An inquest jury has concluded that it was right that a transgender prisoner from Keighley who died at Leeds Prison was held in a male jail - but also found she was let down by a range of services as well as her family.
Vikki Thompson, 21, was found dead in her cell at the prison in November 2015.
An inquest into her death finished on Friday with a jury concluding that she did not intend to take her own life.
The foreman said: "Throughout her chaotic life, Vikki has been let down by various departments including the NHS, Leeds Community Healthcare NHS Trust, the Prison Service and also by her family."
The foreman said: "Although these departments were individually aware of Vikki's history, the overall coordination of her mental and health state were lacking in any form of organisational structure.
"During her last stay at HMP Leeds, the management of her treatment and mental state of mind were also lacking in professionalism and inadequate for an individual of such complex issues."
He said: "On October 19, 2015, Vikki was remanded to HMP Leeds, a male prison, and we, the jury, feel this was the right one for Vikki.
"More attention should have been paid to Vikki as a transgender woman with a history from a previous stay in the prison."
At the beginning of the two-week inquest in Wakefield, Miss Thompson's partner, Robert Steele, told the jury she did not want to be in a male jail and wrote to him saying: "I know I'm going to do something silly."
The court was told she had repeatedly told prison and court escort staff that she would be "carried out in a box".
But, in a statement read to the court, Miss Thompson's mother, Lisa Harrison, said her daughter did not say she had a problem being in a male prison.
The inquest was told that Miss Thompson had identified as female since she was 10 years old but had never had any surgical or hormone treatment.
The coroner said that she did not have a Gender Recognition Certificate establishing her female identity so she was sent to a male prison.
The jury heard about the extensive drug, alcohol, mental health and other problems Miss Thompson had experienced in her life.
At Leeds Prison, she was subjected to hourly checks but not put on the vulnerable prison wing to begin with as staff feared she would be in danger from sex offenders.
She was eventually moved to the vulnerable prisoners' wing at her own request.
She was found dead in her cell on November 13 2015 with a ligature around her neck.
In a statement after the hearing on behalf of Miss Thompson's family, Philip Goldberg, Managing Director of Minton Morrill Solicitors said: "Vikki’s case is a deeply tragic one. She is one of three transgender women to die within the male prison estate since November 2015.
"Yes, Vikki was a transgender woman housed in a male prison but like many others in prison her vulnerability did not make her unique. It was the responsibility of HMP Leeds to ensure she was properly looked after and safe.
"The jury heard that Vikki experienced bullying and sexual harassment on E-Wing that caused her to self-harm before she was moved to the Vulnerable Prisoner’s wing. HMP Leeds has the second-highest number of self-inflicted deaths in the UK and an inability to learn from their mistakes.
"Vikki’s mother remains deeply distressed by the loss of her daughter. Yet hopes that if any good is to come of her death, it’s that the Ministry of Justice also undertakes a complete overhaul of HMP Leeds."
He added: "Vikki’s death has led to a review of the Prison Service Instruction that governs the management of Transgender Prisoners. Whilst we welcome the policy reform, what really matters is that prisons protect those prisoners in real terms. This will require a radical shift in prison staff culture and training."
In a statement issued through INQUEST, Ms Harrison said: "Words cannot describe the upset of losing my daughter Vikki.
"She was such a bubbly personality and so full of life. As a transgender woman, she experienced a number of difficulties throughout her life. She was the victim of a rape and was going through the process of dealing with this not long before she was sent back to HMP Leeds.
"Vikki was anxious to be back in prison and repeatedly expressed her concerns. I do not feel that the prison fully appreciated Vikki's vulnerabilities and I believe their lack of insight has resulted in her death."
Deborah Coles, Director of INQUEST said: "This was a death waiting to happen. A vulnerable, young transgender woman was sent to a men's prison despite the risks of abuse and mistreatment. There was no consideration of the gender she had openly identified with for half her life. "
Ms Coles said she did not believe new measures introduced by the Government to improve the care and management of transgender prisoners could have prevented Miss Thompson's death "given the range of failures uncovered at this inquest".
She said: "Vikki's treatment by the prison and healthcare trust was at best incompetent and at worst inhumane. Recent inquests at HMP Leeds and other prisons have shown staff are unable to implement even the most basic training and policies intended to protect vulnerable prisoners. The incoming Government needs to address the unacceptable death toll in prisons and the high numbers of people in prison who should not be there at all."
A Ministry of Justice spokesman said: “This is a tragic case and our thoughts are with Vikki Thompson’s family and friends.
“We recognise that there were failings in her care, and HMP Leeds has already put in place a number of measures to better support offenders following the PPO investigation.
“We will now carefully consider the findings of the inquest.”
A spokesman at NHS England, said: “We acknowledge the findings reached by the coroner and the jury and will be considering them in more detail working with Her Majesties Prisons and Probation Service (HMPPS) and healthcare providers. We are committed to ensuring patients receive the best care possible.
“We would like to also once again express our condolences to Vikki’s family and friends.”