“…and was found suspended in his cell”.Those factually accurate, if rather mundane words, conclude the narrative verdict of a Jury enquiry into a suicide in Belmarsh prison of an 18 year old.
Introduction
On 13 November 2013 Imran Douglas took his own life in Belmarsh Prison.
On 08 November he had been sentenced to life imprisonment at the Old Bailey.
I had previously blogged about his death here.
Imran was only 18 years old, vulnerable, and was an acknowledged risk of suicide or self-harm. He should have been in Feltham Young Offenders Institution rather than Belmarsh high security adult prison.
Inquest
The Inquest into Imran’s death reconvened on 12 October 2015, the day after what would have been his 20th birthday. The evidence was presented before an Inquest jury at Southwark Coroner’s Court, who heard from representatives of the prison service and social services, amongst others, and lasted three weeks.
Imran’s family attended every day, and I was able to attend for a few days to support Imran’s Mum Carla.
This blog was written with Carla, and is dedicated to her.
Carla has provided the photos of Imran which are reproduced with her permission. Representation below (notes)
The short life and tragic death of Imran Douglas.
Imran was born on 11 October 1995.
His parents separated and Imran was brought up in East London primarily by his father and stepmother, and much later for a short period with Carla in Cambridge.
In April 2012 he was crossing a road in London when he was hit by a speeding police vehicle, which put Imran into a coma, and after he regained consciousness was found to have a severe personality change.
On 24 May 2013 he committed a horrendous murder. He was still only 17.
He was arrested the same day. He remained in custody until his death, less than 6 months later, and just 5 days after he had been sentenced to life imprisonment (with a minimum tariff of 18 years)
He hung himself in a solitary cell, in Belmarsh Prison, on 13 November 2013, just one month after his 18th birthday. Although he should have been under observation, by the time prison staff had found Imran’s body, rigor mortis had begun to set in.
The murder of Mrs Gilbey
In writing about the death of Imran, and describing his life and death as a tragedy, it may be suggested that the enormity of his crime is overlooked. It is not. The principal victim here is Margery Gilbey, the person killed by Imran.
She was an innocent, vulnerable elderly lady who lost her life in a brutal and undeserved attack for which Imran was responsible.
Imran recognised that, acknowledging his guilt by pleading guilty (a rarity in murder cases)
His family also recognise that, were appalled at the crime Imran had committed, and have never sought to justify his act, minimise his role or diminish the enormity of his crime.
Everybody without exception is appalled by that crime, and all feel sorrow at the loss of Mrs Gilbey, and sympathy for her family. Finding sympathy for Imran or his family will understandably be harder, because his short life will be defined by and remembered for his homicidal act. But if it is too much to expect sympathy, we could at least look for understanding.
Carla has had to struggle both to understand how and why her son could have committed that fatal crime, as well as how and why Imran’s life ended so abruptly soon afterwards.
There will be some who say that Imran deserved to die, and doubtless few other than his family who will shed tears at his loss. They are entitled to that view. But for Carla and his family, they have endured a double tragedy. Firstly struggling to come to terms with what Imran did, and the consequences of that for the victim and her surviving family, as well as for Imran and then learning of his sudden death.
And all of us should recognise that a death of a young person in custody is a tragedy, and a failing of our Justice system. We have in the UK the most punitive sentencing regime in Europe, we imprison more young people and for longer than any other European Country, but we do not have the death penalty. If the appropriate penalty is punishment by deprivation of freedom, then we as a civilised Country should expect that the custodial environment should be humane, safe and rehabilitative.
Who was Imran Douglas?
Imran was brought up and schooled in east London.
He had an elder sister. They both lived with his father and step-mother, there was nothing extraordinary about his upbringing, and no indicators of violence, gang associations or issues with drugs or alcohol. He had some behavioural issues at school, and was due to be assessed for ADHD. He was outgoing, communicative and remembered by his family as a happy, outgoing child. Carla recalls his “cheeky smile”.
Imran After the Accident
On 07 April 2012 Imran was hit by a police car travelling at high speed.
