There were “missed opportunities” that could have prevented the death of a woman with severe mental illness from “sustained inhalation of smoke” after a fire in her prison cell, an inquest has found.
Clare Dupree, 48, from Cardiff, died after she used a vape to start a fire at HMP Eastwood Park in Gloucestershire just after Christmas 2022.
Directed to reach a narrative conclusion by the coroner Maria Voisin, after a four-week inquest at Avon coroner’s court, the jury found that a “lack of automatic in-cell fire detection caused a delay in detecting the fire”.
Jurors also found that an incorrect diagnosis of emotionally unstable personality disorder had “contributed to her incarceration” in the first place.
Her sister, Rachel Thorrington, said “Clare was just such a happy, kind, outgoing person, she’d do anything for anyone”. But when she was 14, Dupree had surgery to remove a cancerous cyst near her brain, which deeply affected her. And when she was 15 years old, she was raped. She lost her confidence and stopped leaving the house.
Dupree’s brother, Phillip Thorrington, said “she was never the same” after this. “She started taking drugs, and then that was the end of it.”
Rachel Thorrington said Dupree was introduced to heroin and went “off the rails”. She started mixing with “the wrong people” who “took advantage of her kind nature”, and “by this time she was battling with her mental health anyway”.
In her mid-20s, Dupree was sectioned. She was no longer able to care for her daughters and they were looked after by family members.
Dupree’s mental health would fluctuate; she would have periods where she was very unwell and lose contact with her family, but at times she would take her medication and be better.
One of Dupree’s daughters, Emma Baptiste, said: “People talk about her being on drugs and her mental health, but for me, all that I ever saw was this caring, sensitive, generous, funny, friendly, warm, welcoming, amazing person.”
Dupree was sent to prison for the first time in summer 2022. She had been arrested after threatening a supermarket security guard with a knife when he caught her stealing a pregnancy test.
Her partner had coerced her into the theft, Rachel Thorrington said. “She was in a very, very abusive relationship at the time,” she added. “He literally tried to gouge her eyes out, and he put her whole face through a double-glazed window. I went to the hospital, it was absolutely horrendous.”
Towards the end of her sentence, Dupree was referred to a psychiatric intensive care unit amid concerns over her mental health, but a psychiatrist who visited her in prison twice declined to refer her to hospital and she was instead released into the community.
Dr Inti Qurashi, an independent consultant forensic psychiatrist and expert witness, told the inquest: “If her mental illness had been properly treated, her risk behaviours would have been reduced, my view is that she wouldn’t have ended up in prison.
“She was sent out homeless into the community, which increased her likelihood of her coming into contact with the police and being put back into prison.”
Qurashi told the court that in his view a diagnosis Dupree had been given of personality disorder in 2013 was incorrect and she actually had bipolar disorder. This, the court heard, led to diagnostic overshadowing and the misattribution of her symptoms to drug-induced psychosis.
A spokesperson for Cardiff and Vale university health board, which diagnosed Dupree, said: “We remain committed to openness and learning, and we would welcome the opportunity to meet with the family to discuss the patient’s care in more detail, to listen to any concerns they may have, and to answer any questions where we can.”
In November 2022, Dupree was sent back to HMP Eastwood Park.
Baptiste said the family “were buzzing that she was in prison over Christmas”.
Rachel Thorrington added: “She has a roof over her head, she will have a Christmas dinner, she’s going to be safe.”
But on Boxing Day evening, two police officers knocked on Rachel Thorrington’s door and said her sister had been taken to hospital. “My whole world just fell apart,” she said.
On 28 December, Dupree died from a hypoxic-ischaemic brain injury, a lower-tract respiratory infection and multi-organ failure.
What had led to her death, her family later discovered, was a fire in her cell that she had started with a vape. Staff had not been immediately alerted to the fire, the inquest heard, because her cell was only equipped with a domestic smoke detector outside.
An inspection in 2015 had recommended automatic fire detectors (AFDs) be installed at Eastwood Park, but they still have not been, despite Dupree’s death.
Other prisoners had tried to raise the alarm, with one telling the inquest she heard Dupree “screaming” and shouting “I’m on fire”.
The counsel for the family, Nick Armstrong, told the inquest that regulations stated prisoners should be removed from their cells within 20 minutes of a fire being detected, but Dupree was not recovered from the cell for 33 minutes. When prison staff arrived at her door, the handle was too hot to touch, the inquest heard, and they had to wait for the fire brigade to arrive.
When asked at the inquest whether placing an AFD in Dupree’s cell “might have saved” her life, Justin Ashburn, a fire inspector for the Crown Premises Fire Safety Inspectorate, said: “Potentially. That, in conjunction with the decision-making when staff were alerted.”
The coroner said that given the jury’s conclusion, she would be submitting a prevention of future deaths report to the Ministry of Justice raising concerns about the lack of AFDs at Eastwood Park and other prisons.
Rachel Thorrington said: “This cannot happen to another vulnerable woman in a prison. She should never have been in prison, she should have been at a hospital.”
She added that the impact her sister’s death has had on the family, “especially her children, Darcy, Emma, Cerys, and their three younger sisters, has been horrendous”.
Baptiste still thinks, she said, about “how frightened and alone she must’ve felt in her final moments”.
“I wake up every morning, and there’s a video on her Facebook page, and I watch it every single day, I know it word for word,” she said. “And I cry every single morning, because of the thought of what could have been.”
A Prison Service spokesperson said: “Our thoughts remain with the friends and family of Clare Dupree following her tragic death.”
“The prisons and probation ombudsman conducted an independent investigation and we have accepted and acted on its recommendations. While fire-related deaths in prison are very rare, we take safety extremely seriously and continue to work to reduce risks across the estate.”
