Avon Coroner’s Court has heard stark and troubling evidence concerning the death of Clare Dupree, a 48-year-old woman from Cardiff, whose fatal injuries followed a fire in her prison cell at HMP Eastwood Park. The inquest has become a case study in systemic failure—one that raises acute questions about diagnostic accuracy, clinical thresholds, custodial safeguards, and the interface between mental health services and the criminal justice system.
Factual Matrix and Procedural Posture
Clare Dupree died on 28 December 2022 at Southmead Hospital, Bristol, two days after a vaping device ignited within her cell. The coroner’s inquiry, convened to determine the cause and circumstances of death, has examined a chronology marked by repeated contact with mental health services, custodial episodes, and escalating psychiatric symptoms.
The inquest is not a criminal trial, yet its fact-finding remit carries quasi-judicial weight. It must ascertain, on the balance of probabilities, not only the medical cause of death but also “how” the deceased came by her death in a broader, Article 2-compliant sense, engaging the state’s positive obligations to protect life where there is a real and immediate risk.
Central to the evidential landscape is the question whether Ms Dupree’s mental disorder was correctly identified and treated, and whether any dereliction of duty—clinical or custodial—materially contributed to her death.
Expert Psychiatric Evidence: Diagnosis and Thresholds
The most consequential testimony has come from Dr Inti Qurashi, an independent consultant forensic psychiatrist instructed as an expert witness. In accordance with his overriding duty to the court, Dr Qurashi provided an independent report addressing diagnosis, risk, and the adequacy of prior clinical decision-making.
Dr Qurashi’s opinion was unequivocal: Ms Dupree had been misdiagnosed. Whereas treating clinicians had recorded a personality disorder, he concluded that her presentation was more consistent with bipolar affective disorder, characterised by episodes of mania, psychosis, and impaired reality testing.
This distinction is not merely semantic. It is determinative of treatment pathways, risk stratification, and eligibility for compulsory admission under the Mental Health Act. A misdiagnosis of personality disorder can, in practice, result in therapeutic nihilism or the underestimation of acute risk, whereas bipolar disorder—particularly with psychotic features—demands active pharmacological intervention and, at times, inpatient containment.
Dr Qurashi’s report addressed the “threshold” question: whether Ms Dupree met the criteria for admission to a psychiatric intensive care unit (PICU) during her first custodial period between 11 May and 10 August 2022. He opined that she should have been admitted in August 2022, when concerns about her deteriorating mental state had already triggered a referral. However, a treating psychiatrist had concluded that she did not meet the statutory threshold for admission and she was discharged into the community. The inquest has scrutinised this decision with particular intensity.
Discharge into Homelessness: Foreseeability and Risk
A striking feature of the case is that Ms Dupree was discharged into the community without accommodation. The evidence suggests she was effectively rendered homeless at a time when her mental health was unstable and deteriorating.
Dr Qurashi’s evidence directly linked this discharge to subsequent risk behaviours. In his view, had her mental illness been properly diagnosed and treated, her propensity for behaviours that brought her into contact with law enforcement would have been materially reduced. Instead, her untreated psychiatric symptoms—particularly paranoid ideation—precipitated further interactions with police, culminating in her return to custody.
From a legal perspective, this raises questions of foreseeability and causation. The inquest must consider whether it was reasonably foreseeable that discharging a vulnerable individual, suffering from an untreated mental illness, into homelessness would increase her risk of harm, including reoffending and incarceration.
Community Mental Health Contact: Missed Opportunities
The evidential record also includes Ms Dupree’s contact with a community mental health team in September 2022. During this period, she reported that she had attempted to end her life and described vivid auditory hallucinations involving her family being harmed.
Such disclosures would ordinarily trigger urgent psychiatric reassessment, including consideration of inpatient admission. Yet Dr Qurashi expressed surprise that no consultant-level psychiatric review was arranged.
This omission has been framed at the inquest as a potential breach of clinical duty. The standard of care in such circumstances requires a dynamic risk assessment, incorporating both self-reported symptoms and observed behaviour. The failure to escalate her care may be construed as a systemic lapse rather than an isolated error.
