensure they had the opportunity to discuss any issues arising, and to
offer support. The staff care team also offered support. Officer A was selected as a
hospital escort and accompanied Ms Dupree to hospital.
97. The prison posted notices informing other prisoners of Ms Dupree’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Ms Dupree’s death.
Post-mortem report
98. The post-mortem report gave Ms Dupree’s cause of death as hypoxic brain injury,
lower respiratory tract infection and multi organ failure as a result of inhaling fumes
produced by a fire.
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Other investigations following Ms Dupree’s death
99. Following Ms Dupree’s death, separate investigations were conducted by Avon Fire
Service, Crown Premises’ Fire Safety Inspectorate (CPFSI), and HMPPS Fire
Service.
Avon Fire Service
100. In their investigation report, Avon Fire Service found that Ms Dupree had most likely
deliberately started the fire with a vape pen in the bottom of her wardrobe. Clothes
and part of her mattress were found in the bottom of the wardrobe.
Crown Premises Fire Safety Inspectorate (CPFSI)
101. In their investigation report, CPFSI noted that Ms Dupree’s history did not flag her
as an individual at higher risk from fire and arson in prison. CPFSI reported that it
was not possible to establish the time at which Ms Dupree started the fire but noted
that she was locked in her cell at 3.52pm and the domestic smoke detector outside
her cell went off at 4.39pm, which meant that Ms Dupree was exposed to fire gases
and heat for an unknown length of time during those 47 minutes.
102. The use of domestic smoke detectors fitted outside cells was in line with HMPPS’
approach to mitigate fire risk. However, the cell window vents were open during the
incident, so smoke escaped preventing the detectors sensing the problem sooner.
103. The main fire alarm system for the wing was functioning. However, the fire risk
assessment for residential wings five and six noted that a reasonable fire detection
and warning system was not provided. The system was not considered to
adequately offer life safety to people within that building. Had an in-cell smoke
detector instead of outside cell smoke detectors been in place, it would have been
more likely to have detected the fire within 120 seconds of ignition, whether or not
the cell window was open.
104. CPFSI found no evidence that Ms Dupree pressed her emergency cell bell to draw
staffs’ attention to the situation sooner.
HMPPS Central Operations Services Directorate
105. The report provides a detailed timeline of events and concludes there were
deficiencies with: a) the stacking of fire alarm signals at the main panel b) the
process for clearing faults with the fire alarm panel; and c) the process for servicing
water misting equipment post-use.
106. In response, an automatic repair request was added to the prison’s maintenance
system ‘Planet FM’ to ensure a service request was generated after water misters
were used. The prison confirmed that the fire alarm panel was fixed.
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Findings
Assessment of Ms Dupree’s risk of suicide and self-harm
107. Ms Dupree arrived at Eastwood Park with a number of risk factors. She had a
history of substance misuse, attempted suicides, mental ill-health and relationship
difficulties. She was not identified as a risk of starting fires but had threatened to set
fire to a block of flats when she was arrested by the police in 2022. During both her
periods at Eastwood Park, Ms Dupree did not present with any risks relating to fire
setting prior to the events of 26 December 2022.
108. Ms Dupree was supported by ACCT procedures a day after she arrived at
Eastwood Park, after she told staff she intended to attempt suicide. We found that
although the mental health team attended and contributed to ACCT case reviews,
there were omissions in the management of the process. Staff did not set a date for
the second case review and did not complete the care plan. We were told that the
Safer Custody team were responsible for setting the date for the second case
review once the first review had taken place. This did not happen in Ms Dupree’s
case. Since her death, the prison has changed its process to ensure that ACCT
procedures are allocated to a case manager straight away, who will hold the first
case review and subsequent reviews so that there is consistency with case
coordinators.
109. ACCT procedures were stopped despite there being an outstanding referral for Ms
Dupree to see a psychiatrist for assessment for the Psychiatric Intensive Care Unit,
and although staff had set a date for a post-closure review, it did not take place. A
SO told us that the post-closure review did not take place because it had been an
extremely busy day, and they were short staffed. He said that there were twelve
instances of self-harm that day and he had dealt with five of them. He intended to
hold the post-closure review when he was next due at the prison on 27 December.
110. The prison was unable to provide us with Ms Dupree’s ACCT case review notes.
We note that the prison had also lost the ACCT case review notes in the last self-
inflicted case at Eastwood Park before Ms Dupree’s death. We made
recommendations about the management of ACCT procedures and recommended
that the HMPPS Director of the Women’s Directorate write to the Ombudsman and
set out what action she had taken to satisfy herself that meaningful improvements
had been made to the assessment and management of the risk of suicide and self-
harm at Eastwood Park. In her response in March 2023, the then Director of the
Women’s Directorate outlined several measures that had been put in place
including:
• Appointing a temporary Head of Safety to focus on improvements to the
ACCT process, including case co-ordination, the high number of ACCTs
open at any one time at the prison and ensuring that women received the
right support.
