A mother killed herself on her daughter's birthday after she was allowed out of a psychiatric hospital for the occasion.
Clare Moorhouse was labelled a "medium risk" patient despite several suicide attempts in the months before her death.
She was released from Mill View Hospital in Hove despite warnings from some staff that her daughter's 11th birthday was a key danger date.
Yesterday practices at the hospital were condemned as "worse than useless" at an inquest into her death.
And Brighton and Hove coroner Veronica Hamilton-Deeley demanded the "entire philosophy" of the hospital be rethought.
In a two-day hearing in Brighton she criticised the hospital for:
* Ignoring warning signs Ms Moorhouse might try and kill herself
* Allowing her to stay in a house where she had made two previous suicide attempts, and
* Failing to try to contact her when she did not return to the hospital as planned.
Poor note-keeping, a lack of communication between the hospital and Clare's family, use of "inappropriate" medication and a failure to properly assess her mental state were all criticised by the coroner.
Ms Moorhouse, a 42-year-old landscape gardener, was taken to the Royal Sussex County Hospital after she took an overdose of pills and tried to slash her wrists in February.
Friends told staff there her mental state had deteriorated over the previous 18 months.
They raised concerns she had become involved with a cult which used the powerful hallucinogenic drug ayahuasca, which they believed made her more unstable.
Ms Moorhouse was admitted to Mill View Hospital on March 16. On March 23 she attempted suicide with an overdose of ibuprofen. On March 31 was found in a field after taking 90 paracetamol and was treated at the Royal Sussex County Hospital for seven days.
On May 10 she escaped from the hospital and was found wandering near Beachy Head.
She was discharged to stay with her brother on June 4, but he could not cope with her and on June 8 he asked police to return her to the hospital.
A note from her assessment at the Royal Sussex described Ms Moorhouse as "at high risk of suicide".
It said: "She is very convincing that she is well enough to leave, but she definitely isn't and has nowhere else to go."
Despite the note, Mill View staff assessed her as "medium risk" throughout her treatment.
Ms Moorhouse asked to be discharged for two weeks so she could celebrate her daughter's 11th birthday with her on June 26.
On June 24 Clare Rothington of the hospital's acute home treatment team, tried to assess whether Clare was fit to leave but the interview was a failure.
She said: "She was extremely anxious and unable to talk to us.
"We felt the birthday might make her more at risk."
Friend Simon Waite, who Ms Moorhouse was released to stay with, returned from work on June 26 to find she had hanged herself in his bedroom wardrobe.
Miss Hamilton-Deeley, who recorded a narrative verdict, said: "I find the checks and balances failed on a number of levels. Clear evidence of risk was missed."
She pledged to make a report under coroners' rules outlining what the hospital should do to avoid future fatalities.
After the hearing, Mark Daniels, the father of Ms Moorhouse's daughter, described his former love as a popular character before the onset of her depression.
He said: "At her best she was gregarious. She liked to party.
"She had lots of friends - she always had visitors at Mill View.
"She lost her way badly."
Richard Ford, Sussex Partnership NHS Trust's executive director for Brighton and Hove, said: "This is a tragic event that must have caused great distress and I would like to express my condolences to the family and friends of Clare Moorhouse.
"We will study the coroner's findings carefully so we can learn from what has happened.
"I will make sure the trust makes any changes that are required and I will be keeping in touch with the family to hear from them and share with them the actions we will take."
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