A rehabilitation centre in Swindon which was caring for a man who was a known suicide risk failed on multiple levels to protect him, an inquest jury has found.

Daniel Beswick, who was 31 at the time, was being cared for at Chalkdown House, a specialist brain injury unit in Dorcan, after suffering brain damage caused by a previous suicide attempt.

A jury at Wiltshire and Swindon Coroners Court came to the conclusion that Daniel’s death was a result of "a culture of 'trusting to chance' at all levels” at the rehabilitation centre as well as staff failing to follow observation and monitoring procedures as directed by the multi-disciplinary team.

It has also been put down to insufficient staffing levels and an overreliance on agency staff.

The jury recorded both a suicide and narrative conclusion following the three-day inquest in September.

In September 2015, Daniel had been placed on one-to-one observations which meant that a carer had to be with him at all times. But on September 16, the decision was made during a team meeting to move Daniel from one-to-one observations to every 15 minutes.

This decision was made because Daniel had expressed his discomfort with constantly being observed.

In order to make this change in observations, a clinical psychologist, Rachel Hamblin made the decision to remove items from the room which Daniel could use to harm himself.

Daniel was then found dead in his room on September 17.

The carer in charge at the time, Petua Nugent, explained that the evening before, Daniel had been extremely agitated by the fact that his room had been stripped of items.

In their conclusion, the jury found that: “There were inadequate procedures, checks and controls to ensure the decisions relating to Daniel's care made by the Multi-Disciplinary Team were correctly carried out as directed; in particular, the identification & clearing of potential ligature risks.”

The rehabilitation centre was understaffed the evening of his death and this has been credited as a contributing factor.

The evening of Daniel’s death, two members of staff were offsite as they were taking a resident to the hospital. Another staff member, Samuel Haward was late to his shift.

Ms Nugent told the coroner's court on Monday, September 25 that she took responsibility for there not being enough staff on shift that evening. She explained that she had taken a risk by letting staff leave before new staff had joined her.

Chalkdown House closed down in 2017.

If you need support, contact the Samaritans' 24/7 helpline on 116 123.