\n<\/p>\n
There were \u201cmissed opportunities\u201d that could have prevented the death of a woman with severe mental illness from \u201csustained inhalation of smoke\u201d after a fire in her prison cell, an inquest has found.<\/p>\n
Clare Dupree, 48, from Cardiff, died after she used a vape to start a fire at HMP Eastwood Park in Gloucestershire just after Christmas 2022.<\/p>\n
Directed to reach a narrative conclusion by the coroner Maria Voisin, after a four-week inquest at Avon coroner\u2019s court, the jury found that a \u201clack of automatic in-cell fire detection caused a delay in detecting the fire\u201d.<\/p>\n
Jurors also found that an incorrect diagnosis of emotionally unstable personality disorder had \u201ccontributed to her incarceration\u201d in the first place.<\/p>\n
Her sister, Rachel Thorrington, said \u201cClare was just such a happy, kind, outgoing person, she\u2019d do anything for anyone\u201d. But when she was 14, Dupree had surgery to remove a cancerous cyst near her brain, which deeply affected her. And when she was 15 years old, she was raped. She lost her confidence and stopped leaving the house.<\/p>\n
Dupree\u2019s brother, Phillip Thorrington, said \u201cshe was never the same\u201d after this. \u201cShe started taking drugs, and then that was the end of it.\u201d<\/p>\n
Rachel Thorrington said Dupree was introduced to heroin and went \u201coff the rails\u201d. She started mixing with \u201cthe wrong people\u201d who \u201ctook advantage of her kind nature\u201d, and \u201cby this time she was battling with her mental health anyway\u201d.<\/p>\n
In her mid-20s, Dupree was sectioned. She was no longer able to care for her daughters and they were looked after by family members.<\/p>\n
Dupree\u2019s mental health would fluctuate; she would have periods where she was very unwell and lose contact with her family, but at times she would take her medication and be better.<\/p>\n
One of Dupree\u2019s daughters, Emma Baptiste, said: \u201cPeople <\/em>talk about her being on drugs and her mental health, but for me, all that I ever saw was this caring, sensitive, generous, funny, friendly, warm, welcoming, amazing person.\u201d<\/p>\n <\/span>Phillip Thorrington, the brother of Clare Dupree, with Emma Baptiste, one of Dupree\u2019s daughters.<\/span> Photograph: Dimitris Legakis\/Athena\/The Guardian<\/p>\n Dupree was sent to prison for the first time in summer 2022. She had been arrested after threatening a supermarket security guard with a knife when he caught her stealing a pregnancy test.<\/p>\n Her partner had coerced her into the theft, Rachel Thorrington said. \u201cShe was in a very, very abusive relationship at the time,\u201d she added. \u201cHe literally tried to gouge her eyes out, and he put her whole face through a double-glazed window. I went to the hospital, it was absolutely horrendous.\u201d<\/p>\n Towards the end of her sentence, Dupree was referred to a psychiatric intensive care unit amid concerns over her mental health, but a psychiatrist who visited her in prison twice declined to refer her to hospital and she was instead released into the community.<\/p>\n Dr Inti Qurashi, an independent consultant forensic psychiatrist and expert witness, told the inquest: \u201cIf her mental illness had been properly treated, her risk behaviours would have been reduced, my view is that she wouldn\u2019t have ended up in prison.<\/p>\n \u201cShe was sent out homeless into the community, which increased her likelihood of her coming into contact with the police and being put back into prison.\u201d<\/p>\n Qurashi told the court that in his view a diagnosis Dupree had been given of personality disorder in 2013 was incorrect and she actually had bipolar disorder. This, the court heard, led to diagnostic overshadowing and the misattribution of her symptoms to drug-induced psychosis.<\/p>\n A spokesperson for Cardiff and Vale university health board, which diagnosed Dupree, said: \u201cWe remain committed to openness and learning, and we would welcome the opportunity to meet with the family to discuss the patient\u2019s care in more detail, to listen to any concerns they may have, and to answer any questions where we can.\u201d<\/p>\n In November 2022, Dupree was sent back to HMP Eastwood Park.<\/p>\n Baptiste said the family \u201cwere buzzing that she was in prison over Christmas\u201d.<\/p>\n Rachel Thorrington added: \u201cShe has a roof over her head, she will have a Christmas dinner, she\u2019s going to be safe.