A young autistic man with an IQ higher than Einstein escaped from the Campbell Centre and took his own life while suffering from psychosis, an inquest ruled.
Billie Lord, 26, was selectively mute and also had anxiety and depression.
His stress levels increased when was moved from a single room into a dormitory just after he was admitted to the mental health unit.
Though Coroner Tom Osborne ruled the move did not contribute to Billie’s death, he has vowed to ask health chiefs for a review of the use of dormitories.
He said he was “fearful” the situation would lead to more deaths in the future.
Billie wrenched a toilet from the wall and smashed a double glazed window to break out of the Eaglestone centre in July 2017. He made his way to the railway track, where he was hit by a train.
His mother Fay Lord, who lives in Milton Keynes, was concerned that staff at the Campbell Centre did not make reasonable adjustments to take account of her son’s autism.
She told the inquest the move to a communal dormitory would have taken Billie’s stress to an “intolerable level.”
Mr Osborne recorded a verdict of suicide whilst suffering from psychosis.
Billie’s family said he enjoyed collecting jewellery and had a great sense of humour. He was extremely intelligent and became a member of Mensa aged 11 with an IQ of 171.
The Campbell Centre is a secure mental health unit managed by the Central and North West London NHS Trust.
A spokesman for the Trust said after the inquest: “Our staff take patient safety very seriously. Sadly, this was an event that no-one could have prevented or predicted.”
The spokesman added: “The coroner found there was an appropriate level of care at the Campbell Centre and did not identify any actions that would have prevented the incident.
“Our thoughts today though are with the family and friends of Mr Lord.”
Dr Nicola Smith, chair of the local CCG said: “This is a particularly sad case and our sincere condolences go out to the family and friends of Billie Lord.
“We welcome the verdict from the coroner and will take on board the suggestions made.”