Richard Hunt

Director General of Operations 
HM Prison and Probation Service 
8th  Floor Ministry of Justice 
102 Petty France 
London 
SW1H 9AJ 

4 March 2026 

Fiona Butler 
Asst. Coroner Rutland and North Leicestershire 
Coroner's Office 
Town Hall 
Town Hall Square 
Leicester 
LE1 9BG 

Dear Ms. Butler, 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR RICHARD HUNT 

Thank you for your Regulation 28 Report dated 8 October 2025 concerning the tragic death 
of Mr Richard Hunt at HMP Stocken. I am providing the response on behalf of His Majesty’s 
Prison and Probation Service (HMPPS).  

I know that you will share a copy of this response with Mr Hunt’s family, and I would first like 
to express my condolences for their loss. Every death in custody is a tragedy and the safety 
of those in our care is my absolute priority. I fully acknowledge, on behalf of myself and the 
Governor  of  HMP  Stocken,  the  very  serious  concerns  raised  in  your  report  and  we  are 
committed  to  taking  robust  and  systemic action  to  prevent  such a tragedy  occurring  in  the 
future. I apologise that this response, which describes action already taken, has taken some 
time to coordinate.  

You raise concerns, in advance of the forthcoming inquest into Mr Hunt’s death, relating to 
the aspirating fire system and in particular that this system is vulnerable to tampering. As your 
report sets out, on 19 March and 11 July 2025, Mr Hunt set fire to his cell. In the first instance 
(on  K  Wing)  Mr  Hunt  alerted  staff  by  sounding  his  cell  bell,  and  on  the  second  (I  wing)  a 
member of staff was alerted by the smell of smoke and raised the alarm. In neither case did 
the buzzer in the wing office sound to alert staff as it should have done.  

Following the serious incident on 19 March, a full audit was conducted on 31 March 2025 by 
the  Crown  Premises  Fire  Safety  Inspectorate  (CPFSI)  following  which  HMP  Stocken  was 
issued  with  a  28-day  notice  requiring  the  development  and  implementation  of  a  strategic 
action  plan.  This  action  plan,  which  will  be  disclosed  to  you  in  advance  of  the  inquest, 

 
 
 
 
 
 
 
 
 
 
 
 identified  26  actions  including  high  level  requests  for  changes  to  fire  safety  and  detection 
systems as well as tasks for immediate actions such as replacing sounders on the fire alarm 
panels. To date, 19 of these actions have been completed with most of the remaining actions 
awaiting approval of spending bids.  

A subsequent CPFSI inspection on 27 January 2026 returned a positive outcome, with the 
inspectorate  judging  the  local  fire  safety  arrangements  to  be  “generally  suitable  and 
sufficient,” meaning the fire safety measures and management systems broadly meet legal 
requirements for identifying risks and implementing proportionate controls. 

Following Mr Hunt’s death and the discovery that the fire panel located in the wing office had 
been tampered with, preventing the buzzer from sounding, immediate action was taken and 
a replacement fire panel installed. The prison’s Health and Safety team was further tasked 
with undertaking a review of the physical security of the fire alarm panels, which found that 
the panels could be accessed, posing a significant risk to operational safety. Work is ongoing 
to  rectify  this  issue,  with  access  to  fire  alarm  panel  keys  to  be  restricted  to  authorised 
personnel only - namely ADT (the fire alarm installer and maintainer), Amey, and Health & 
Safety advisors, preventing further unauthorised access and ensuring compliance with safety 
protocols. 

Notably,  a  review  of  ADT  documentation  indicates  that  the  report  two  weeks  following  the 
death, when the panel was discovered to be blocked, was the first to reference the blockage. 
Earlier reports when engineers attended the site on four occasions between 11 July and 29 
July) contain no mention or evidence of a blockage within the panel. 

Nationally, in response to the March incident, on 3 April 2025 a Service Managers Instruction 
(SMI) was issued to all prison maintenance teams, reiterating their responsibility to ensure 
that all fire safety equipment is maintained in an efficient and fully operational condition. Data 
from responses to this instruction is being used to provide assurance that panels’ fault alerts 
are unsilenced, and that action is being taken to rectify any remaining issues.  

On 3 July 2025, during routine assurance checks conducted by the prisons internal Health & 
Safety team, a fault was found and was reported on Planet FM system. It detailed that the fire 
panel  in  the  I  Wing  office  was  not  sounding.  Planet  FM  records  show  that  this  issue  was 
marked as resolved on 10 July 2025, one day prior to the incident involving Mr Richard Hunt 
who set fire to his cell. 

Locally, the Governor has introduced a daily feedback system into the morning meeting he 
chairs  whereby  all  fire  faults are  discussed and  reported.  There  is  a  specific  focus  on  any 
alarms which are not sounding when in fault, and alarms which are continually sounding. This 
is to ensure that follow-up actions are completed where appropriate by prison staff and also 
that the maintenance provider is made aware of faults which require attention. 

In regards to your concern regarding the link between the fault panels on the wings and the 
main  Control  Room,  in  November  2025  Ministry  of  Justice  Property  Directorate  issued  a 
mandate for the full replacement of the fire alarm systems on I and K wings and the Care and 
Separation Unit, with full networking back to the Control Room master fire alarm panel to allow 
any alarms or faults raised by the local fire alarm control panels on those wings to be visible 
in the Control Room. This is currently in the design and tendering stage with the intention that 
it will be rolled out as soon as practicable.   

