On the night of Flint Cahan's death, staff on the ward were found to have been asleep on the job and on their phones for long periods.

East London NHS Foundation Trust (ELFT) says the failings identified were "wholly unacceptable" and that it has undertaken a "significant programme of work" to improve inpatient services.

The coroner's Prevention of Future Deaths report highlights 14 concerns. These include failing to carry out "timely and thorough observations" of patients, then falsifying records "in the safe knowledge that staff on duty would not report or escalate the deception".

The document also says there were delays in starting CPR on Flint Cahan when he was discovered, that staff misled the police as to what the patients had been doing on the night of the incident, and that staff colluded with each other to take two-hour unauthorised breaks.

Torres-Pena was given a hospital order with no time limit after pleading guilty to manslaughter by diminished responsibility in 2023.

The coroner also raised concerns that many of the failings had been brought up at a previous inquest he'd conducted.

"The findings in this inquest are strikingly similar to the findings of an inquest before this court in 2021, remedial measures reported in that case do not appear to have been implemented effectively by the trust", the report says.

"Findings of dishonesty on this scale are extraordinarily rare in a coronial investigation. The public are entitled to expect a clear explanation of how this was allowed to happen and what is being done to ensure it never happens again," says James Cahan, the family solicitor and Hugo's cousin.