A Port Erin man died as a result of gross systemic failure on the part of the Department of Health, an inquest has heard.
It was told 25-year-old Ben Hall died as a result of hanging from a non-collapsible shower rail whilst an inpatient at Grianagh Court in June 2012.
Mr Hall had been suffering with acute schizophrenia disorder and often claimed to have voices in his head telling him to end his life.
However, he was not considered to be at a high risk of suicide because he was insightful of his condition.
The coroner of inquests, John Needham, was unable to place specific blame, after none of the witnesses were able to recollect the shower rail fittings.
Also, the computer with the relevant files had been wiped, leading him to question whether reports had been completed in the manner expected.
The Department of Health and Social care, as it now is, has issued a statement in response to Mr Needham's findings.
It expresses the department's condolences to Mr Hall’s family and friends following the conclusion of the inquest into his death, and accepts the coroner’s verdict and recommendation.
It adds that following Mr Hall’s death the department undertook an immediate and comprehensive review of the incident and implemented a number of measures in response.
The department will now urgently address the coroner’s recommendation to determine whether there are any additional measures that were not contained within the department’s own action plan.