An inquiry has found that the deaths of hundreds of people with mental health conditions who were held in detention could have been avoided.

The inquiry focused on adults detained on psychiatric wards, in police cells and prisons between 2010-13.

The criminalisation of mental health that has been bought about by law enforcement detaining people suffering from issues in prison cells rather than specialist care units is an outrage in itself, but for these vulnerable people then to die when to do is avoidable is unforgivable.

The report, commissioned by The Equality and Human Right Commission said there were a myriad of factors involved, all of which are simple to overcome.

Basic errors and a failure to involve patients families were the primary causes to blame.

Not adequately monitoring patients and prisoners at a serious risk of suicide is indicative of a culture that does not give mental health problems the credence that it deserves and necessitates, and so too, poor communication between staff which results in loss of information further compounds the idea that to some, mental health does not matter.

But when there is loss of life, and indeed 367 adults died over the course of the time period studied, it clearly is crucially important.

So what needs to happen?

First of all, and this is societal-wide not just within institutions, mental health needs to be given the same level of importance as physical health.

If someone had broken their leg in prison, they would have regular visits and be put in a position where they could not damage this leg further.

So too, if someone is suffering from mental health problems, they need to be monitored so they cannot harm themselves, if that is something that they are likely to do.

Secondly, these institutions should commit to what the Department of Health has suggested that the NHS do, a ‘zero suicide’ ambition.

This is modelled on a depression care programme in Detroit, which had great success and resulted in no suicides for more than two years.

To read more about the report, go to