 
 
 
 
 
 
 
 
 
 Following the concerns regarding the tampering of fire alarm control panels the Governor of 
HMP  Stocken  commissioned  two  fact-finding  investigations  to  determine  if  staff  may  have 
been involved with the tampering of fire safety equipment, and if so whether those staff could 
be identified. While it has not been possible to identify any individuals, the Governor has made 
clear to staff the seriousness of such action, and that anyone engaging in any tampering of 
the fire alarm system will be subject to formal disciplinary action.  

On  15  August  2025  a  Governor’s  Order  was  issued  mandating  that  tampering  with  fire 
equipment is a disciplinary offence and will be investigated. This has been reiterated at a face 
to face, full staff meeting on 24th September 2025, in weekly blogs and in briefings to staff 
issued in April, July and August 2025. These set out clearly staff’s personal responsibility for 
fire safety, reminding staff of the need to ensure they understand the equipment in place and 
to report all faults and issues immediately, signposting how this is done and where support 
can be sought from. The Governor has also met with and written to the senior team outlining 
their responsibilities within their functions with regards to fire safety.   

In the aftermath of these devastating incidents, HMP Stocken fully recognise the responsibility 
to ensure that all staff are equipped with the necessary knowledge regarding fire safety and 
the regulations we are obligated to follow. Fire safety training for all uniform grades currently 
sits at 98% and all staff covering night duty have up to date training. 

I hope this response provides assurance that HMPPS is actively addressing the issues raised 
in your report. HMPPS will continue to offer our full assistance to the investigation into the 
tragic death of Mr Hunt. 

Yours sincerely, 

Interim Director General of Operations

OFFICIAL-SENSITIVE

Crown Premises’ Fire Safety Inspectorate

RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
RECEIVED FROM HM CORONER FOR RUTLAND & NORTH
LEICESTERSHIRE.

FIRE FATALITY AT HM PRISON STOCKEN ON 11th JULY 2025.

CPFSI LOCATION NUMBER:

INSPECTING OFFICERS:

RESPONSE CREATED BY: Justin Ashburn Designation: Custodial Team
Leader.

RESPONSE SUBMITTED BY:

Signature

Name:
Fire Safety

Date:

CONTENTS PAGE

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Description
Contents Page

Glossary of Terms

References

Terms of Reference

Methodology

Executive Summary

Background [Cell fire – K Wing. 19th March 2025]

Introduction [Fatal cell fire – I Wing. 11th July 2025]

11th July 2025. Initial post fire visit.

16th July 2025. Post fire inspection.

Post inspection actions taken by CPFSI.

Prevention of future fire deaths in custodial settings.

Appendix A – Exhibits List

Page Number
2

2-3

3

4

4

5-6

7-8

8-10

10-11

11-13

13-16

16-17

18

Crown Premises’ Fire Inspectors, collectively known as the Crown Premises’ Fire Safety
Inspectorate (CPFSI), are appointed by the Secretary of State responsible for Government fire
policy under Article 25 (1) (e) of the Regulatory Reform (Fire Safety) Order 2005 (the Order).
They are appointed to enforce the requirements of the Order in properties owned or occupied by
the Crown, of which HMP Stocken is one.

Glossary of terms

ACCT – Assessment, Care in Custody & Teamwork.

AFC – Accommodation Fabric Check

APOM – Area Property Operations Manager [MOJ Property Services]

ASD – Aspirating Smoke Detection

CCTV - Closed Circuit Television

CPFSI – Crown Premises’ Fire Safety Inspectorate

CPIN – Crown Premises Incident Notification

CPR – Cardio-Pulmonary Resuscitation

DI – Detective Inspector

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EMAS – East Midlands Ambulance Service

FM – Facilities Management

FIO – Fire Investigation Officer

FRS – Fire and Rescue Service

HSE – Health and Safety Executive

HSF&L – Health, Safety Fire & Litigation

LFRS – Leicestershire Fire and Rescue Service

HM – His Majesty’s

HMP – His Majesty’s Prison

HMPPS – His Majesty’s Prison and Probation Service

H, S ,F & L – Health, Safety, Fire & Litigation.

MOJ – Ministry of Justice

MOU – Memorandum of Understanding

OSG – Operational Service Grade

PPO – Prisons and Probation Ombudsman

RPE – Respiratory Protection Equipment

RPOM – Regional Property Operations Manager [MOJ Property Services]

SAD – Stand-alone detector [aka Domestic Smoke Detector – DSD]

SOCO – Scenes of Crime Officers

WRDP – Work-Related-Death-Protocol

References.

Regulatory Reform (Fire Safety) Order 2005 (the Order)

Regulation 28: REPORT TO PREVENT FUTURE DEATHS. (8th October 2025)

Work-related Deaths: A protocol for liaison (England and Wales)

MEMORANDUM OF UNDERSTANDING between PRISONS AND PROBATION OMBUDSMAN
and CROWN PREMISES’ INSPECTION GROUP The investigation of deaths in custody
[December 2015]

MOJ Technical Specification FIRE ALARM SYSTEMS: STD/E/SPEC/014.

