Hundreds of deaths in psychiatric units, prisons and police cells between 2010 and 2013 were avoidable and were caused by repeated “basic errors” by staff ignorant of mental-health risks, human rights advocates have said. Numerous suicides in detention came after failures to monitor patients or to remove hanging risks, according to a report from the Equality and Human Rights Commission. Its seven-month inquiry into deaths in UK hospital and prison settings concluded that, despite repeated warnings, “serious mistakes have gone on for far too long”. “The same errors are being made time and time again, leading to deaths and near misses,” the report said. Between 2010 and 2013, 367 adults with mental health conditions died of “non-natural causes” in detention in psychiatric wards and police cells. Another 295, many of whom had mental health problems, died in prisons. While not all the deaths were avoidable, the commission said that simple interventions could have prevented the majority of them. In many cases, failures were down to not listening to or involving individuals and their families. Information which might have prevented deaths, such as warnings about painful anniversaries of bereavement that might trigger self-harm, was often not made known to all staff or acted upon, the inquiry found. Prisons were criticised for not monitoring the number of people with mental-health conditions behind bars, with prison officers urged to ensure inmates were not punished for behaviours “viewed as disruptive but in fact… symptomatic of illness”. There was also criticism of NHS regulation, with the inquiry concluding no national body had taken responsibility for ensuring investigations into deaths in detention took place – thus squandering opportunities to learn from mistakes. Mark Hammond, CEO of the Equality and Human Rights Commission, said his organisation’s inquiry revealed “serious cracks in our systems of care for those with mental-health conditions”. “The improvements we recommend aren’t necessarily complicated or costly: transparency and learning from mistakes,” he said. The report recommended all prisons and psychiatric units should set up “trigger systems” to alert staff to dates that could prompt someone to self-harm or attempt suicide.