Inquest Exposes Systemic Failures in Prison Death Case
An inquest has concluded that there were "missed opportunities" to prevent the tragic death of Clare Dupree, a 48-year-old woman with severe mental illness, who died from smoke inhalation after starting a fire in her prison cell. The jury found that a lack of automatic fire detection and an incorrect mental health diagnosis significantly contributed to the incident.
Background and Personal Struggles
Clare Dupree, from Cardiff, faced immense challenges throughout her life. At age 14, she underwent surgery to remove a cancerous cyst near her brain, which profoundly impacted her. The following year, she was raped, leading to a loss of confidence and social withdrawal. Her brother, Phillip Thorrington, noted that she was "never the same" after these events, turning to drugs and struggling with mental health issues.
Her sister, Rachel Thorrington, described Dupree as a "happy, kind, outgoing person" who was introduced to heroin and fell in with "the wrong people," exacerbating her mental health battles. In her mid-20s, Dupree was sectioned and unable to care for her daughters, who were then looked after by family members. Despite periods of stability with medication, her condition fluctuated, leading to incarceration in summer 2022 after an incident involving theft and a knife threat, which her family attributed to an abusive relationship.
Mental Health Misdiagnosis and Incarceration
Jurors determined that an incorrect diagnosis of emotionally unstable personality disorder in 2013 had "contributed to her incarceration." Dr. Inti Qurashi, an independent forensic psychiatrist, testified that Dupree actually had bipolar disorder, leading to diagnostic overshadowing and misattribution of symptoms to drug-induced psychosis. He argued that proper treatment could have reduced her risk behaviors and prevented her imprisonment.
Towards the end of her sentence, Dupree was referred to a psychiatric intensive care unit, but a psychiatrist declined hospitalization, releasing her homeless into the community. Qurashi highlighted that this increased her likelihood of reoffending and returning to prison. In November 2022, she was sent back to HMP Eastwood Park in Gloucestershire, where her family initially felt relief that she would have shelter and safety over Christmas.
Fatal Fire and Safety Failures
On Boxing Day evening 2022, Dupree used a vape to start a fire in her cell. The inquest heard that staff were not immediately alerted because the cell only had a domestic smoke detector outside, despite a 2015 inspection recommending automatic fire detectors (AFDs). Other prisoners attempted to raise the alarm, with one reporting hearing Dupree "screaming" and shouting "I'm on fire."
Nick Armstrong, counsel for the family, noted that regulations require prisoners to be removed within 20 minutes of fire detection, but Dupree was not recovered for 33 minutes. When staff arrived, the door handle was too hot to touch, delaying rescue until the fire brigade arrived. Fire inspector Justin Ashburn testified that installing an AFD "potentially" could have saved her life, in conjunction with better staff decision-making.
Aftermath and Calls for Change
Dupree died on December 28, 2022, from a hypoxic-ischaemic brain injury, respiratory infection, and multi-organ failure. Her daughter, Emma Baptiste, expressed ongoing grief, stating she wakes up daily to watch a video of her mother and cries over "what could have been." The coroner, Maria Voisin, announced she would submit a prevention of future deaths report to the Ministry of Justice, addressing the lack of AFDs at Eastwood Park and other prisons.
Rachel Thorrington emphasized that this tragedy "cannot happen to another vulnerable woman in a prison," asserting Dupree should have been in a hospital, not incarcerated. The Prison Service spokesperson offered condolences and noted that recommendations from an independent investigation have been accepted, with ongoing efforts to reduce risks across the estate.