Crown Premises Fire Safety Inspectorate Enforcement Policy Statement January 2019

[National Fire Chiefs Council] CFOA Fire Safety Guidance Audit Form 8211 Version 42 on
website as at 110825

Terms of Reference.

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CPFSI received a Regulation 28: REPORT TO PREVENT FUTURE DEATHS by e-mail from
HM Coroner for Rutland and North Leicestershire on 9th October 2025.

Section 3 of the report states that on 16th July 2025, HM Coroner commenced an investigation
into the death of Richard Charles Hunt.

Section 6 of the report states that HM Coroner is of the opinion that CPFSI has the power to
take such action to prevent future deaths.

Section 7 of the report states that CPFSI is under a duty to respond to the report by 3rd
December 2025.

Methodology

The methodology applied to compile this response has been to:

 Carry out an initial post fire visit to quickly gather vital information to establish and

understand the facts of the fire event that occurred on 11th July 2025 in preparation for a
post fire inspection.

 Carry out a post fire inspection for the purpose of identifying any failures of the general fire
precautions and the associated failures of fire safety management or general maintenance
which may have contributed to the fire in cell 30 on I Wing on 11th July 2025.

 Having identified failures in respect of compliance with the Regulatory Reform (Fire Safety)

Order 2005, take the appropriate regulatory action.

 To liaise and exchange information with Leicestershire Police and the Health and Safety
Executive over investigating the incident under the Work-Related Deaths: A Protocol for
Liaison, to consider whether there was evidence for proceedings in relation to the Corporate
Manslaughter and Corporate Homicide Act 2007



Liaise with Leicestershire Fire and Rescue Service and the Prisons and Probation
Ombudsman, for the purpose of ensuring that full information from their investigations was
available for compiling this response.

 Compile all evidence from CPFSI’s post fire actions and inspections to provide a response to

the Regulation 28 Report issued by HM Coroner for Rutland and North Leicestershire.

Executive Summary.

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Richard Charles Hunt was pronounced dead at approximately 14:32 hours on 11th July 2025
following a fire in cell 30 on I Wing at HMP Stocken on the 11th July 2025.

Mr. Hunt had previously set a fire in his cell on K Wing on 19th March 2025 following which he
had been hospitalized and then subsequently returned to HMP Stocken.

On 31st March 2025, CPFSI conducted a post-fire inspection at HM Prison Stocken, whereupon
it served a 28-day action plan notice on the Governing Governor. On 24th April 2025, an action
plan was provided by the Governor, detailing the actions already taken and planned action to
comply with the Notice.

At HMP Stocken I and K wing and the Segregation Unit are all furnished with in-cell aspirating
smoke detection systems [ASD]. These systems use a fan to draw air from the cell through an
air sampling point (often referred to as a “pepper pot”) in the cell wall or ceiling, along a
sampling pipe to the fire detector from where it is discharged to atmosphere through an exhaust
pipe.

Aspirating fire detection systems can be vulnerable to tampering, obstruction and damage by
prisoners, as well as being subject to environmental contamination. Consequently, the air being
drawn from the cell towards the detector head can often be restricted, or even totally blocked. In
such circumstances, there is real potential - in the event of a cell fire - for a significant delay in
the time taken for smoke to travel from the cell via the pipework towards the detector head, or
for the detector head to not detect smoke and raise the alarm at all.

As a result, prison staff may not be alerted to the incident and therefore, unable to respond and
deal with a cell fire in sufficient time before the conditions inside the cell become untenable for
the occupant.

During both fire events in March and July 2025, the in-cell air sampling point had been taped
over in Mr Hunt’s cell. This blockage had resulted in a low air flow fault being displayed at the
fire alarm panel in the respective wing offices [on K and I Wing]. In both instances, this fault
should have been accompanied by a local, clear audible fault alert at the fire alarm panel in the
wing office.

The consequence of the blocked air sampling points was that both of the fires set by Mr Hunt
were not detected by the in-cell ASD system and relied on Mr Hunt activating his cell call facility
[in March ‘25], and prison staff noticing smoke emitting from Mr. Hunt’s cell [in July ‘25] to alert
staff to each incident.

CPFSI inspectors had established that the fire alarm panel in I Wing did have a local, audible
fault alert facility [buzzer], but this was not easily heard at normal working and ambient
conditions.

Despite the fire alarm panel having the facility to display a visual indication of a fault, an
additional clear audible alert [buzzer] could have alerted prison staff to the fault in Mr. Hunt’s cell
prior to the fire being set, or at least during the incipient stages of the fire before it became
harmful.

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CPFSI inspectors also established that there was a link from the wing fire alarm panels which
could relay an alert of a fire situation back to the main fire panel in the prison control room.

This link did not include the facility to communicate an individual low air flow fault with the in-cell
ASD systems on the wings. Had this facility been available, prison control room staff may have
had the opportunity to advise wing staff of the fault and investigate the cause.

For context, MOJ Technical Specification FIRE ALARM SYSTEMS: STD/E/SPEC/014 states
the following:

Paragraph 6.12 in Section 6 Local Control Panels: In the event of any alarm, pre-warning or
fault signal being received, a local audible alarm shall be raised at the control panel as well
as the visual display describing the occurrence.

Paragraph 7.05 in Section 7 Central Indicator Panel of MOJ Technical Specification 014 states:
The [Central Indicator] panel shall monitor the incoming circuits and display any alarms or
faults raised by the local control panels.

