Belmarsh's first 18-year-old offender was found hanged with a twisted bedsheet tied around his neck just days after he was sentenced for murder, an inquest was told.

Imran Douglas turned 18 a month before he was sentenced to life in prison in November 2013 for murdering bed-ridden pensioner Margery Gilbey, 88, in her sheltered accommodation in Shadwell, east London.

When he arrived at the prison his self-harm warning form highlighted worries of his legal team that he may become volatile and "turn it on himself".

But the warning was missed by reception and medical staff who processed him, believing Douglas didn't pose a risk to himself despite his young age and his 18-year sentence.

Belmarsh began taking 18 to 21-year-olds from September 2013, but many of the prison staff who gave evidence said at the time of Douglas' death they had not had any training in dealing with youngsters.

The inquest report by senior coroner Andrew Harris points to several factors which contributed to Douglas' death, including a "serious and unacceptable inadequacy in communication" and his handling while at Belmarsh - a prison he was never even supposed to go to.


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HMP Belmarsh in Woolwich.

Douglas was intended to return to HMP Feltham - a young offenders institution where he had been remanded in custody - but reception staff at Belmarsh missed the note on his paperwork.

Despite the warning on his self risk form, and a letter Douglas wrote to the judge before sentencing which contained a "direct threat to kill himself", an Assessment, Care in Custody & Teamwork (ACCT) was never opened.

An ACCT would have alerted prison officers to his vulnerability and imposed a designated amount of routine checks.

Five days after his arrival at around 9.20am on November 13 Douglas was found dead in his cell with a suicide note left nearby.

Giving evidence during his inquest prison officer William Pettengell described the moment he found the teenager.

While doing his morning checks he had intended to tell Douglas he was going to unlock his cell at 9.45am to give him time to shower and make a phone call.

Mr Pettengell told the jury: "I stood outside the door, put the observation hatch back to look in and it was then I realised something was wrong.

"Mr Douglas had a green prison issued bed sheet tied around his neck and tied around the window bars. The sheet was twisted.

"I realised that I needed assistance."

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Imran Douglas, 18, was found dead in his cell at Belmarsh.

With the help of another officer they were able to cut Douglas free from the ligature around his neck.

Mr Pettengell told the jury: "Once we attempted to lower him down it became quite apparent that he was very cold to the touch.

"From my experience as a prison officer and having dealt with this situation on more than one occasion as I left the cell I didn’t feel the prisoner was alive."

A jury of five men and five women returned a verdict of suicide after the inquest at Southwark Coroners Court.