A man was found hanged after escaping from a secure Berkshire mental health hospital where he had been assessed as a high suicide risk, an inquest heard.
Jonathan Lowbridge, 20, was admitted as a voluntary patient to Prospect Park Hospital in Reading, after he attempted to commit suicide on 21 May 2009.
Mr Lowbridge had tried to commit suicide three times, the court heard.
He is thought to have fled from a locked ward via an unlocked fire door on 23 May. He was later found dead.
The inquest heard on Monday that Mr Lowbridge had recently moved to Berkshire from Norfolk, where he had been treated for depression as he grew up.
'Very unhappy lad'
The hearing was told that he was first assessed in Berkshire for his mental health condition in November 2008.
Psychiatrist Dr Wagdy Saad said that Mr Lowbridge had very low self-esteem, talked about wanting to commit suicide and had visions.
Mr Lowbridge underwent a counselling programme until he was discharged on 11 May 2009.
Psychologist Dr Stephen Barton said that he had by this stage become more self-confident, the inquest heard.
But Mr Lowbridge's father, Michael, said: "He was a very unhappy lad, he couldn't cope with life."
Ten days later, Mr Lowbridge made three attempts to commit suicide.
It was these incidents which led to him being arrested and admitted to Prospect Park Hospital. The inquest heard that Mr Lowbridge voluntarily allowed himself to be admitted to the hospital but he would have been sectioned under the Mental Health Act if he had not agreed.
The hearing heard a doctor at the hospital diagnosed Mr Lowbridge as "high risk" and advised he be placed under "close observation", which would have required constant supervision.
But the inquest heard that his written suggestion was interpreted as the patient should be checked upon four times an hour.
The hearing continues.