Following the post fire inspection on 16th July 2025, CPFSI took enforcement action by serving
28-day action plan notices to each of the Governing Governor, MOJ Property Service, Amey FM
and HMPPS Director General Operations.

Action plans were subsequently provided by the respective duty holders, which set out the
actions already taken and those which were planned to comply with each Notice.

On 9th August 2025, Amey FM provided an action plan which recorded a glove being found
lodged in the back of the alarm panel in I wing. CPFSI received a copy of an Engineer Call Out
Report which recorded that that a glove had been “stuffed” inside the front door of the panel to
muffle the buzzer noise.

CPFSI enacted its MOU with the PPO and has furnished the PPO inspector with the relevant
CPFSI information and documents to support their investigation.

CPFSI has invoked the WRDP with Leicestershire Police and has liaised with its investigators
and provided them with the relevant CPFSI information and documents to support their
investigation.

CPFSI continues to monitor progress with the actions being taken to comply with each Notice
served and intends to conduct a follow up visit to HMP Stocken during January 2026.

Background. [cell fire - K Wing. 19th March 2025]

On 19th March 2025, LFRS notified CPFSI of their attendance at a fire in cell 69* on K wing at
HM Prison Stocken. An emergency call to the FRS was recorded at 04:45 hours. The

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notification [CPIN] recorded the following information:

Cell Fire - Cell 69 on Kilo Wing. Prisoner was inside but removed by prison staff. Fire service
attended and dealt with fire using 2 Breathing Apparatus, 1 hose reel jet and 1 main jet outside.
Ambulance service was requested by the prison staff for the prisoner who was in the cell,
prisoner was conveyed to Peterborough Hospital due to potentially life threatening injuries due
to being in the smoke for apprx 5 minutes.

*Later confirmed by the prison’s fire advisor to be Cell 98 on K Wing.

Initial enquiries were made by the regional CPFSI inspector,
advisor which provided the following significant findings:

[MB] to the prison’s fire

 The occupant of cell 98 [now known to be Mr. Hunt] had covered over the air sampling point
for the in-cell ASD system and consequently, the fire alarm system did not activate and alert
staff to the fire.



It was believed that Mr Hunt had set two fires [under the bed and under the desk] using a
vape device.

 The covering of the air sampling point should have resulted in an audible fault alert being
provided at the fire alarm panel on K Wing. The prison’s fire advisor informed MB that the
fire alarm panel in K Wing had displayed a fault some 40 minutes prior to the alarm being
raised by the prisoner, who had used their cell call facility to alert staff to the fire.

 Further enquiries revealed that the audible fault alert facility had been switched off for at

least 12 months.

 No water was applied to the fire in cell 98 for approximately 14 minutes, with a damaged

power cable for the Mobile 8 water misting equipment cited for the delay in commencing fire-
fighting action.

 Mr. Hunt was removed from the cell 17 minutes after staff had been alerted to the fire. He

was unconscious and remained unresponsive for 20 minutes having been given 1st aid and
CPR. Mr Hunt was conscious by the time he was transferred to Peterborough Hospital by
ambulance.

 Mr Hunt remained in hospital until 21st March 2025 when he returned to HMP Stocken.

 Full details of these initial enquiries are documented in the Note for File created by

inspector,

[CPFSI Exhibit No: 1]

Following these enquires, it was decided that on 31st March 2025, a post-fire inspection would
be undertaken by two CPFSI inspectors,
[PW]. Details of the
lines of enquiry made and inspection findings are documented in the Note for File created by
MB and PW. [CPFSI Exhibit No: 1]

r [MB] and

On 4th April 2025, a single enforcement outcome of a 28-day action plan notice [CPFSI Exhibit
No: 2] was served to Governor Lund for the failures of fire safety judged to have been under his
control, namely:

 The disablement of the audible fault warning facility on the fire alarm system in K Wing.



Ineffective measures were in place to deter prisoners from tampering with fire detectors. E.g.
use of sanctions

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 The reporting by staff of faults associated with the automatic fire detection and warning

system in K Wing.

 Selection of inappropriate fire-fighting media for dealing with cell fires.

 The numbers of prison staff who were not in date with their RPE and Cell Fire Response

refresher training.

 The need to revisit the cell fire response drills to factor in the time required for staff to view
the fire alarm panel in the office on K Wing to specify the specific location of a cell fire.

On 24th April 2025 Governor
plan detailing the measures to be implemented and necessary steps to comply with the 28-day
notice. A copy of the fire safety action plan is provided at [CPFSI Exhibit No: 3]

responded by e-mail to the 28-day Notice, providing an action

Row 1 of the action plan recorded that on 25th March 2025, remedial action was taken by the
APOM [
audible systems on the Segregation Unit and I and K Wing. This was taken as the Governor’s
written assurance that this work had been completed.

] and the AMEY FM maintenance team to reinstate the ASD local alert

The remaining actions were considered to be appropriate proposed courses of action and a
Satisfactory Action Plan letter [CPFSI Exhibit No: 4] was issued to confirm this on 7th May
2025.

Introduction. [fatal cell fire - I Wing. 11th July 2025]

Richard Charles Hunt was pronounced dead at approximately 14:32 hours on 11th July 2025
following a cell fire at HMP Stocken on the 11th July 2025.

