A sectioned psychiatric patient hanged himself with a holdall strap handed to him by a nurse.
Michael Dodds, diagnosed with post-traumatic stress disorder, took his own life at NHS Tayside’s Carseview Intensive Psychiatric Care Unit in Dundee.
An inquiry into his death heard that trainee GPs with no psychiatric experience were left to care for vulnerable patients.
It also emerged that the hospital kept no record of whether patients had items they could use to harm themselves.
Mr Dodds, 38, of Dundee, hanged himself on September 8, 2007.
During the fatal accident inquiry at Dundee Sheriff Court, Dr Helen Millar, a consultant psychiatrist at Carseview for 10 years, criticised a system that put GP trainees with no psychiatric experience on a three-month rotation there.
Dr Millar wrote to the medical director urging that the system be changed. This eventually happened but only after Mr Dodd’s death.
In a written ruling, Sheriff Derek Pyle said: “The failures in this case were obvious.
“The system for a written record of possessions was totally ignored.
“The movement of such possessions was not recorded in writing in the nursing notes, resulting in there being no record that Mr Dodds was already in possession of a trouser belt.”
The sheriff said staff nurse Stephen Duncan failed to take “even the most basic steps” before he gave Dodds the belt that claimed his life.
He added: “The decision to give Mr Dodds the holdall strap was taken by one nurse without consultation with his colleagues, in particular a doctor.
“Having given the strap to Mr Dodds he (Stephen Duncan) failed to watch closely what Mr Dodds wanted to do with it, and he failed to record the event in the nursing notes.”
Sheriff Pyle also found that nursing staff lacked refresher training and they there was insufficient supervision from superiors.
The Dodds family solicitor, Brian Bell, said: “This is one of the most shocking cases of neglect we have encountered.”