A transgender prisoner who was found dead at Leeds Prison was held in the correct jail but let down by a range of services as well as her family, an inquest jury has concluded.
Vikki Thompson, 21, had been on remand for a month when she was found dead in her cell at the prison in November 2015.
After a jury at Wakefield Coroners Court delivered a narrative conclusion, lawyers acting for Miss Thompson demanded a "complete overhaul" of the jail.
At the end of a two-week long inquest, the jury foreman outlined a range of failings by the prison and health services but also recognised agencies "under immense pressure, understaffed and working in extremely difficult day-to-day situations".
He said: "Throughout her chaotic life, Vikki has been let down by various departments including the NHS, Leeds Community Healthcare NHS Trust, the Prison Service and also by her family.
"Although these departments were individually aware of Vikki's history, the overall coordination of her mental and health state were lacking in any form of organisational structure.
"During her last stay at HMP Leeds, the management of her treatment and mental state of mind were also lacking in professionalism and inadequate for an individual of such complex issues."
But he said: "All evidence points to services under immense pressure, understaffed and working in extremely difficult day-to-day situations."
The foreman said the jury had concluded that the prison was "the right one for Vikki".
Miss Thompson, who was from Keighley, West Yorkshire, had identified as female since she was 10 years old but never had any surgical or hormone treatment.
The inquest heard she did not have a Gender Recognition Certificate establishing her female identity so she was sent to a male prison.
The jury also heard about the extensive drug, alcohol, mental health and other problems Miss Thompson had experienced in her life.
She was initially placed on a normal wing as staff thought sex offenders may pose a danger to her on the vulnerable prisoner wing.
But Miss Thompson suffered verbal and physical abuse on E Wing and began to self harm. Her request to be transferred to the vulnerable prisoner wing - A Wing - was eventually granted.
The inquest heard how she was on an hourly watch but was found on November 13 2015 in her cell with a ligature round her neck.
The inquest jury concluded that Miss Thompson did not intend to take her own life.
The prison officer who found her told the jury he was the only officer working on A Wing that evening.
At the beginning of the two-week inquest in Wakefield, Miss Thompson's partner, Robert Steele, told the jury she did not want to be in a male jail and wrote to him saying: "I know I'm going to do something silly."
The court was told she had repeatedly told prison and court escort staff that she would be "carried out in a box".
But, in a statement read to the court, Miss Thompson's mother, Lisa Harrison, said her daughter did not say she had a problem being in a male prison.
In a statement issued after the inquest: Ms Harrison said: "Words cannot describe the upset of losing my daughter Vikki.
"She was such a bubbly personality and so full of life."
Ms Harrison said: "Vikki was anxious to be back in prison and repeatedly expressed her concerns. I do not feel that the prison fully appreciated Vikki's vulnerabilities and I believe their lack of insight has resulted in her death."
Speaking outside court, Miss Thompson's family solicitor Philip Goldberg said it was a "a deeply tragic" case.
He said: "Yes, Vikki was a transgender woman housed in a male prison but like many others in prison her vulnerability did not make her unique.
"It was the responsibility of HMP Leeds to ensure she was properly looked after and safe."
Mr Goldberg said Leeds Prison has the second-highest number of self-inflicted deaths in the UK and "an inability to learn from their mistakes".
He said: "Vikki's mother remains deeply distressed by the loss of her daughter yet hopes that if any good is to come of her death, it's that the Ministry of Justice also undertakes a complete overhaul of HMP Leeds."
Mr Goldberg welcomed recent policy change relating to the the care and management of transgender prisoners but said there needed to be a "radical shift in prison staff culture and training."
Deborah Coles, director of Inquest, said she did not believe the new measures introduced by the Government could have prevented Miss Thompson's death "given the range of failures uncovered at this inquest".
She added: "Vikki's treatment by the prison and healthcare trust was at best incompetent and at worst inhumane."