At 06:33 hours on 11th July 2025, CPFSI received a CPIN from Leicestershire Fire and Rescue
Service. The notification stated that on 11th July 2025 at 04:18 hours the Service received an
emergency call from the prison. The CPIN included the details of the incident stop message as
follows:

“Cell fire with prisoner still in cell, cell 30 India wing. Cell was inundated by Prison staff for
approx. 20mins prior to Fire Service arrival. 2 breathing apparatus and one hose reel used.
Prisoner removed from cell unconscious, not breathing and defibrillator used. EMAS and
Helimed attended to work on the casualty. Corridor was heavily smoke logged which was
removed by prison extraction system. One male casualty transferred to Peterborough hospital
not breathing for himself. Police put a scene preservation on the cell and took over the incident.
Tier two Fire investigation to be carried out”.

Initial actions taken by the CPFSI Custodial Team Leader,

[JA] were as follows:

 Advising the CPFSI team of the incident details and requesting inspector availability to liaise
with the FIO from Leicestershire Fire and Rescue Service and Leicestershire Police, and to
attend the fire scene to gather information in preparation for a post-fire inspection.

 Contacting the HMPPS National Fire Safety Advisors to inform them of the incident and

request a tele-call to agree the next steps.

 Established contact with the FIO from Leicestershire Fire and Rescue Service,

[VH], who advised me of the following:

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o A Tier 1 Fire Investigation had already been completed.
o A Tier 2 Investigation was being completed later that morning. VH was meeting with

SOCO in approx. 45 minutes.

o The ASD air sampling point in the fire cell had both been covered/taped over.

[photographs of this had already been taken]

o Clothing/blankets had been piled up behind the door. [photographs of this had already

been taken]

o VH had yet to establish what had alerted prison staff to the fire.
o VH confirmed that automatic fire detection was present in the cell corridor outside cell

[insert number] but that there was no SAD installed outside the cell doors.

o JA asked VH if he could examine the air leakage paths [air gaps] around the cell door to
see if there was a possibility that the detection in the cell corridor had detected the fire
and alerted staff.

o JA asked VH if he could examine the fire alarm panel to confirm if there were any faults

displayed and to take photographs of this.





o VH advised that he intended examine the incident CCTV footage.
JA explained to VH the purpose of the cell call system and asked if he could identify if the
footage showed whether the cell call lamp illuminated at any point prior to the Mr. Hunt’s
release from the cell.
JA advised VH that there would be a CPFSI presence on site that morning and would
confirm the attending inspectors in due course.

 VH agreed to call JA back once he has completed the Fire Investigation.





JA held a conference call via Teams with CPFSI inspectors and agreed that
[MM] and
initial information gathering exercise, with a view to returning and carrying out a themed fire
safety inspection focussed around the cell fire on I Wing.

[AH] would attend the prison on 11th July 2025 and commence an

JA contacted the prison to confirm the arrangements for the arrival of the two inspectors at
HMP Stocken and ensured that they were furnished with the necessary resources to
conduct their work.

MM and AH attended the prison on 11th July 2025 with a member from each of the HMPPS
National Fire Safety Advisors team and the prison’s HSF&L Team to quickly establish the facts
of the fire event.

[PW] made a further visit on 16th July 2025 to
Three CPFSI inspectors MM, AH and
undertake a post fire inspection. The two senior advisors from the HMPPS National Fire Safety
Advisors team also attended on 16th July 2025.

As a fire death occurring in Crown premises, the fire safety inspection was undertaken by
inspectors of the Crown Premises’ Fire Safety Inspectorate, who are the fire safety enforcing
authority. [Ref: Article 25 (1) (e) The Regulatory Reform (Fire Safety) Order 2005]

11th July 2025. Initial post fire visit.

Key outcomes from the visit conducted by MM and AH were:

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 An OSG working on I Wing on 11th July 2025 stated that she was alerted to the fire in cell 30
at approximately 04:17 hours by smelling smoke whilst she was carrying out an ACCT check
on the occupant of cell 21 (adjacent to cell 30).

 The ACCT for the prisoner in cell 21 included hourly observations. There was no CCTV

footage of these observations being carried out prior to the OSG entering the wing at 04:17
hours. However, observations of cell 21 had been recorded for 02:04, 02:59, 03:53, 04:53,
05:25 and 06: 40 hours on 11th July 2025





Interrogation of the fire alarm panel by one of the HMPPS National Fire Advisors on I Wing
revealed a fault was present in cell 30 at 10:22:54 on 10th July 2025 and again at 02:42:52
hours on the 11th July 2025.

It was confirmed that remedial works to the fire alarm panels for Segregation, I and K Wings
had been carried out by ADT [fire alarm engineers] in March 2025 following the issuing of
the 28-day action plan notice by CPFSI and was also confirmed by the APOM Simon Oates
that this work was carried out on the 25th March 2025.

 Mr Hunt was not on an ACCT at the time of the fire on 11th July 2025. The last recorded

ACCT for Mr Hunt was opened on 19th March 2025 and closed on 1st April 2025.

 Mr Hunt had used multiple clear bin bags which appeared to have been weaved together to

seal the door and prevent smoke from entering the corridor.

