A series of failings at troubled Bedford prison led to an inmate hanging himself in his cell, an inquest has concluded.
Mark Vagnoni, 35, was being checked every half an hour because of his state of mind and record of self-harming.
But 15 minutes after an officer spotted him running his bedsheets through his fingers, he was found hanging.
Despite attempts to save him, Mr Vagnoni died in hospital two days later.
The inquest heard he was upset after being fired from his job in the prison kitchen due to a row over an apple crumble.
He suffered from schizophrenia, had used drugs in the past and had complained to his family that he was being bullied in prison.
Recording a narrative conclusion, the inquest jury wrote: “We find that placing him in a single cell left him extremely vulnerable.”
They were unable to conclude that Mr Vagnoni intended to commit suicide, saying: “We feel that he may have been making a call for help or perhaps was acting wholly irrationally, whilst under the influence of drugs.”
The jury added: “There were systemic failures, on the part of the trust and the prison service to share information.
“These failures led, we feel, to circumstances in which Mr Vagnoni’s actions (leading to his eventual death) became far more likely.”
They said the absence of universal training for medical and senior prison staff and the absence of systems for consideration of wing observation books appeared to be at the core of the failures.
An Her Majesty’s Inspectorate for Prisons report conducted in May 2016 found that conditions in the prison had declined to unacceptable levels.
In November 2016, there was a riot at HMP Bedford involving 230 prisoners.