Black Country coroner Zafar Siddique said staff at Oak House mental health rehabilitation unit in Tipton had failed 24-year-old Shannon Quinn, who was on five-minute suicide watch.
She was found hanged in her room on January 9 after a critical observation was missed.
Staff and paramedics tried to resuscitate her but she was declared dead at the scene. The unit has since been placed in special measures by the Care Quality Commission.
Mr Siddique said he would be writing to the CQC and the Department of Health raising concerns about Oak House, in particular over a lack of information-sharing by agencies involved in her care, and the failure to train staff in her complex psychiatric condition.
Miss Quinn, who dropped out of a Fine Arts degree in her second year at Birmingham University, suffered from Asperger's Syndrome, anxiety, depression and emotionally unstable personality disorder.
She had a history of self-harm, the week-long inquest in Oldbury was told.
She was an inpatient at Mary Seacole House, a psychiatric intensive care unit in Birmingham, before being moved to Oak House, run by Camino Healthcare, in August last year, seen as a halfway stage to her leading an independent life.
But she continued to self-harm and exacerbated her condition by drinking alcohol.
Entries from Shannon's diary revealed she felt upset by staff's lack of supervision, including failing to search her when she returned to the centre with bottles of gin and razor blades, which she saw as a rejection of her.
Staff had been given just 90 minutes training which was "only a basic overview" of her complex condition, former CQC inspector Lisa Clayton told the inquest.
Although they worked "exceptionally hard" to support Shannon and were devastated by her death, staff didn't have the skills set to cope with her. Ms Clayton said her death was the result of "a tragic set of circumstances."
On the day she died, Miss Quinn was checked at 5.55pm when she was observed sitting on her bed but a vital 6pm check had not taken place and she was found at 6.05pm.
If was some minutes before resuscitation attempts started. A 999 call was made at 6.17pm. The coroner said "a window of opportunity" to save her had been lost.
Concluding that her death was accidental but that neglect had been a "direct contributory factor", he said there had been gross failings by Oak House in her care, including the lack of CPR training and ligature management.
Mr Siddique also questioned Shannon's placement so far from her Solihull home, which had meant a two-hour £70 round-trip taxi ride for her concerned family.