24th January 2014

The jury at the inquest into the death of Amy Friar at HMP Downview has returned a conclusion that she took her own life.

Amy was found hanging in her cell at HMP Downview on 30 March 2011.  She had a long history of mental ill health, depression and self harm. Her father committed suicide when she was very young. She had also been a victim of rape and domestic violence.  Amy had a history of drug dependency and had served several short prison sentences for drug offences.   

Amy was sentenced in August 2010 and was transferred to HMP Downview a week later. On 14 March 2011 a former prisoner with whom she had been having a relationship was found murdered in the community.  Because of her distress, the prison began suicide and self harm management which involved prison officers checking on her twice an hour when she was locked in her cell.

A decision was then taken to reduce her observations to night time only. A senior prison officer raised concerns about the absence of daytime observation.  The prison officer receiving this information decided to address the issue in a review meeting to be held the next morning. The meeting was then rescheduled for the afternoon.  As a consequence, there were no observations in place for the lunchtime of 30 March 2011 when Amy was found hanging in her cell.

According to a wealth of academic and official research and the comprehensive review carried out by Baroness Corston, women are five times more likely than men to self harm in prison. This is in part due to their complex histories of abuse, drug dependency and poor mental health. Despite this, the head of the safer custody team stated in her evidence to the inquest that the level of risk to the prisoner depended on the individual rather than their gender, demonstrating a worrying lack of understanding of the well known and documented vulnerabilities of women prisoners.

The Coroner has stated he will make a Regulation 28 report to prevent future deaths concerning the emergency response codes used by prisons.

Amy was 24 years old at the time of her death and had a daughter who was 8 years old.

Her mother Karen Gammon said:

“This inquest has been a very difficult experience, made harder by the lack of financial assistance from Legal Aid, and initially the prison HMP Downview, which meant that I was not able to attend and hear all the evidence. Although I am disappointed with the brevity of the verdict, I have been reassured by the number of changes the prison made following Amy's death, including a complete overhaul of their self-harming and suicide prevention measures.

“For other bereaved families who are in this same sad situation, I would encourage them to keep pushing for changes, to ensure prisons do learn and continue to lower the rate of deaths in custody. If the changes made following Amy's death save one life, then this process will be worth it.”

Deborah Coles, co-director of INQUEST said:

“This is another entirely preventable death of a young mother who had complex mental health needs and who, despite being on a self harm and suicide monitoring programme, was able to take her own life.  However the failings in this case lie in a criminal justice system that imprisons women like Amy in institutions fundamentally ill-equipped to deal with their complex needs.

“What is needed is a complete overhaul with the way women are dealt with by the criminal justice system, and investment in community-based alternatives. As we have said time and again these deaths will continue until we stop imprisoning women into institutions that cannot keep them safe.”

The family is represented by INQUEST Lawyers Group members Trudy Morgan from Hodge Jones and Allen solicitors and barrister Philip Dayle of No5 Barristers Chambers.


Notes to editors:

  1. The jury further stated that:
  • Amy had many mental health issues and history of substance abuse
    • She had previous episodes of self harm and suffered from depression, highs and lows
    • Amy was further affected by her partner's death
  1. INQUEST has produced a comprehensive report on the deaths of women in prison: Preventing the deaths of women in prison: the need for an alternative approach
  2. Baroness Corston’s report is available here