A VULNERABLE young man hanged himself after absconding from a mental hospital through a door that was likely to have been left unlocked and unalarmed, an inquest heard.

Staff at Prospect Park Hospital in Reading showed Bracknell man Jonathan Lowbridge, 20, the potential to get out through the fire door, which should have been kept locked and alarmed, when they got him and other patients to use it to load a vehicle for a car boot sale. A few hours later the same day, May 23, 2009, he left through it and hanged himself in nearby woodland.

Mr Lowbridge’s parents, Michael and Margaret Lowbridge, and sister Gemma Lowbridge, said he was “much loved and would be badly missed”.

In a statement after the two day inquest at Reading Civic Centre on Tuesday, they criticised poor procedures around securing the fire door and said: “This subsequently led to Jonathan taking his own life. We are now considering making a formal complaint to the ombudsman.” The inquest heard that Mr Lowbridge was admitted on May 22, 2009, after trying to gas himself in the car park of the community mental health team the day before.

There was initially confusion over how frequently he should be checked but staff agreed five times an hour. And there were inconsistencies over when these were reported to have been actually carried out and whether his absence was discovered at 1.15pm or 1.30pm on May 23. CCTV footage showing him leaving was lost without a time being noted.

The police were not notified of his disappearance until up to an hour later, at 2.12pm. His body was found in woodland near the Meadway by a passerby at 7.55pm.

The inquest heard inconsistencies between support worker Christine Hyde and ward manager Lin Rosier as to which member of staff was seen monitoring a patient next door who had to be constantly monitored and when.

Berkshire coroner Peter Bedford recorded a narrative verdict and said: “It is likely that the alarm was regularly deactivated throughout a complete shift and that staff used the fire exit door as a short cut to the car park when going off-duty.

“It is further likely, on the balance of probabilities, that Jonathan left the ward unseen through the unlocked fire exit door at a time when the alarm had been deactivated and therefore staff were not alerted to the fact of the door being opened.” An independent report given to Mr Bedford said the fire door locks and alarm systems have been changed. Berkshire Healthcare NHS Foundation Trust, which runs the hospital and is consulting on moving all mental health inpatients in the county there, said in a statement after the inquest that it acknowledged the finding and expressed sincere condolences to the family and an investigation had been carried out.

It added: “The Trust has commissioned a detailed investigation into the circumstances of Jonathan’s death and a number of steps have been taken to address the findings of that investigation. The outcome of the investigation has been shared in full with Jonathan’s family.” "A DISASTER WAITING TO HAPPEN" AN inquest into the death of Jonathan Lowbridge heard how the 20-year-old attempted suicide in the car park of Church Hill House where he had been treated.

His father, Michael Lowbridge, questionned why staff did not take his son's case more seriously and said he told them: "Jonathan is a disaster waiting to happen." Mr Lowbridge jnr was referred to Berkshire Healthcare NHS Foundation Trust's community mental health team after suffering psychotic systems and being assessed by Dr Wagdy Saad on November 25, 2008, who thought he may be autistic. Mr Lowbridge told Dr Saad he had had suicidal thoughts and said: “Every time I look in the mirror I feel disgusted to be me, it’s my personality, I hate my personality.” Staff from the early intervention in psychosis team, community psychiatric nurse Joanne Davies and psychologist Stephen Barton, arranged for Mr Lowbridge to do an assertiveness course and other treatment but felt he was not at risk of suicide.

Ms Davies discharged Mr Lowbridge from her care on April 11, 2009, not realising that Mr Barton had done likewise days earlier.

Mr Lowbridge said he later took two failed medicine overdoses that month then at 7pm on May 21, 2009, was seen trying to gas himself in a car parked outside Church Hill House in Bracknell - base of the community mental health team.

His father Michael Lowbridge said in the inquest after hearing from Ms Davies: “I feel strongly the reason he attempted suicide in her car park was to show her that she thought he was a fraud. He did it to make the point that he was serious, not a fraud. Why do you think he tried to do commit suicide in your car park?” She replied: “I don’t have the answer to that.” Two staff members saw Mr Lowbridge, who drove off, and called police, who found him 40 minutes later making another attempt in Threshfield, Easthampstead. They took him to the Royal Berkshire Hospital in Reading for carbon monoxide poisoning and later arranged his admittance to Prospect Park Hospital.