Yesterday Paul Boateng, Labour's spokesman on legal affairs, and Inquest, which investigates deaths in custody, called for an inquiry into "this very tragic and avoidable death"
after an open verdict was returned on Michael McDonough, of Fleetwood, Lancashire.
The jury was told that the 21-year-old had been assessed as fit and normal between the two incidents at the prison last October. But five hours after the diagnosis, he was found dead.
Although an epileptic, Mr McDonough had not taken his daily medication, which may have had a slight affect on his behaviour, the court was told.
He had been in prison five days, remanded by magistrates for pre-sentence reports on a criminal damage charge - while he was drunk, he had smashed the window of an off-licence and entered the shop.
Mr McDonough was one of 59 people who killed themselves in prison last year. In the first three weeks of this year, five more prisoners have committed suicide.
"What on earth was this man doing in prison on such a charge in the first place?" Mr Boateng asked yesterday. "The system has failed him every step of the way - the criminal justice system failed him and the penal system failed him."
The jury at Preston coroner's court was told that Mr McDonough's cell-mate, Shahid Shah, had alerted staff when he started behaving strangely - shouting and banging on the door.
Brian Bennett, a night patrol officer, said he saw Mr McDonough just before 3am standing on the radiator in his cell with his pullover tied to the window frame and around his neck.
Other officers were called and he was taken to a special unfurnished cell for the rest of the night where he was under observation every 15 minutes.
Mr McDonough's normal clothes were taken away and he was issued with special prison clothing so that he could not harm himself.
At 9am he was seen by Dr John Gordon, who assessed him as being normal. He was given his clothes back and transferred to a cell on his own in the hospital observation block. Five hours later, he was dead.
Yesterday, his father, Michael McDonough, 43, an employment law consultant, said: "I wanted the verdict to show that the staff at the prison had failed in their duty to ensure the health and safety of my son.
"What I cannot forgive is that his death was so senseless and so preventable. How you can just lock somebody away who has already tried to hang himself and then not stop them doing it again is beyond me.
"They obviously do not look on prisoners as human beings otherwise they would not treat people like that. My son was not some hardened criminal, he was a very sensitive young man."
Helen Shaw, of Inquest, said: "This case highlights obvious failures within the prison service. There must be a full inquiry to find out exactly what went wrong and to recommend changes to prevent other families suffering similar tragedies."Reuse content