Neglect by medical staff led to a man dying of dehydration in a hospital bed, a coroner has ruled.
Medical staff at St George's Hospital in Tooting, south London, did not give Kane Gorny vital medication to help him retain fluids.
The 22-year-old, who was a keen sportsman, even phoned police from his hospital bed as he was so desperate for a glass of water, the inquest heard.
Deputy Coroner Dr Shirley Radcliffe told the hearing "a cascade of individual failures has lead to an incredibly tragic outcome".
She recorded a narrative verdict at Westminster Coroner's court and said Mr Gorny had died from dehydration contributed to by neglect.
Dr Radcliffe said: "Kane was undoubtedly let down by incompetence of staff, poor communication, lack of leadership, both medical and nursing, a culture of assumption."
Speaking outside the court, James Stevenson, the solicitor for Mr Gorny's family, said they were "devastated by the number of missed opportunities" to prevent his death.
Mr Stevenson said: "There were systemic and individual failures in the level of care provided to Kane."
Mr Stevenson, who was standing beside Mr Gorny's mother Rita Cronin, added: "Kane was a well-liked, adoring and loving son, brother and friend."
Dr Radcliffe told the inquest she would write to the hospital about nurses involved in fluid management and sedation following Mr Gorny's treatment there.
A post mortem examination revealed high sodium levels caused by dehydration had caused his death.
Mr Gorny was suffering from diabetes insipidus, a condition which caused him to be aggressive towards nurses on May 27 2009, the day before he died.
Mr Gorny, a supermarket employee, from Balham, south London, had been sedated and put in a side room following his outburst.
Staff nurse Adela Taaca, who was the senior nurse in Mr Gorny's ward on the night of May 27, previously told the inquest she did not take observations or ensure he took his medication.
She said this was because she was mindful of his earlier behaviour, and that his brother, who was sitting next to his hospital bed, asked her to let him sleep as he was sedated.
Shortly after her shift ended, Mr Gorny's condition deteriorated and despite frantic efforts to save his life for two-and-a-half hours, he was pronounced dead at 11.20am.