An inquest into the death of a 23-year-old mental health patient has found he was failed by local services.
Jayden Booroff was being cared for at the Linden Centre in Chelmsford, Essex, when he escaped in October 2020 and died after being hit by a train.
The inquest heard how Mr Booroff had a history of cannabis use.
He was sectioned twice - first at The Lakes mental health hospital, then at the Linden Centre after suffering periods of psychosis.
But he managed to walk out of the centre, tailgating a member of staff through three doors and out through the reception.
Two hours later, he had taken his own life.
At the conclusion of his inquest the jury recorded a narrative verdict, highlighting failings in the unit's handling of records, inconsistencies in communication and an unclear policy of how to deal with absconding.
"I entrusted them with my son's life and I feel I was naive to believe that he was in a place of safety and being cared for and was going to get the help he needed," his mum, Michelle Booroff, said.
"He was told he'd be in there for at least a month, but a month later I'm at my son's funeral."
"It just feels like there was a lot of complacency and lack of care, observation and as a result I've lost my son and he's lost his life.
"He was 23, he should still be here, he should still be able to follow out his dreams.
"They say 'lessons learned, lessons learned' - my son should not be a lesson learned.
"I just feel that nothing is changing, and I think until actions and consequences start taking place, then maybe things will start changing."
Jayden's mother said she continually raised concerns to staff over his suicidal thoughts and the risk of him absconding.
The jury heard how the Linden centre had experienced nine similar incidents of tailgating between 2017 and 2020 where inpatients followed staff through doors
Melanie Leahy's son Matthew died while he was in the care of the Linden centre in 2012.
"This shouldn't be happening," she told ITV News.
"Jayden should have been safe, the same that my son should have been safe.
"Every person that's in and out of that establishment should have been kept safe, and it's sick that it's allowed to happen and I want it to be held to account."