An inquest jury has found that gross failures and neglect by staff led to a patient’s death at a privately-run psychiatric hospital in Bradford.

After the jury returned its unanimous findings yesterday, Karen Barnes said she hoped lessons learned from her son Peter’s death may stop other tragedies.

And Assistant Bradford Coroner Neil Cameron, who heard four weeks of evidence, said he would write to the Cygnet hospital in Wyke about his concerns.

Mr Barnes, who was 32, had only been admitted to the hospital weeks before he went missing on an unsupervised cigarette break on October 13, 2011.

Despite searches, it was a week before he was found hanged in its grounds. A post-mortem examination showed he had died hours after he went missing.

Jurors, who decided Mr Barnes had taken his own life while the balance of his mind was disturbed, also stated in their findings that the hospital’s systems and methods of communication ensuring his clinician had all the information needed to decide whether or not to allow unescorted ground leave had been “inadequate” and had led to an error which gave him the opportunity to take his own life.

The response of the hospital and its staff to him going missing was also “untimely and inappropriate” they said in regard to the efforts they made to find him and the time and the nature of information passed on to police.

The jury foreman concluded: “His death was contributed to by neglect, namely by the aforementioned gross failures of hospital systems and the failure to communicate and identify significant events which led to him wrongly being granted unescorted ground leave.”

The inquest had heard Cygnet Wyke’s most senior clinician Dr Keith Rix, who had allowed Mr Barnes unescorted leave, had not been told about marks seen on his neck or how he had been heard talking about ending his life with shoelaces days before he took his life.

After the hearing, Mrs Barnes, 54, of Lincoln, who had attended daily with her other son Christopher, said it had been an “agonising” two years waiting for the inquest.

She said: “At long last Peter’s voice has been heard through his inquest. We have heard what he was feeling – making himself heard was something he had to fight for all through his illness.

“The jury’s determination is what we knew all along.

“He was failed by Cygnet. We now hope what happened to Peter and the outcome of the inquest will be used as a precedent and lesson to be learned stopping any other families going through the agony we have suffered.”

In a statement last night a Cygnet spokesman said: “We were struck during these proceedings by the love and care that Mr Barnes was given by his family all through his life and our thoughts are with his family and friends at what must be an incredibly difficult time.”

“We have already made numerous changes to further improve our services. Communication inside Wyke has been totally overhauled.”