A coroner has said that there were "catastrophic failings of systems and individuals" at a hospital in Powys where a psychiatric patient died.
Sylvan Money was found hanging from a bedroom curtain rail
Artist Sylvan Money, 26, from Presteigne, used her nightgown cord to hang herself from a curtain rail at Bronllys hospital near Brecon in 2004.
Coroner Geraint Williams listed 36 errors as he recorded a narrative verdict contributed to by neglect.
Four members of staff at the psychiatric unit were later sacked.
In a three-hour summary of evidence he also expressed disbelief, anger and deep irritation at many of the staff responsible for Ms Money's care.
No structure to way information was passed on to staff
Records not properly kept and many staff did not appear to read patient files.
Not enough time was spent with Sylvan
Daily reviews of suicide watch frequency not carried out
General attitude among many staff that there was no need to inform anyone if they could not carry out their hourly suicide watch duties.
When Ms Money had been admitted to the unit she was put on 15-minute suicide watch for at risk patients.
Within days that was downgraded to 30 minutes, despite evidence suggesting her mental state had not improved.
But a catastrophic breakdown in operating the rota meant she had not been checked for more than an hour when she was discovered dead.
Mr Williams highlighted the fact that none of the nursing staff had had any training for suicide watch.
He said he would be sending a letter to Powys Local Health Board calling for nursing staff to be habitually trained, and annually updated, in suicide awareness, current observation policy and practice and risk management.
Among his concerns was the fact that one member of the care staff had reading difficulties which had apparently been unknown even to a colleague of 20-years standing.
Senior staff at the unit also failed to carry out obligations to provide a safe environment.
A report instructing the hospital to check for potential ligature points was passed on to a department which then ignored or forgot it for almost 18 months.
Senior staff members believed curtain and other rails at the unit had been made safe or collapsible, to prevent them being used as ligature points, when that was not the case.
But the inquest at Ystradgynlais heard all curtain rails have since been removed from the unit, which only opened in 2002, and major changes to the monitoring system are in place or under way.
Mr Williams praised psychiatrist Dr Dineon Murugesan and also Dr Gillian Todd, the medical director of Powys Local Health Board, who he said was "genuinely distressed" by what had happened.
After the hearing, Ms Money's parents Christopher Money and Carol Horne, said: "We are still filled with overwhelming grief and desperation for ever admitting Sylvan into such an environment.
"We thought she was safe and would be looked after. But if we had not done that, she would still be here today."
Powys LHB said since Ms Money's death, it had been "very clear of its responsibility to learn from this case".
It said it had undertaken "considerable work", including revising policies, improved record keeping, staff training and replacing curtain rail with magnetic track.