Jack Portland died on December 27, 2015 and his inquest was held last week at Buckinghamshire Coroner’s Court in Beaconsfield.
The inquest heard how, although being popular at school and described by his friends as ‘lively and outgoing’, Mr Portland had struggled with drug addiction.
He became so desperate that he deliberately shoplifted, intending to use a stay in prison to get clean.
But when he was sentenced to serve time at HMP Woodhill the drug Spice was widely available, and he began to experience psychotic symptoms.
Jack was a patient at the Whiteleaf Centre at the time of his death, and the inquest found failing in risk assessment process, communication with Jack’s family, leave systems and how the centre responds to patients absent without leave.
The inquest heard that Jack, 29, died while on unescorted community leave scheduled for an hour by the centre.
But when Jack failed to return it took an hour-and-a-half for the alarm to be raised, and the police were not called for more than two hours.
During the search, Jack’s family were not informed that he had gone missing.
A statement from Jack’s family, issued after the hearing, said: “Losing a loved one is very difficult, losing a child in tragic circumstances is a lifetime sentence in regret, losing the life experiences we all enjoy have been cut short for him, wishing things were different.
“One of the last things Jack wrote was ‘life is short, don’t be lazy’, good advice son, I hope we have done you justice.
“We value the opportunity to participate in the inquest process and the resulting findings of the jury.
“The culmination of the inquest process and the recognition of Jack as a person, exhibiting and experiencing a constellation of health concerns, demonstrated by the jury’s finding that there were failings in his care, is some relief to us.”
Oxford Health NHS Foundation Trust, which runs the Whiteleaf Centre, said: “The trust offers its sincere condolences to Jack Portland’s family and friends following his tragic death.
“The inquest had highlighted a number of issues around Jack’s care and the trust has acknowledged mistakes were made in the way our procedures were carried out around missing patients, and the process by which leave was granted.
“Prior to this week’s findings, we had already looked at our services and carried out investigations into the circumstances surrounding Jack’s death, and following this have reviewed, and continued to review, processes and procedures to reduce the risk of these mistakes from happening again.
“We have extended an invitation to Jack’s family for them to meet with senior clincians and staff at the trust to discuss any concerns they may have.”