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The home secretary and the health secretary are obliged to respond to the coroner within 56 days of the PFD being published, to provide details of action being taken or proposed action due to be taken to prevent future deaths.

His parents, Zoe and Lewis Steeper, have welcomed the PFD report and hope change will come from it.

This was the third PFD report highlighting the same issues within 12 months.

In the PFD report about Henry's death, assistant coroner Dr Séan Cummings said there was a "culture of not recording contemporaneous notes" and communication between staff was "very informal" with "no record kept of important messages relayed".

Since Henry's death, the evidence from campaigners suggests nine other other mental health patients have died with some of the same safety issues raised in the PFD reports.