The PPO report makes 35 recommendations after highlighting serious flaws in Christopher Wardally’s care.

The report found he was sometimes given little or the wrong medication, and that his care plan was poorly maintained and not up to date.

It also raises the question that Mr Wardally could have been better cared for in hospital, not prison.

Mr Wardally was incorrectly discharged from a vulnerable persons wing and not told he would be moved back to Wandsworth, which caused him anxiety.

He had a history of mental issues, including schizophrenia and hearing voices, and had been in and out of prison since a teenager.

One prison incident left him with compartment syndrome – where muscle swells, blocking veins in the arteries – and a limp. He also suffered with wryneck – a stiff neck associated with muscle spasm.

He started hearing voices in 2003, and later had a mental breakdown.

He started using drugs and alcohol, but despite spells in prison – Mr Wardally was housed in at least seven different prisons at various stages – Mrs Wardally said her son was looking forward to his release in March 2009.

He was released from Wandsworth on licence in March 2009, but re-offended for a motoring offence in April.

He was remanded in custody after appearing in court, which led to him missing an appointment with the Probation Service – who then started procedures to recall him to prison.

The next day he tried to commit suicide in Pentonville and after recovering was moved to Wandsworth.

After a court appearance on May 26, he was mistakenly moved to Pentonville – despite his suicide attempt – instead of Wandsworth.

Despite being placed under observation in a vulnerable prisoners wing and expressing suicidal thoughts he again tried to commit suicide on June 1.

He eventually returned to Wandsworth on June 9, and was found hanged on June 12.

The draft report notes: “Between 9 and 12 June staff on the Onslow Centre (vulnerable persons unit) only maintained hourly checks at night, recording intermittent observations during the day.”

It also notes “during the morning Mr Wardally was observed by three officers, who all noted he did not respond to them and was staring at the wall. Despite one officer expressing concerns and telling colleagues he was worried, his observations were not increased.”