 The prison’s fire advisor had conducted a review of the fire risk assessment for I Wing on 3rd
July 2025 in which he identified that the audible fault warning facility on the fire alarm panel
was not operating. The advisor reported this fault to AMEY on 3rd July 2025. Despite a
works order being raised by the Amey FM team on 10th July 2025, there was no evidence
available to confirm that these remedial works had been carried out to reinstate the audible
fault alert.

 The door to the local [GENT] fire alarm panel on I Wing [for the in-cell ASD system] had a
key in it with the door found open, which gave access to the main control panel, circuit
boards, power supply units etc.

 Records of AFCs carried out by prison staff recorded the residential spur being checked, but
the records did not include an individual entry for each cell. A separate aspirating check
sheet formed part of the AFC record. Records of checks carried out on 10th July 2025 had
been logged as completed, with no additional comments or issues recorded.

 The air sampling point in cell 30 had been taped over and appeared to have been painted

over as well.

 MM requested that the WRDP be invoked and provided the attending Detective Inspector

from Leicestershire Police [

] with his contact details.

 No regulatory action was taken by CPFSI during this initial visit.

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A more complete account of this visit is provided in the note for file [CPFSI Exhibit No: 5]
composed by MM.

16th July 2025. Post fire inspection.

Key outcomes from the post fire inspection conducted by PW, MM and AH were:

 An ADT fire alarm engineer is present on site 2 to 4 days a week and carries out re-

active repairs to the fire alarm systems.

 Test records and service sheets did not provide an accurate picture of the planned and

reactive work undertaken on the fire alarm systems in the residential wings. For
example:

o The records of the remedial works completed on the ASD systems by ADT on 10th

July 2025 did not identify any works being completed on I Wing.

o Test records and service certificates provided by ADT did not record any faults

identified with the fire alarm systems.

 Works to repair a detector in cell 5 on I Wing were completed on 3rd July 2025. No other

remedial or preventative works on I Wing were recorded.

 A reactive works order dated 14th July 2025 had been raised for ADT, which recorded a
fault with the alarm panel for I Wing, with the fault alert facility [buzzer] not working and
requiring replacing. A single tender procurement action [aka a green route action] to
repair the fault alert facility [buzzer] on I Wing had already been raised.

 The ADT engineer interrogated the fire alarm panel for I Wing and advised that the panel
only had capacity to hold 255 faults in its memory. Consequently, no faults could be
seen for the period between 10th and 11th July 2025.

 The detector for cell 30 [the fire cell] was still showing as being in fault on the fire alarm
panel in I Wing. The fault alert facility [buzzer] could be heard if one stood close to the
panel and placed their ear to it. Under normal working and ambient conditions, prison
staff would not be able to hear this alert.

 The ADT engineer stated that the fault alert facility was integral to the alarm panel but

was very quiet. The engineer also advised that critical fire alerts are relayed to the prison
control room, but that the fault alerts were not relayed.



Inspectors observed a practical test of the ASD system on I Wing, in which the air
sampling point in cell 50 was blocked to create a fault. A fault was displayed on the fire
alarm panel in the wing office, but the fault alert was very quiet.

 Further practical tests were carried out in cells on K Wing and Segregation Unit, with all

of these detectors failing to register a low air flow fault and raise an alert on the

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respective fire alarm panel.

 The RPOM stated that the action to provide new fire alarm panels for I, K Wing and

Segregation, raised following a review of the fire risk assessment by the prison HSF&L
advisor, was sat with MOJ Property Services for approval.

 Records of AFCs carried out on I Wing on 10th July 2025 [day prior to the fire] included a
check of the in-cell air sampling point for the ASD system. No issues were recorded.

 A review of the CCTV footage of the incident in cell 30 on 11th July 2025 is recorded in

the Note for File [CPFSI Exhibit No: 6] composed by PW. Key events in the footage are:

o 04:18 hours [approx.] – OSG is observed walking back and forth on the corridor and

using her radio (smoke is seen escaping from cell 30).

o 04:22 hours [approx.] – inundation of the cell 30 commences using water misting

equipment.

o 04:51 hours [approx.]– Mr. Hunt is removed from the cell by fire-fighters from LFRS.
This was approximately 33 minutes after the fire was discovered and 29 minutes
after inundation of the cell commenced.

 During the inspection debrief Governor

stated that he had not been made aware of
the failure of the audible fault warning facility on the fire alarm panel in I Wing which had
been identified by the prison’s fire advisor following his review of the fire risk assessment
for I Wing on 3rd July 2025.

Three enforcement outcomes resulted from the post fire inspection on 16th July 2025 as follows:

 Governor

- 28 day action plan [CPFSI Exhibit No: 7] for the following key failures:

o Implementing regular checks by wing staff of the fire alarm panel on I Wing to identify
and report faults for repair, until such time as a new panel is installed or the fault alert
facility is reinstated.

o Implementing effective measures to deter prisoners from tampering with fire

detectors.

o Revisit staff training & drills. CCTV footage of incident on 11th July 2025 revealed
that several staff had not followed the procedures and instructions for dealing with
cell fires, particularly the correct use of RPE hoods.

 MOJ Property Services – 28 day action plan [CPFSI Exhibit No: 8] for the following key

failures:
o The fire alarm panels for I, K and the Segregation wings did not have the facility to

communicate faults to the Control Room.

o The fault alert facility on the fire alarm panel for I Wing was not in effective working

order.