• Providing extra support visits from the Women’s Directorate and the National
Safety Team to focus on ACCT processes and procedures, upskilling staff on
risks, triggers and protective factors and drawing up an action plan in
conjunction with the Governor containing short, medium and long term goals.
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• Implementing a new regime giving women there more access to purposeful
activity and greater time out of cell, hopefully leading to more meaningful
staff-prisoner relationships.
111. We note that senior managers conduct assurance visits every 12 weeks and to
date, there have been no self-inflicted deaths at Eastwood Park since Ms Dupree’s.
We do not make a recommendation, but the Director of the Women’s Directorate
and the Governor will want to continue to drive improvements in the prison.
Emergency response
112. HMPPS’ document “Cell fire and safe systems of work for cell fires & Respiratory
Protection Equipment (RPE) Learners’ refresher handbook v.5.2” sets out specific
instructions on what staff should do in the event of a fire. It says staff should raise
the alarm by pressing the fire alarm call point and inform the control room using the
radio net. Eastwood Park’s Fire Orders and Evacuation Plan also says that the
Communications Officer will need the following information in the event of a fire:
location, number of people involved and life at risk.
113. At 4.39pm, staff were first aware there was a fire in Ms Dupree’s cell. Officer B
called for assistance but did not say over the radio that there was a fire. The officer
was not available for interview.
114. Smoke detectors went off at 4.39pm and a prisoner activated the fire alarm at
4.40pm. However, because of the fire panel’s fault, staff in the control room did not
know there was a real fire until an officer phoned them at 4.46pm.
115. An OSG said that when he came on duty, he was made aware that the fire panel
was incorrectly showing a fire on residential wing nine and it had been stuck like
that all day. It would not re-set and staff had reported it. However, the on-call
maintenance person who arrived was a plumber and could not fix it. We understand
HMPPS Fire Service raised the fire panel issue with the prison. The prison told us
that the fire alarm panel was repaired.
116. We note that there was a seven minute delay between the fire alarm being
activated and the emergency services being called. We do not know what impact
the delay had as although the fire service arrived on the wing at 5.03pm, it was still
another nine minutes before the cell had been sufficiently inundated to allow staff to
open the cell door safely (5.12pm).
117. The investigator asked the Governor and the prison’s Senior Health, Safety and
Fire Advisor about the delay in calling the emergency services and any action taken
at the time to prevent this happening again. They did not respond. We make the
following recommendation:
The Governor should ensure staff are prepared and confident of their
responsibilities in the event of a fire, including raising the alarm correctly, by
running regular emergency planning exercises.
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Clinical Care
118. The clinical reviewer concluded that the care Ms Dupree received at Eastwood Park
was good. The mental health team, including psychiatrists, regularly reviewed her
and mental health nurses attended ACCT meetings. A plan to move Ms Dupree to
residential wing four was appropriately considered.
119. She did note, however, that healthcare staff should have requested Ms Dupree’s
community mental health records to obtain a more comprehensive record of her
mental health picture. The prison has put a process in place for obtaining GP
records but not mental health records. The clinical reviewer has made a
recommendation about this which we do not repeat here but which the Head of
Healthcare will wish to address.
120. On 26 December, Ms Dupree did not collect her medication and the mental health
team were not aware. The Local Operating Procedure ‘Managing omitted doses of
medication’ should have been initiated. As this omission occurred within hours of
Ms Dupree setting the fire, it represents a potential missed opportunity for a
member of the mental health team to have visited her at what was clearly a time of
crisis. We recommend:
The Principal Pharmacist should undertake regular clinical audits to ensure
that the policy for managing omitted doses of medication is complied with
and prescribers are alerted to any non-compliance.
Governor to Note
121. The investigator was not able to view CCTV of the incident despite travelling to
Eastwood Park to do so. The acting Head of Safety told her there were technical
issues despite being assured beforehand that the footage would be available for her
visit. The investigator was also told it could not be downloaded to a disc and could
only be viewed at the prison. While the investigator was able to get a timeline from
the other investigations, it is imperative that the PPO is furnished with the evidence
it requires, and in a form that allows for its proper interrogation.
122. After the emergency response, Officer A was sent on an all-night bedwatch with Ms
Dupree. Her physical and mental wellbeing was not checked on first. While we
appreciate that staffing levels were low, the Governor may wish to consider whether
this was appropriate and whether other staff could have been called in to take over
the bedwatch duties.
Inquest
123. The inquest hearing into the death of Ms Dupree concluded on 19 February 2026.
The Coroner gave Ms Dupree‘s medical cause of death as hypoxic brain injury
caused by inhalation of products of combustion.
124. The Coroner established that factors relevant to Mr Duprees’ death included the
delay in a PICU assessment which possibly contributed to her death as a timely
assessment would have resulted in hospitalisation and appropriate care; and the
use of DSDs instead of AFDs also possibly contributed to Ms Dupree’s death. The
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Coroner concluded that Ms Dupree died from sustained inhalation of smoke due to
a delay in detection of fire as a result of arson.
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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