Clare Dupree

M E Voisin 
HM Senior Coroner for Avon 
Avon and Somerset Coroners Court,  
Old Weston Road,  
Flax Bourton,  
Bristol,  
BS48 1UL 

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

22 May 2026 

Dear Ms Voisin 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: Ms CLARE DUPREE 

Thank you for your Regulation 28 Report dated 18th March 2026 concerning the tragic death 
of Ms. Clare Louise Dupree at HMP Eastwood Park. I am providing the response on behalf 
of His Majesty’s Prison and Probation Service (HMPPS). We would first like to express 
sincere condolences to Ms. Dupree’s family and have carefully considered the findings of 
the inquest and the concerns identified by the Court. 

We acknowledge the jury’s conclusion that delayed detection of the fire possibly contributed 
to Ms Dupree’s death. We also recognise the Coroner’s concern that the absence of in-cell 
Automatic Fire Detection (AFD) caused a delay in alerting staff to the fire, and that the use 
of battery-powered Smoke Detectors (DSD) located outside cells provides a less effective 
form of protection. HMPPS accepts that in-cell AFD represents the most effective means of 
detecting fires within prison cells and minimising the risk of harm.  

HMPPS’ national position is that in-cell AFD is necessary to minimise the risk of harm from 
fire and should be installed within all prison cells. A national resourced programme of work 
is in place to deliver this, and substantial progress has already been made, with more than 
40,000 prison places equipped with in-cell AFD since 2009.  

The implementation of this programme presents significant practical challenges. Installing 
AFD within prison cells is not a straightforward equipment upgrade; it involves complex 
infrastructure works, particularly in older custodial buildings. It requires cells and adjacent 
areas to be decanted for sustained periods, alongside enabling works, construction activity, 
and subsequent reinstatement. These works cannot be undertaken safely without decanting 
prisoners, and the prison estate is currently operating close to full capacity. As a result, only 
a limited number of cells can be taken out of use at any given time, which requires a phased 
and sequential approach to delivery rather than simultaneous installation across multiple 
sites. The guiding principle is to do the works as quickly as possible taking out as much 
capacity as the system can safely spare. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Prisons are prioritised for fire safety works through a structured, risk-based national process 
that draws on multiple data sources. Fire Risk Assessments identify hazards and remedial 
actions, which are then consolidated into Prison Information Cards that assign risk scores to 
key safety factors at each site. These scores inform a national dataset and feed into a Fire 
Safety Improvement List, which ranks prisons according to overall risk and need. This 
enables HMPPS to plan and sequence works strategically across the estate, ensuring that 
the highest-risk sites and most critical issues are addressed first, whilst balancing practical 
constraints such as prison capacity, decant availability, and the complexity of delivering 
infrastructure works safely and efficiently. 

At HMP Eastwood Park, a full programme of Fire Safety Improvement works has been 
developed which includes the installation of in-cell AFD alongside wider upgrades to smoke 
ventilation, fire compartmentation and fire doors. The project has progressed through 
business case approval and procurement and is currently in its pre-construction phase. 
Works on site are scheduled to commence in June 2026, with completion expected in 
Winter 2028. The pace of delivery at this site, as elsewhere, is constrained by the need to 
safely decant prisoners, with capacity limitations in the women’s estate further restricting the 
scale and speed of the works.  

We recognise that risk remains while this estate wide programme is ongoing and HMPPS 
has therefore taken a number of steps to minimise that risk across the estate. In all cells 
where in-cell AFD has not yet been installed, battery-powered Smoke Detectors are 
positioned immediately outside the cell door, which is a mitigatory measure agreed in 
consultation with CPFSI. Physical mitigations have also been carried out such as ensuring 
there is sufficient airflow around cell doors to enable smoke to reach the detector in the 
event of a fire. While we acknowledge that these systems are far from perfect, they provide 
coverage across the estate during the transition period and have detected over 1,200 fires 
since their introduction. 

These arrangements are supported by a wider framework of controls designed to reduce 
risk as far as reasonably practicable. Fire Risk Assessments are conducted at least 
annually and inform a nationally coordinated prioritisation process for capital works. 
Operational measures, including staff training, emergency procedures and arson reduction 
strategies, are embedded across all establishments. Other examples of important 
developments, which are the result of HMPPS constantly exploring ways to accelerate 
works which achieve the maximum possible impact on fire safety risks in the shortest time, 
include: 

Tier 2 Fire Detection Devices  

A project to implement a new technology involving Integrated Smoke Detectors (ISDs). This 
is a custom project developed by HMPPS in collaboration with Hispec (a leading provider of 
life safety systems) to address the particular challenges with the installation of AFD in the 
estate. The challenge with the installation of AFD is that it requires cells to be vacated and 
the installation of infrastructure within the cell. ISDs, by contrast, can be installed outside of 
cells and rely on Wi-Fi to work, thereby avoiding the need for hard wiring. The ISD system 
operates so that where one ISD is triggered, that will be relayed to a remote control panel 
and all other alarms which are simultaneously triggered, so that staff are visually and 
audibly aware of an incident and then can quickly identify which ISD was originally 
activated. It is hoped that ISDs will reduce substantially one of the drawbacks of DSDs, 
namely that they are less likely to be heard by prison staff, thus reducing response times. 
ISDs have been trialled at one prison (HMP Wymott), and HMPPS intend to further evaluate 
the application of this technology through trials at HMP Whatton and The Mount. Following 
evaluation, HMP Eastwood Park is one of the prisons likely to have Tier 2 Integrated Smoke 
Detectors (ISDs) installed. This would be to cover areas where some prisoners who are 

 
 
  
 
 
 higher-risk fire-setters must be housed outside the areas already covered by AFD due to 
their specific needs. 

