A 29 year-old sectioned man who battled drug addiction was 'let down' by the care he received in prison at HMP Woodhill as well as at the Whiteleaf Centre.
Jack Portland died just after Christmas when he was granted one hour unescorted leave on December 27, 2015.
A jury heard details of his life at Beaconsfield Coroners Court from January 23 and gave their conclusions on Friday February 3.
The jury concluded on Friday 3 February that there had been a range of failures by the public bodies responsible for keeping Jack safe when in custody and when sectioned under the Mental Health Act in hospital.
Jack was lively and outgoing growing up and played rugby for Amersham and Chiltern Rugby Club but battled drug addiction. The inquest heard how in a bid to get clean Jack decided to get caught shoplifting, landing him a stint at HMP Woodhill.
In the Milton Keynes prison he was exposed to the drug Spice, which was widely available and led him to developing psychotic symptoms for the first time. Jack's parents concerns went unanswered.
HMP Woodhill has been repeatedly criticised by Coroners and the Prison and Probation Ombudsman for shortcomings in its safety procedures and protection for its most vulnerable prisoners. The jury ruled that there were failings in Jack's discharge and resettlement.
In 2016 HMP Woodhill recorded the highest number and highest rate of self-inflicted deaths across the entire prison estate.
Jack was later a patient at the Whiteleaf Centre in Alylesbury, where Jack was a patient at the time of his death. The jury found failings in risk assessment process, communication with Jack's family, leave systems and how they respond to patients absent without leave (awol).
Jack died while on one-hour unescorted community leave from the Centre but his absence went unnoticed for an hour-and-a-half after he was due to return. The Police were not called for over two hours. His family were never informed he was missing.
In a statement released after the verdict, the family of Jack Portland said:
"The family are grateful for the professional services of the coroner's office and the process they have experienced in the past two weeks, and over the past year in preparation for the inquest of their son, Jack Portland.
"Losing a loved one is very difficult, losing a child in tragic circumstances is a life time sentence in regret; knowing 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's short, don't be lazy', good advice son and 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.
“However we are saddened that the experience of people with impaired mental health, coupled with addiction, is continuing to be misunderstood, a stigma applied and their care mismanaged.
“It’s evident that society still has a long way to go in treating everyone with equal concern. The family will continue to try and effect a positive change for people in need of support and understanding.
“The family would like to thank the legal team and inquest.org for all their hard work and support.”
The family were represented by Caoilfhionn Gallagher of Doughty Street Chambers and Merry Varney and Benjamin Burrows of Leigh Day, members of the Inquest Lawyers Group.