A former British Army Gurkha soldier drowned in his own blood after hospital staff reported he was "in bed asleep, observed breathing", an inquest has heard.
Paramedics reported that 39-year-old Prem Rai had lain dead for hours before they were called to save his life, a coroner said at the inquest.
NHS staff, who were supposed to be checking on him every 15 minutes, had said that he was asleep in a mental health ward.
The coroner said in a statement:
"The paramedics in attendance felt that Mr Rai had been dead for some time and reported that rigor mortis had already started to set in.
"The observation records said that Mr Raid was in bed asleep with breathing observed... however, when staff entered his room shortly before 9am he was found to be unresponsive and not breathing."
Mr Rai had been admitted to Peterborough City Hospital after suffering from a psychological breakdown known to affect soldiers.
The father of one had served for 20 years with the Gurkha regiment, a unit who are renowned for their fearsome fighting.
Following his service, Mr Rai began suffering seizures and occasionally lost the ability to speak.
He was eventually diagnosed with a "conversion disorder" and a severe form of blood-clotting illness 'factor V deficiency', by doctors at Chelsea and Westminster Hospital.
Mr Rai was later transferred to a mental health unit in Peterborough, where he was supposedly "observed" every 15 minutes.
Whilst in the hospital's care, Mr Rai suffered bleeding injuries at least four times prior to his death, consultant psychiatrist Dr Maheshi Wikramanayake told the inquest.
Dr Wikramanayake described the disorder from which Mr Rai suffered, saying:
"It's associated with acute stress.. It's self-limiting 95% of the time, more common in females and apparently when I read literature it's common in soldiers who have been exposed to combat."
Mr Rai was given anti-depressants, anti-psychotics and sedatives to reduce "aggressive" psychotic episodes that resulted from his condition.
However, Dr Wikramanayake said this was unlikely to be a factor in Mr Rai’s death:
She said her medical team followed specialist guidance for Mr Rai's "severe" factor V Deficiency diagnosis which stated:
"We need to be aware that he may experience bleeding... and if we were to observe any of those findings we were to get specialist opinion on to how to manage that.
"The clinical team looking after him need to be informed of a factor V Deficiency... no routine follow-up is required."
"I'm satisfied that, with the information that we had and what we knew at the time with the clinical presentations, appropriate actions were taken to consider the risks and to manage the presentation at the time."