Mini - Fire Safety Improvement (FSI) 

Advanced AFD works which are delivering c.600 AFD protected cells dispersed across  
the prison estate to be able to accommodate the highest risk fire setters. This is an 
important step in risk reduction whilst awaiting the full rollout of AFD. 

Virtual Reality fire extinguisher training  

HMMPS have also developed a Virtual Reality (VR) fire extinguisher training solution, which 
has been endorsed by CPFSI. Delivered by in-house Health and Safety trainers, VR training 
offers a cost-effective method for ensuring that staff across the estate continue to be trained 
to the standard required by the Regulatory Reform (Fire Safety) Order 2005.  These 
technologies have been promoted by CPFSI for a range of reasons including due to their 
flexibility in delivery to meet demand, because it allows for several virtual locations and 
scenarios to be included in the training (e.g. fire ground, different types of bespoke prison  
accommodation etc), it provides an immersive experience for learners and there is no 
clean-up of extinguisher content required.  These VR training packages can also be 
designed to be bespoke to particular prisons. 

Fire reduction measures   

In addition to the steps taken around fire detection, HMPPS has been moving ahead with 
important fire risk reduction measures. These include the Moja Safer Vape Pen (SVP) 
project and trials of Arc Fault Detection Devices.   

(a) Safer Vape Pen (SVP) project  

Vape pens are permitted as prisoner possession items in prisons having been introduced as 
a smoking cessation aid following the introduction of the smoke-free prisons project in 2017. 
Currently, over 2 million vape capsules are sold to prisoners per month through the ‘prison 
canteen’.  Fire setting in prisons has always been prevalent with ignition sources 
traditionally being cigarette lighters, but with the prohibition of smoking in prisons in 2020, 
the primary ignition source became the heated coil of the vape pen. Typically, the vape pen 
is dismantled to expose the coil with a taper wick placed against the heated element until  
ignition temperature is reached. The taper is then used to light larger objects or heat illicit 
chemical substances.  Deliberate fires set using vape pens accounted for the majority of 
fires set each year.  

Given these fire risks, HMPPS launched an initiative in January 2025 to introduce a “safer” 
vape pen product in prisons with the aim of cutting the number of deliberate fires set. This 
has been a significant success and since its introduction, vape-related fires have declined 
by 92%, with zero incidents attributed to the Moja SVP device. Overall, fires have reduced 
by 46% across the prison estate during this period.   

(b) Arc Fault Detention Devices  

While the Safer Vape Pen project has been highly successful in reducing the overall 
number of fires across the prison estate, there has been an increase in electrically set fires 
during this period and steps have been taken to try and mitigate that new development. 
HMPPS is currently trialling new technology – Arc Fault Detection Devices (AFDDs) – to 
address this fire risk. AFDDs protect electrical circuits from arcing-related fire (i.e. fires 
which start when an electrical arc produces enough heat to ignite surrounding materials).  

 
 
 
 
 
 
 
 
 
 
 
 HMPPS is working with Electrium (an electrical installation manufacturer) to adjust the 
detection algorithm so that it can identify tampering-induced sparking by prisoners 
interfering with equipment. Early trials of standard AFDDs are underway at HMP Werrington 
and HMP Wetherby. This will be followed by trials of a new prison-specific AFDD variant.    

In summary, HMPPS continues to work at pace to take forward plans to bring all prisons 
into compliance as soon as possible, whilst also exploring – and where appropriate 
implementing – interim measures to mitigate risks whilst this takes place.   

The matters identified by the Coroner in this case reflect a broader challenge rather than an 
isolated deficiency at a single establishment. The response to that challenge is national in 
scope and carefully sequenced to ensure that the available capacity within the estate is 
used to deliver the greatest possible reduction in risk. HMPPS continually looks for ways to 
accelerate programme delivery. This includes adopting a different approach in certain 
prisons, whereby AFD is installed first, with other infrastructure installed at a second phase, 
so as to expedite the installation of AFD, with other necessary works such as ventilation and 
suppression mechanisms to be installed subsequently, thereby delivering the most effective 
intervention as soon as possible, with limited effects on the installation of later projects. 

We continue to meet with CPFSI to review progress in this area, and engagement between 
the organisations remains ongoing. At a meeting in late February 2026 between the 
HMPPS CEO, 
change in approach to the delivery of AFD, including the move to an “AFD-first” programme 
where appropriate, and for the pace at which HMPPS is now working. 

, and the Chief Inspector, CPFSI expressed support for the 

In conclusion, HMPPS fully accepts the importance of early fire detection and the role of in-
cell AFD in achieving that. We remain firmly committed to completing installation across the 
estate. The time required to do so reflects the complexity of delivering major infrastructure 
change within a live custodial environment, rather than any lack of recognition of the risk. 
Within those constraints, we want to assure you that we are working to ensure that we are 
doing everything that can be reasonably done to bring the estate into compliance with fire 
safety standards as quickly and effectively as possible. 

Yours sincerely, 

Interim Director General Operations HMPPS