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o Limited supply of spare components available for the ASD systems. No plan in place

for longer term replenishment once current stock depleted.

o Inadequate monitoring of the performance of the facilities management provider.

Specifically, ensuring accurate record keeping to provide necessary assurances of
safety and timely completion of remedial works.

 AMEY Facilities Management – 28 day action plan [CPFSI Exhibit No: 9] for the

following key failures:

o Practical tests of the ASD systems on K Wing and Segregation Unit failed to register
a low air flow fault and raise an alert on the respective fire alarm panel. A wider
review and adjustment of the system settings is required.

o Inadequate monitoring of own compliance. Specifically, ensuring accurate record

keeping to provide necessary assurances of safety and timely completion of remedial
works.

Post inspection actions taken by CPFSI.

On 22nd July 2025, the above action plan notices were served by email to the respective duty
holders.

A response from each of the duty holders – in the form of an action plan setting out the
proposed actions to address the risks set out in the schedule to each Notice - was expected on
or before 19th August 2025.

On 9th August 2025 an action plan c/w supporting documents [CPFSI Exhibit No: 10] was
received from AMEY FM.

Analysis of this action plan revealed in [Row 2 Column D] that the fault alert buzzer on the I
Wing fire alarm panel was working correctly, but the replacement of the alarm panel was going
ahead as planned. This action also recorded that a glove was found lodged in the back of the
fire alarm panel.

This had not previously been identified by the ADT engineer, nor had CPFSI inspectors been
made aware of this during their visits. At the time of receiving this action plan it could not be

determined whether the presence of the glove had a negative effect on the audibility of the fault
alert facility [buzzer].

On 12th August 2025 a further, updated action plan [CPFSI Exhibit No: 11] was provided by
AMEY FM.

Analysis of this action plan update revealed that the entry which had previously recorded the
presence of the glove inside the fire alarm panel on I Wing, had been removed. The entry
confirmed that the fault alert on the fire alarm panel in I Wing was functioning.

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Having reviewed the completed and proposed actions in the action plan, a Satisfactory Action
Plan letter was issued on 14th August 2025. [CPFSI Exhibit No: 12] The supporting e-mail
advised that CPFSI would be undertaking a follow up visit at a later date.

On 19th August 2025 an action plan [CPFSI Exhibit No: 13] was received from Governor
Truman.

Having reviewed the completed and proposed actions in the action plan, a Satisfactory Action
Plan letter was issued later on 19th August 2025. [CPFSI Exhibit No: 14] The supporting e-mail
to Governor
part of 2026, to check on progress against the action plan which should provide sufficient time
to allow the actions to become embedded in the day-to-day operations of the prison.

advised that CPFSI would be undertaking a follow up visit during the early

On 27th August 2025 CPFSI e-mailed the Chief Property Officer to chase the required response
from MOJ Property Services.

On 28th August 2025 an action plan [CPFSI Exhibit No: 15] was received from MOJ Property
Services.

The review of the action plan provided by MOJ Property Services confirmed that they had
submitted funding bids to HMPPS Estates for the replacement of the fire alarm panels on I, K
Wings and Segregation and the longer term planning for the replacement of spare components
for the ASD systems.

As HMPPS Estates falls under the control of the Director General for Operations at HMPPS, a
28-day action plan notice was served to the Director General [as a fire safety duty holder] on 2nd
September 2025. [CPFSI Exhibit No: 16]

On 1st September 2025 CPFSI requested further confirmations from MOJ Property Services
regarding the replacement of the fire alarm panel on I Wing and the provision of documentary
evidence to support the repairs of faults to the fire alarm systems by ADT.

On 3rd September 2025 CPFSI received copies of service and fault reports from ADT and
confirmation that a replacement fire alarm panel had been installed on I Wing, with the fault alert
facility operating and alarm panel door secured. [CPFSI Exhibit No: 17]

On 3rd September 2025 a Satisfactory Action Plan letter was issued to MOJ Property Services.
[CPFSI Exhibit No: 18]

On 13th October 2025 CPFSI e-mailed the HMPPS Director General for Operations requesting a
response to the 28-day action plan notice served on 2nd September 2025.

On 24th October 2025 CPFSI an action plan was received from the HMPPS Director General for
Operations. [CPFSI Exhibit No: 19]

The action plan provided by HMPPS Director General for Operations stated that main fire alarm
panel in the Central Control Room at HMP Stocken receives critical alerts for fire incidents and
system faults.

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CPFSI sought confirmation from the RPOM [MOJ Property Services] that a fault alert is indeed
relayed to the main fire alarm panel in the Central Control Room from the ASD systems for I, K
Wings and Segregation at HMP Stocken.

CPFSI also sought confirmation that the Amey FM team and MOJ Property Services team
[APOM/RPOM] at HMP Stocken are aware of the arrangements to request spare components
for the ASD systems from the national stock of spares held at the HMPPS National Distribution
Centre.

On 5th November 2025 CPFSI received an electronic copy of the modification certificate from
Amey FM following the installation of the new fire alarm panel in I Wing. The associated
Engineer Call Out Report recorded that the Gent Fire Alarm panel had sustained damage to the
front door of the panel and that a glove had been “stuffed” inside the front door to muffle the
buzzer noise. [CPFSI – Exhibit No: 20].

