The man was strangled to death by another patient.
Both were wearing belts, which neither should have been, and the attacker used one to kill his victim. As well as that breach of security, staff hadn’t been checking on patients at least once an hour as they were supposed to.
The new report also claims the victim shouldn’t even have been in the psychiatric ward at the time, as he had been deemed fit enough to be discharged, but local authorities couldn’t agree on who would pay for somewhere for him to live.
Previous investigations had denied there were any safety failings.