The Role of Other Expert Witnesses
While Dr Qurashi’s psychiatric evidence has been pivotal, the inquest has also relied upon a constellation of expert witnesses, each discharging a distinct forensic function.
1. Forensic Pathologist
A consultant forensic pathologist provided a post-mortem report establishing the medical cause of death. The report addressed the extent of thermal injuries, inhalation of smoke, and any contributory factors such as pre-existing disease. The pathologist’s duty was to furnish an objective, scientifically grounded account of the physiological mechanisms leading to death.
2. Fire Investigation Expert
Given that the fatal incident involved a fire originating from a vaping device, a fire investigation expert was instructed to examine the ignition source, fire dynamics, and cell conditions. The expert’s report analysed whether the device malfunctioned, whether it was modified, and how the fire propagated within the confined environment of the cell.
This evidence is critical in determining whether the fire was accidental, foreseeable, or preventable, and whether prison authorities had implemented adequate fire safety measures.
3. Custodial Practices Expert
An expert in prison operations and custodial safety provided an assessment of HMP Eastwood Park’s policies and procedures. This included an evaluation of cell safety protocols, supervision levels, and the management of prisoners identified as vulnerable.
The expert’s duty extended to considering whether the prison’s actions were compliant with national standards and whether any systemic deficiencies contributed to the incident.
4. Mental Health Nursing Expert
A specialist in mental health nursing reviewed the care provided to Ms Dupree both in custody and in the community. This expert examined clinical records, risk assessments, and care plans, and provided an opinion on whether nursing staff adhered to accepted standards of practice.
The report also addressed communication between multidisciplinary teams, a recurrent issue in cases involving complex psychiatric needs.
5. Toxicology Expert
Although not determinative, a toxicology report was adduced to exclude the influence of substances that might have impaired Ms Dupree’s behaviour or contributed to the fire. The toxicologist’s duty was to analyse biological samples and provide an objective account of any substances present.
Legal Issues: Causation and Article 2
The inquest engages the jurisprudence of Article 2 of the European Convention on Human Rights, which imposes a duty on the state to take reasonable steps to protect life. This includes a procedural obligation to conduct an effective investigation where a death occurs in custody.
The coroner must grapple with complex issues of causation. It is not sufficient to establish that errors occurred; it must be shown that these errors more than minimally contributed to the death. The concept of “material contribution” is likely to be central to the jury’s deliberations.
Dr Qurashi’s evidence provides a potential causal chain: misdiagnosis → inadequate treatment → discharge into homelessness → reoffending → incarceration → exposure to the risk of a cell fire. Whether this chain is legally sufficient to ground a conclusion of neglect or systemic failure remains to be determined.
Systemic Implications
Beyond the individual tragedy, the case illuminates systemic fault lines. It underscores the dangers of diagnostic overshadowing, where complex psychiatric presentations are simplified into less acute categories. It also highlights the fragmentation of services, where individuals fall between the gaps of community care and custodial management.
The inquest has heard that Ms Dupree’s contact with the police was driven by paranoid beliefs. This raises broader questions about the criminalisation of mental illness and the adequacy of diversion mechanisms.
The death of Clare Dupree presents a confluence of clinical misjudgment, systemic inadequacy, and custodial risk. The expert evidence, particularly that of Dr Qurashi, has laid bare the consequences of diagnostic error and the failure to meet intervention thresholds.
It underpinned the lack of in-cell automatic fire detection (AFD) "possibly contributed" to Dupree's death.
As the inquest proceeds, its findings will resonate beyond Avon Coroner’s Court. They will inform not only the practices of mental health professionals but also the policies governing the treatment of vulnerable individuals within the criminal justice system.
At its core, the case is a reminder that legal and medical duties are not abstract constructs. They are safeguards designed to protect life. When they fail, the consequences are measured not in procedural deficiencies, but in human loss. The findings prompted the coroner to submit a prevention of future deaths report raising concerns about the lack of AFDs in prisons.
In statements to the inquest, Clare Dupree, who had six children, was described by her family as a "delightful and sensitive" individual who had a long history of mental health problems.
By Edward Price
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