On 11th November 2025 CPFSI responded to the action plan provided by the HMPPS Director
General for Operations by requesting further clarity regarding the ability of the fire alarm system
to relay a low air flow fault from a detector in an individual cell back to the Main Control Panel in
the Central Control Room.

The response from the HMPPS Director General for Operations regarding the failure of the
automatic fire detection system to provide sufficiently robust protection stated that the main fire alarm
panel in the Central Control Room received critical alerts for fire incidents and system faults.

CPFSI approached the on-site MOJ Property Services and Amey FM teams on this matter and
they confirmed the following:

'I, K & Seg wings all have aspirating units that report back to the gent panel in the local wing
office. This then relays the information to the static 900 panel which links back to comms. The
only information reported back from this is related to a live fire activation in the wing, it doesn't
provide a specific location, ie. the alert would only provide information for the building such as 'I
Wing'. If there are faults on the wing, the local gent panel in the office would contain specific
information around the fault, but none of this information is relayed to comms.'

This information appeared to contradict HMPPS’ response and CPFSI’s inspectors findings
following the post-fire inspection at HM Prison Stocken on 16th July 2025.

CPFSI wrote to the HMPPS Director General for Operations requesting clarification of the term
“critical alert”, particularly in the context of relaying a low air flow fault from a detector in an
individual cell back to the Main Control Panel in the Central Control Room.

Currently, a satisfactory action plan letter has not been issued to HMPPS Director General for
Operations, following the outcomes of the above, ongoing enquiries.

Prevention of future fire deaths in custodial settings.

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CPFSI has enacted its MOU with the PPO and has furnished the PPO inspector with the
relevant CPFSI information and documents to support their investigation.

CPFSI has invoked the WRDP with Leicestershire Police and has liaised with its investigators
and provided them with the relevant CPFSI information and documents to support their
investigation.

CPFSI continues to make itself available to both agencies to support their respective enquiries
and investigations.

CPFSI continues to monitor progress with the actions being taken to comply with each Notice
served and will be conducting a follow up visit to HMP Stocken in January 2026.

Should inspectors find that the planned actions set out by the fire safety duty holders in their
respective fire safety action plan have not been completed satisfactorily, they will apply the
principles of the Regulators Code and Enforcement Management Model* and consider formal
enforcement action where it is judged to be the appropriate next step.

Crown bodies must comply with the provisions of the Order**, but they cannot be subject to
prosecution**. Non-Crown Responsible Persons and others with duties under the Order in
Crown premises can be prosecuted.

Where CPFSI considers that continued non-compliance (of safety critical aspects of fire safety)
will have a major impact on safety and the likelihood of fire on the premises remains high, it can
issue an Enforcement Notice.

CPFSI has reviewed its business processes for inspecting residential wings in prisons.
Specifically, by creating a revised aide memoire which provides inspectors with specific,
detailed lines of enquiry to confirm that fire detection and warning systems can always provide
effective detection performance. This is supported by: the provision of systems and components
that are in accordance with the recommendations of relevant British Standards and expectations
of MOJs own Technical Specifications; robust day-to-day management systems to deter
tampering with life safety equipment and monitoring arrangements which ensure that specialist
planned maintenance and remedial works are completed in a competent and timely fashion.

In accordance with its enforcement policy, CPFSI will continue to take consistent and
transparent enforcement action which is proportional to the risk.

*The process of auditing and inspecting premises, assessing risks and making enforcement decisions where appropriate will embody the
principles, expectations and methodology of the Enforcement Management Model (EMM) produced by the Health and Safety Executive
(HSE), which is considered national best practice. NFCC has adapted and summarised this model for use by Fire & Rescue Authorities.
CPFSI also uses this model.

** The Regulatory Reform (Fire Safety) Order 2005 Article 49 Application to the Crown and to the Houses of Parliament

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APPENDIX A.

Exhibits List: (In attached ZIP file)

1. 25-03-25 NFF HMP Stocken LOC.28956 cell fire K-wing 19-03-25 MB-PW

2. 4-04-25 28DAP HMP Stocken LOC.28959-HMPPS Gov

3. 24-04-25 Response to Inspection and Action Plan STOCKEN

4. 7-05-25 SAT Action Plan HMP Stocken LOC.2859-HMPPS Gov

5. MM-Note for Case-HMP Stocken fatality 11-07-25 Mr R Hunt

6. 08-08-25 – NFF – HMP Stocken PFI LOC.28959

7. 22-07-25 28DAP – HMP Stocken – HMPPS GG

8. 22-07-25 28-day - MOJ PD

9. 22-07-25 28-day - Amey

10. AMEY&MOJ Action Plan & sup docs. [zip file]

11. Stocken CPFSI 28 Day Action PLAN 12.8.25

12. 14-08-25 Sat AP – HMP Stocken - Amey

13. HMPPS Response to Inspection Letter – Stocken 12-08-25

14. 19-08-25 Sat AP – HMP Stocken – HMPPS GG

15. SKI_Action_Plan_MOJ_ In progress

16. 02-09-25 28DAP – HMP Stocken – HMPPS DG

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17. 3-09-25 Copies of service and fault reports [zip files]

18. 3-09-25 Satisfactory Action Plan [MOJ Property Services]

19. HMP STOCKEN CPFSI (28 DAP) ACTION PLAN LOC-28959

20. DGS030335 (3)

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