‘missed Opportunities’ To Prevent Woman’s Death In Prison Cell Fire, Inquest Finds

There were “missed opportunities” that could person prevented nan decease of a female pinch terrible intelligence unwellness from “sustained inhalation of smoke” aft a occurrence successful her situation cell, an inquest has found.

Clare Dupree, 48, from Cardiff, died aft she utilized a vape to commencement a occurrence astatine HMP Eastwood Park successful Gloucestershire conscionable aft Christmas 2022.

Directed to scope a communicative conclusion by nan coroner Maria Voisin, aft a four-week inquest astatine Avon coroner’s court, nan assemblage recovered a “lack of automatic in-cell occurrence discovery caused a hold successful detecting nan fire”.

Jurors besides recovered that an incorrect test of emotionally unstable characteristic upset had “contributed to her incarceration” successful nan first place.

Her sister, Rachel Thorrington, said “Clare was conscionable specified a happy, kind, outgoing person, she’d do thing for anyone”. But erstwhile she was 14, Dupree had room to region a cancerous cyst adjacent her brain, which profoundly affected her. And erstwhile she was 15 years old, she was raped. She mislaid her assurance and stopped leaving nan house.

Dupree’s brother, Phillip Thorrington, said “she was ne'er nan same” aft this. “She started taking drugs, and past that was nan extremity of it.”

Rachel Thorrington said Dupree was introduced to heroin and went “off nan rails”. She started mixing pinch “the incorrect people” who “took advantage of her benignant nature”, and “by this clip she was battling pinch her intelligence wellness anyway”.

In her mid-20s, Dupree was sectioned. She was nary longer capable to attraction for her daughters and they were looked aft by family members.

Dupree’s intelligence wellness would fluctuate; she would person periods wherever she was very unwell and suffer interaction pinch her family, but astatine times she would return her medication, and beryllium better.

One of Dupree’s daughters, Emma Baptiste, said: “People talk astir her being connected narcotics and her intelligence health, but for me, each that I ever saw was this caring, sensitive, generous, funny, friendly, warm, welcoming, astonishing person.”

Phillip Thorrington, nan relative of Clare Dupree, pinch Emma Baptiste, 1 of Dupree’s daughters. Photograph: Dimitris Legakis/Athena/The Guardian

Dupree was sent to situation for nan first clip successful summertime 2022. She had been arrested aft threatening a supermarket information defender pinch a weapon erstwhile he caught her stealing a gestation test.

Her partner had coerced her into nan theft, Thorrington said. “She was successful a very, very abusive narration astatine nan time,” sheadded. “He virtually tried to gouge her eyes out, and he put her full look done a double-glazed window. I went to nan hospital, it was perfectly horrendous.”

Towards nan extremity of her sentence, Dupree was referred to a psychiatric intensive attraction portion amid concerns complete her intelligence health, but a psychiatrist who visited her successful situation doubly declined to mention her to infirmary and she was alternatively released into nan community.

Dr Inti Qurashi, an independent advisor forensic psychiatrist and master witness, told nan inquest: “If her intelligence unwellness had been decently treated, her consequence behaviours would person been reduced, my position is that she wouldn’t person ended up successful prison.

“She was sent retired bum into nan community, which accrued her likelihood of her coming into interaction pinch nan constabulary and being put backmost into prison.”

Qurashi told nan tribunal that successful his view, a test Dupree had been fixed of characteristic upset successful 2013 was incorrect and she really had bipolar disorder. This, nan tribunal heard, led to diagnostic overshadowing, and nan misattribution of her symptoms to drug-induced psychosis.

A spokesperson for Cardiff and Vale assemblage wellness board, which diagnosed Dupree, said: “We stay committed to openness and learning, and we would invited nan opportunity to meet pinch nan family to talk nan patient’s attraction successful much detail, to perceive to immoderate concerns they whitethorn have, and to reply immoderate questions wherever we can.”

In November 2018, Dupree was sent backmost to HMP Eastwood Park.

Baptiste said nan family “were buzzing that she was successful situation complete Christmas”.

Thorrington added: “She has a tile complete her head, she will person a Christmas dinner, she’s going to beryllium safe.”

But connected Boxing Day evening, 2 constabulary officers knocked connected Thorrington’s doorway and said her sister had been taken to hospital. “My full world conscionable fell apart,” she said.

On 28 December, Dupree died from a hypoxic-ischaemic encephalon injury, a lower-tract respiratory infection, and multi-organ failure.

What had led to her death, her family later discovered, was a occurrence successful her compartment that she had started pinch a vape. Staff had not been instantly alerted to nan fire, nan inquest heard, because her compartment was only equipped pinch a home fume detector outside.

An inspection successful 2015 had recommended automatic occurrence detectors (AFDs) beryllium installed astatine Eastwood Park, but they still person not been contempt Dupree’s death.

Other prisoners had tried to raise nan alarm, pinch 1 telling nan inquest she heard Dupree “screaming” and shouting “I’m connected fire”.

The counsel for nan family, Nick Armstrong, told nan inquest that regulations stated prisoners should beryllium removed from their cells wrong 20 minutes of a occurrence being detected, but Dupree was not recovered from nan compartment for 33 minutes. When situation unit arrived astatine her door, nan grip was excessively basking to touch, nan inquest heard, and they had to hold for nan occurrence brigade to arrive.

When asked astatine nan inquest whether placing an AFD successful Dupree’s compartment “might person saved” her life, Justin Ashburn, a occurrence inspector for nan Crown Premises Fire Safety Inspectorate, said: “Potentially. That successful conjunction pinch nan decision-making erstwhile unit were alerted.”

The coroner said that fixed nan jury’s conclusion, she would beryllium submitting a prevention of early deaths study to nan Ministry of Justice raising concerns astir nan deficiency of AFDs astatine Eastwood Park and different prisons.

Thorrington said: “This cannot hap to different susceptible female successful a prison. She should ne'er person been successful prison, she should person been astatine a hospital.”

She added that nan effect her decease has had connected nan family, “especially her children, Darcy, Emma, Cerys, and their 3 younger sisters, has been horrendous”.

Baptiste still thinks, she said, astir “how frightened and unsocial she must’ve felt successful her last moments”.

“I aftermath up each morning, and there’s a video connected her Facebook page, and I watch it each azygous day, I cognize it connection for word,” she said. “And I outcry each azygous morning, because of nan thought of what could person been.”

A Prison Service spokesperson said: “Our thoughts stay pinch nan friends and family of Clare Dupree pursuing her tragic death.”

“The prisons and probation ombudsman conducted an independent investigation and we person accepted and acted connected its recommendations. While fire-related deaths successful situation are very rare, we return information highly earnestly and proceed to activity to trim risks crossed nan estate.”