Imran suffered a severe brain injury as a direct result, and was admitted to hospital where he remained in a coma. He suffered “focal haemorrhages in both his frontal lobes” and post-traumatic amnesia for three weeks. After coming out of the coma, it was recorded that he was left with the mental capacity/cognition of a 6-11 year old, with “mood swings, memory loss and episodes of extreme low mood when he considers harming himself”.
It was also noted that his IQ was reduced to 55, which places him in the category of “learning difficulty”.
Initial repors post-accident show Imran had problems with memory recall, planning, impulsivity and organising. (Later assements (Bluebell House, below) appeared to show some progress in recovery, but the family believe he never fully recovered and continued to exhibit erratic behaviour )
He became short-tempered, and his family noted anger-management issues and occasional aggressive behaviour. After his release from hospital, Carla noted a severe personality change. “It was as if Imran were a different person”.
Imran was seen by Occupational Health until November 2012, but by January 2013 Imran was reported to have become “morose”, withdrawn and “talking about killing himself.”
After discharge from hospital Imran remained in East London initially with family before putting himself into the care of Tower Hamlets Council (he became a “looked after person”)
By April 2013 Imran was regularly “missing” from home, and his father asked Social Services for help.
On 15 May Imran was by agreement taken into care by Tower Hamlets Local Authority. He was accommodated in Norman Grove Care Home, but this was a bad judgement and the placement did not go well. Imran’s father asked for him to return home, but with support.
Sadly, the next call they had was following Imran’s arrest.
Imran in custody
Imran remained in custody from his arrest, as would be normal on a murder charge. As a 17 year old remanded in custody Imran spent some time in Medway Secure Training Centre (run by G4S) following his arrest, and the remaining time in Feltham Young Offenders Institution (other than a period of assessment in Bluebell House secure hospital for assessment) .
As an 18 year old following sentence, he was technically eligible to be detained in an adult prison, following a recent (and controversial) change in prison regulations. In his particular case, although he was therefore eligible for transfer to an adult prison, he should NOT in fact have been sent to Belmarsh after sentence, but returned to Feltham until a transition plan was prepared.
He arrived at Belmarsh, without all the proper paperwork, and the little information available was ignored. He was given a perfunctory assessment, and confined in a solitary cell in a normal wing.
He was the first eighteen year old ever to be sent directly to Belmarsh following sentence.
He lasted less than a week.
Questions
The inquest was an enquiry into the cause of death for Imran.
How is it that a young man in custody and therefore in the care of the State, is able to take his own life? Much of what Carla wanted to know was beyond the remit of the jury, but she had the following questions:-
-To what extent (if at all) was the car accident that apparently changed his personality a causal or contributory factor to Imran’s homicidal act? No jury findings on this point
-Was Imran properly assessed and adequately cared for and supervised by the health and mental authorities responsible for his discharge from hospital and post discharge care and treatment? No answers on this point
-Did Tower Hamlets Council, responsible for Imran’s care after he became a “looked after” child under the responsibility of Social Services, properly discharge their duty of care to him?
Not directly answered by the jury, but the sentencing judge had been very critical of Tower Hamlets’ failure to appropriate place Imran before the offence.
-What was it that caused Imran to kill (Carla appreciates that it is unlikely she will ever receive an answer to that question)
-Why after sentence was Imran sent to Belmarsh high security adult prison, rather than Feltham YOI?
The jury found a catalogue of errors, of planning, supervision and communication.
-Why did Belmarsh not receive the proper paperwork and medical records, alerting them to Imran’s risk and vulnerabilities? Why did Belmarsh fail to properly assess or recognise Imran as a vulnerable young person, particularly given the obvious circumstances of his age and the sentence that had just been passed. The inquest heard of a woefully poor assessment system, that ignored warning factors
-Why did he take his own life? He was depressed, suicidal and vulnerable, but warning signs were ignored.
-How was he able to take his own life, and why did the prison authorities fail to prevent him?
Tragically, Imran was just one of many young people who took their life in prison. Report into prison deaths here.
