'Operational inconsistencies' in the prison system contributed to the death of an inmate at HMP Wormwood Scrubs, an inquest has found.
Lee Crossley was found hanged in his cell at the jail in Du Cane Road, White City, on December 23 - just five days after being locked up again for breaching his licence conditions.
A jury at West London Coroner's Court concluded that the 39-year-old designer, of The Ham, Brentford, had taken his own life.
Jurors found that better communication between staff may have helped identify Mr Crossley as a risk to himself, ensuring a suitable care programme could be put in place, which may have prevented his suicide.
"We believe based on the evidence that operational inconsistencies in the prison system (all disciplines) contributed to Mr Crossley's state of mind at the time of his death (eg failure to provide secondary mental health screening)," they concluded on Tuesday, February 9, at the end of a six-day hearing.
'Information was not shared or reviewed'
"Relevant information was not consistently shared or reviewed between different disciplines (this appeared to lead to a situation where an ACCT (Assessment, Care in Custody and Teamwork) was never opened but may have been had information been shared)."
An ACCT is a care planning system used in the prison service to better monitor and support inmates identified as being at risk of suicide or self-harm.
The inquest heard how Mr Crossley was convicted in 2012 of a historic offence involving an "indecent act with a minor", and was sentenced to two years' imprisonment.
He was released on licence later that year but was recalled to prison on December 18, 2013 after he was found to be selling children's items on eBay.
This was a breach of his licence conditions, which required him to declare any new work.
Jurors were told how Mr Crossley had previously attempted suicide while in custody prior to his conviction.
But the court heard he had not since disclosed any suicidal thoughts to his probation officer and had appeared "very stable" to the nurse who assessed him on admission to Wormwood Scrubs.