A jury has concluded that a series of systemic failings and missed opportunities contributed to the death of 47-year-old Clare Dupree, who died following a cell fire at HMP Eastwood Park.
The inquest at Avon Coroner’s Court heard that Dupree, a mother of six with a history of severe mental illness, died on 28 December 2022. She had used a vape pen to start a fire in her cell two days prior while being held at the Gloucestershire facility. The jury issued a critical verdict, finding that a lack of automatic in-cell fire detection caused a delay in detecting the fire.
Under the prison’s existing safety protocols, Ms. Dupree’s wing relied on domestic smoke detectors located outside the cells rather than automatic fire detectors (AFDs) inside. This created a critical delay in alerting staff, subjecting the vulnerable prisoner to a 33-minute wait before being recovered, well beyond the 20-minute safety window.
Dr. Inti Qurashi, an independent consultant forensic psychiatrist, told the court that a 2013 diagnosis of personality disorder led to diagnostic overshadowing, a process where physical or psychiatric symptoms are wrongly attributed to a pre-existing condition rather than a new or underlying illness. Dr. Qurashi argued that this error meant her actual condition, bipolar disorder, went untreated, as her symptoms were dismissed as drug-induced psychosis or behavioural issues . He testified that if her bipolar disorder ‘had been properly treated, her risk behaviours would have been reduced’ and she likely ‘wouldn’t have ended up in prison’.
This misdiagnosis directly informed the subsequent failure to hospitalise Ms. Dupree in August 2022 when she was experiencing psychosis. Because her symptoms were filtered through the lens of a personality disorder rather than an acute mental health crisis, she was released into the community with nowhere to live. The jury identified this as a ‘missed opportunity to ensure she received the appropriate care and support to reduce re-offending,’ effectively creating a trajectory that led her back to HMP Eastwood Park in November 2022.
Concerns extend to the operational integrity of the prison’s emergency response. Evidence revealed that one officer’s radio battery was flat, while technical issues and a lack of staff understanding meant the control room could not see the fire alert on their panel. These findings echo the Prison Inspectorate’s recent condemnation of appalling living conditions at the jail, where Chief Inspector Charlie Taylor warned that ‘no prisoner should be held in such terrible conditions’.
The jury’s conclusion has prompted the coroner to submit a prevention of future deaths report to the Ministry of Justice regarding the lack of AFDs. Legal representatives for the family, Clare Hayes and Betty McCann, warned that ‘women’s prisons are not safe spaces’ and called for urgent reform to prevent further ‘tragic deaths’ in cell fires.
