An inquest jury has identified a series of failings that contributed to the death of Clare Dupree, who died after a fire in her cell at HMP Eastwood Park shortly after Christmas 2022.
Ms Dupree, who was 48, had severe mental health problems. A vape started the blaze, she became trapped, and the smoke overcame her.
The inquest ended at Avon Coroners Court in March 2026. The jury returned a narrative verdict setting out the faults it said had contributed to her death.
Among them, the jury said the criminal justice system had failed to identify her mental health needs. The jury also cited the absence of an automatic fire alarm in her cell and delays in gaining access to the area to try to get her out.
Records from 2015 had noted that the outdated fire and smoke alarms at Eastwood Park needed replacing. That work never happened.
The stipulated time for getting her out of the cell was 20 minutes. Instead, she remained inside for more than 30 minutes.
Justin Ashburn, who works as a Fire Safety Inspector for the Crown Premises Fire Safety Inspectorate, gave evidence. He told the inquest that a working fire and smoke alarm would “probably” have saved her life.
One expert witness said Ms Dupree’s problems were consistent with bipolar disorder.
Her family said they had felt relieved by her arrest, because she had been sleeping rough before then. They said the news of the fire shattered their lives.
A Ministry of Justice spokesperson said: “Our thoughts remain with the friends and family of Clare Dupree following her tragic death.”
The ministry said the Prisons and Probation Ombudsman had carried out an independent investigation. It said it had accepted the ombudsman’s recommendations and acted on them.
The spokesperson added: “While fire-related deaths in prison are very rare, we take safety extremely seriously and continue to work to reduce risks across the estate.”
HMP & YOI Eastwood Park is a women’s prison in the South West. Its most recent full inspection before the inquest, in September 2025, rated safety and purposeful activity as not sufficiently good. Inspectors judged respect and preparation for release reasonably good.
