The death of a 14-year-old girl may have been prevented if she had received proper care at a Sussex mental health hospital, according to an inquest jury.
Amy El-Keria was found hanged in her room at the Priory Hospital, Ticehurst, after tying a scarf around her neck.
The inquest in Horsham heard staff were not trained in resuscitation and did not call 999 quickly enough.
The jury said Amy died of unintended consequences of a deliberate act, contributed to by neglect.
It said staffing levels were inadequate, and a lack of one-to-one time caused or contributed to the teenager's death in November 2012 in a "significant" way.
Amy had a complex range of problems and mental health diagnoses, and died within three months of being moved to the Priory after being asked to leave her specialist boarding school in Berkshire.
The inquest heard that while at school she had drawn a picture of herself hanging with the words: "If only this could happen, but I haven't got the guts."
She made several attempts to end her life in early 2012, and was deemed high-risk when she was admitted to the hospital.
The inquest was told hospital staff had not always been able to give the teenager one-to-one time due to pressure on wards.
Jurors found that risk assessments were not properly carried out, staff did not assess the risk of Amy being able to take her own life in her room and opportunities were missed to remove the scarf from her.
A delay in checking on her on the evening she died also contributed significantly to her death.
Speaking after the inquest, Amy's mother, Tania El-Keria, said: "For 14 years we kept Amy safe. In less than three months under the care of the Priory she was dead.
"If I had treated Amy and neglected her needs in the way Ticehurst House did, she would have been taken away from me."
Dr Sylvia Tang, Priory Group medical director, said: "We would like to offer an unreserved apology and our heartfelt sympathies to Amy's family.
"Following the incident, we undertook an extensive investigation and strengthened a number of our procedures at the hospital.
"We will now review the findings of the inquest very carefully and consider whether further improvements can be made including in relation to staffing, care plans and risk assessments," she said.