In 2015 a 23-year-old inmate called Ryan Harvey hanged himself in his cell at Woodhill Prison in Milton Keynes.
Ryan, who had a learning disability and was classed as a vulnerable adult, was the eighth in a series of 18 self-inflicted deaths at HMP Woodhill over a three year period (2013-2016).
He took his own life just days after arriving at the prison.
A six day inquest in Ryan's death ended yesterday (Tuesday).
Coroner Tom Osborne heard how overstretched staff were “firefighting” to look after 800 inmates
The inquest concluded that multiple failings by HMP Woodhill led to Ryan’s death.
The inquest jury found staff failed to remove a ligature from Ryan’s cell after he had used it in a previous bid to take his own life.
Jurors said a number of systemic failures and repeated failures to share “critical” information had contributed to the death.
The Coroner said Ryan’s suicide had prompted significant improvements by the new governor at the prison.