A 20-year-old man died at a mental health centre after staff “missed opportunities” to provide better care, a coroner in Essex said.
Matthew Leahy was found hanged in his room at the Linden Centre in Chelmsford on 15 November 2012.
Chelmsford Coroner’s Court heard Mr Leahy’s paperwork was incomplete and a key worker was not assigned to him.
In an open narrative verdict, Coroner Caroline Beasley Murray said the health trust should now consider an inquiry.
A statement read out to the court by the lead juror said: “Matthew Leahy had been subjected to a series of multiple failings and missed opportunities over a long period of time.
“Relevant processes and procedures had not been adhered to.”
Mr Leahy did not have a care plan, but after his death staff falsified one and back-dated it, the court heard.
One member of staff was sacked and faces a disciplinary hearing at the Nursing and Midwifery Council, alongside two others from the centre.
North Essex Partnership NHS Foundation Trust insisted the actions of these staff had no bearing on the quality of care Mr Leahy received.
The court heard how during his stay at the centre Mr Leahy had believed he had been raped in hospital.
A post-mortem examination revealed the cause of Mr Leahy’s death was hanging.