Ondrej Suha was found hanged in his cell after reading that he could be sent back to Slovakia, which he left at age of four

A 19-year-old killed himself at a youth prison after being told he could be deported to a country he had not lived in since he was four, a jury has found.

Slovakian-born Ondrej Suha, who had just started a 14-month sentence for burglary and assault, had also witnessed his cellmate attempting to take his life a few days earlier.

Suha had tried to kill himself twice the month before he died and had told staff at Brinsford young offender institution in Wolverhampton he no longer wanted to live. But he was taken off suicide watch the day after his unsuccessful suicide attempts by a prison officer who later said he did not know that Suha had tied two separate ligatures.

The teenager from Walsall, who thought of himself as “British through and through”, was discovered hanged in his cell on 21 December 2015, shortly after receiving a letter from the Home Office telling him he was liable to be deported to Slovakia after his sentence, despite having lived in the UK since he was four years old. He was taken to New Cross hospital in Wolverhampton but died on Christmas Day.

The prison officer who served Suha with the papers told the hearing that he would have preferred to do this during the core prison day rather than shortly before lock-up.

An inquest jury in Stafford found that Suha’s death was caused by being told that he could be deported just before being locked away for the night, and therefore outside of the “core day”.

Prison medical records revealed that no one began cardiopulmonary resuscitation until a nurse arrived seven minutes after the teenager was found. During the six-day inquest it also emerged that the prison had delayed calling an ambulance, in breach of national rules.

The senior coroner for South Staffordshire, Andrew Haigh, said he would be writing to the head of the National Offender Management Service because he was concerned that inadequate training for night staff and a national policy allowing prisons to operate with only one CPR-trained member of staff on duty at any one time could lead to other deaths.

Suha’s sister, Andrea Suhova, said: “Our family has been devastated by losing Ondrej. Knowing that more could have been done to protect him has only made our pain worse.

“Ondrej grew up in the UK and thought of himself as British through and through. We will never understand why the prison thought it was appropriate to give him that letter, knowing full well it was informing him he might be deported, before locking him away for the night. He had only recently tried to harm himself and told staff that he wanted to die.

“It is now so important that the prison service, and HMYOI Brinsford in particular, learns from Ondrej’s death so that other young people are safe and other families don’t have to experience the same pain as us.”

An investigation into Ondrej’s death by the Prisons and Probation Ombudsman (PPO) found a number of concerns about the emergency response on the night of 21 December, the jury heard. These included that officers “appear to have been confused about where to find the key” to Ondrej’s cell and failed to provide CPR.

The PPO also expressed concern about the fact that the prison nurse did not have the necessary keys to attend the scene of the emergency, but instead had to wait for prison staff to escort them, leading to further delay.

Gus Silverman, a civil liberties lawyer at Irwin Mitchell, representing Suha’s family, said: “The failures in this case are depressingly familiar from other prison deaths. Whether because of poor training, understaffing or simple lack of care HMYOI Brinsford failed to keep Ondrej safe.

“This inquest has also heard worrying evidence that the prison service considers it is appropriate to allow prisons to operate with only one member of CPR-trained staff on duty at any one time. Ondrej’s family now look to the head of the National Offender Management Service to act on the concerns of the coroner regarding this policy.”

Deborah Coles of the campaign group Inquest said: “Our society needs to ask itself how many more prisoners must die before prison safety is made a priority.

“It defies belief that such unsettling news was delivered before night lock-up to someone with a history of self-harm and who’d told staff he wanted to die. This was cruel and insensitive treatment of a vulnerable teenager who should have been supported and protected.

“Familiar criticisms in the way prison staff manage prisoners at risk and the emergency response points to the lamentable failure of [the National Offender Management Service] to act on these systemic national issues of concern that are repeated time and again at inquests.”