Chronology
11/10/95 Imran born
07/04/12 Imran hit by police vehicle
15/05/13 Imran taken into care
24/05/13 Imran commits murder
13/07/13 transfers to Bluebird House hospital for psychiatric assessment
17/09/13 transferred to Feltham YOI
07/10/13 Imran pleads guilty to murder
08/11/13 Imran sentenced to life imprisonment, goes to Belmarsh
13/11/13 Imran dies in Belmarsh Prison.
A Note Summarising the Findings of the Jury
Jury Conclusion : Suicide. Narrative Note summarised:–
Imran Douglas had a history of suicidal thoughts of which his family, the youth offending team, and some,but unfortunately not all, of those responsible for his welfare in custody were aware. Despite the manifest risk of suicide there were a number of significant factors contributing to his death, including a lack of planning, and a failure of care.
“There was a systemic lack of communication between, and within, almost all the agencies involved most notably within Feltham Young Offenders Institution”
Imran had just turned 18 and was sentenced following the introduction of a new policy of locating offenders aged 18 to 21 in an adult prison family.
A principal factor was his presence in Belmarsh prison, to which it was never intended to should be sent. He arrived in the month after his 18th birthday having been sentenced to a minimum of 18 years for murder (far longer than he had expected)
The reason Imran was in Belmarsh was the failure of management and staff at Feltham to draw up a transition plan for him as he neared his 18th birthday and sentence.
Nobody took responsibility to make arrangements, and inexplicably nobody contacted the youth Justice board regarding his future allocation
As a result no one was aware of what was intended for Imran on the day he was sentenced.
The jury found a “serious and unacceptable failure in communication.”
When Imran did not return to Feltham no enquiries were made as to where he had gone.
There were reports about Imran which showed in the starkest terms that he was a suicide risk.
A critical shortcoming was the basis of decisions about Imran when he was at Feltham. starting off with his discharge from mental health care which wrongly placed him as a “low risk”
Imran then had sent a letter to the judge before sentence containing a direct threat to kill himself and there were further indicators of self harm in a Pre-Sentence Report which again appear to have been disregarded by all those who should have acted.
When Imran arrived at Belmarsh, reception staff were dismissive of any potential risk and a Care UK nurse at reception dismissed any concerns as “inappropriate”.
Imran was superficially assessed and passed fit.
It is clear from the evidence that staff at Belmarsh were well aware the prison was about to handle 18 to 21-year-olds for the first time, however there was no effort to pay any special attention to particularly young prisoners arriving, nor where they told anything about the environment from which they were coming. “Even experienced officers were not aware of Imran’s background from his records at Feltham”
Staff did not act on the fact that he had transferred straight from a young offenders institution and in very difficult circumstances.
He was given the most basic of assessments and a GP examination was even more cursory, merely noting that Imran “feels okay”.
A Psychiatric report had been faxed to Belmarsh by the court and uploaded by mental health staff at the prison, but not fully opened or read.
When a decision was finally made that Imran should be transferred to the ” vulnerable prisoner unit”, it was full so he was placed in an ordinary adult block. His cell, by the admission of prison staff at all levels, was not suitable.
He had limited scope for association. Staff on his block were not told they had a vulnerable person or an 18 year old in their charge. Those who saw him on the Tuesday noted that he did not want to come out other than to collect his meal (not even to make a phone call that might have told the outside world where he was) but detected no signs of abnormality. However, a prisoner in an adjoining cell had conversations with Imran and found him nervous.
Imran remained under routine supervision until the moment next morning when he was found suspended in his cell.
Conclusion
Imran was the first 18 year old ever sent to Belmarsh prison following sentence.He lasted less than a week.
Carla hopes that lessons will be learned, so that if youths continue to be sent to Belmarsh, they will be better looked after than Imran was.
Notes
1 To find out more about the issues surrounding the shocking rate of self-harm and suicide in British prisons, check out and support the campaigning charity INQUEST
2 Carla was supported by Inquest, and represented by Kirsten Heaven instructed by Charlotte Haworth Hird of Bindmans