\u201d<\/p>\n But on Boxing Day evening, two police officers knocked on Rachel Thorrington\u2019s door and said her sister had been taken to hospital. \u201cMy whole world just fell apart,\u201d she said.<\/p>\n On 28 December, Dupree died from a hypoxic-ischaemic brain injury, a lower-tract respiratory infection and multi-organ failure.<\/p>\n What had led to her death, her family later discovered, was a fire in her cell that she had started with a vape. Staff had not been immediately alerted to the fire, the inquest heard, because her cell was only equipped with a domestic smoke detector outside.<\/p>\n An inspection in 2015 had recommended automatic fire detectors (AFDs) be installed at Eastwood Park, but they still have not been, despite Dupree\u2019s death.<\/p>\n Other prisoners had tried to raise the alarm, with one telling the inquest she heard Dupree \u201cscreaming\u201d and shouting \u201cI\u2019m on fire\u201d.<\/p>\n The counsel for the family, Nick Armstrong, told the inquest that regulations stated prisoners should be removed from their cells within 20 minutes of a fire being detected, but Dupree was not recovered from the cell for 33 minutes. When prison staff arrived at her door, the handle was too hot to touch, the inquest heard, and they had to wait for the fire brigade to arrive.<\/p>\n When asked at the inquest whether placing an AFD in Dupree\u2019s cell \u201cmight have saved\u201d her life, Justin Ashburn, a fire inspector for the Crown Premises Fire Safety Inspectorate, said: \u201cPotentially. That, in conjunction with the decision-making when staff were alerted.\u201d<\/p>\n The coroner said that given the jury\u2019s conclusion, she would be submitting a prevention of future deaths report to the Ministry of Justice raising concerns about the lack of AFDs at Eastwood Park and other prisons.<\/p>\n Rachel Thorrington said: \u201cThis cannot happen to another vulnerable woman in a prison. She should never have been in prison, she should have been at a hospital.\u201d<\/p>\n She added that the impact her sister\u2019s death has had on the family, \u201cespecially her children, Darcy, Emma, Cerys, and their three younger sisters, has been horrendous\u201d.<\/p>\n Baptiste still thinks, she said, about \u201chow frightened and alone she must\u2019ve felt in her final moments\u201d.<\/p>\n \u201cI wake up every morning, and there\u2019s a video on her Facebook page, and I watch it every single day, I know it word for word,\u201d she said. \u201cAnd I cry every single morning, because of the thought of what could have been.\u201d<\/p>\n A Prison Service spokesperson said: \u201cOur thoughts remain with the friends and family of Clare Dupree following her tragic death.\u201d<\/p>\n \u201cThe prisons and probation ombudsman conducted an independent investigation and we have accepted and acted on its recommendations. While fire-related deaths in prison are very rare, we take safety extremely seriously and continue to work to reduce risks across the estate.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":" There were \u201cmissed opportunities\u201d that could have prevented the death of a woman with severe mental illness from \u201csustained inhalation of smoke\u201d after a fire in her prison cell, an inquest has found. Clare Dupree, 48, from Cardiff, died after she used a vape to start a fire at HMP Eastwood Park in Gloucestershire just<\/p>\n","protected":false},"author":1,"featured_media":47002,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[51],"tags":[2858,376,189,77,9265,4192,8238,6491,2798,2413,2414,4645],"class_list":{"0":"post-47001","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-health","8":"tag-cell","9":"tag-death","10":"tag-finds","11":"tag-fire","12":"tag-inquest","13":"tag-missed","14":"tag-opportunities","15":"tag-prevent","16":"tag-prison","17":"tag-prisons","18":"tag-probation","19":"tag-womans"},"_links":{"self":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts\/47001","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=47001"}],"version-history":[{"count":0,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts\/47001\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/media\/47002"}],"wp:attachment":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=47001"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=47001"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=47001"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}