Army leaders have pledged the death of an officer cadet at Royal Military Academy Sandhurst (RMAS) three years ago will lead to transformational change.
Olivia Perks was found dead in her room on 6 February 2019 after failing to turn up for a training exercise.
A Service Inquiry was convened to investigate the circumstances leading to Olivia's death and to consider the policy and practice surrounding the identification and management of vulnerable Army personnel.
Fifty-seven witnesses gave evidence either in person or through written submissions including officer cadets, RMAS staff and medical professionals.
The panel concluded there were huge failings in welfare, mental health awareness and communication within the chain of command.
Olivia joined the commissioning course at RMAS in Surrey in May 2018. Two months later, whilst 'heavily intoxicated' the report says she 'deliberately self-harmed' after a barbeque that followed a visit to the Royal Engineers in Dorset.
Despite an assessment by the Department of Community Mental Health, she was returned to training two days later.
The Service Inquiry panel found the Chain of Command did not 'fully understand or investigate the deep rooted issues' Olivia was struggling with nor 'sufficiently investigate' the self-harm incident.
There were two further drunken incidents known to the Directing Staff but despite discussing Olivia's behaviour at a number of meetings 'no positive action took place' to support her.
On 1 February, Olivia went to a charity ball organised by her Company. Witnesses told the Inquiry she drank to excess and in the days after, shut herself away from the rest of the Officer Cadets.
One witness told the inquiry: "She was isolated. Who could she speak to because all the people around her she knows are gossiping about her."
The same witness also spoke of how Olivia was feeling about the impact her actions would have on her career.
A day after being interviewed about events at the Ball, Olivia failed to turn up for training and was later found unresponsive in her room. She was later pronounced dead.
The Service Inquiry panel said Olivia wasn't given an 'adequate, acceptable and co-ordinated level of support' by the Chain of Command, Welfare Department and Chaplaincy Department - describing it as 'substandard'.
It details a wealth of failings across Sandhurst's staff and structures and has made 61 recommendations for improvements at all levels.
The Chief of the General Staff, General Sir Patrick Sanders, said in response to the report: "I am utterly determined that we continue to foster the culture needed to ensure that the British Army remains a great institution – one that is great to be in for everyone and one that maintains the trust, respect and affection of the nation we protect and serve.
"Those whose behaviour is found to be unacceptable or is in breach of our Values and Standards, or those who wilfully ignore or tolerate such behaviour, will be held to account."
The current Commandant Royal Military Academy Sandhurst, Major General Zac Stenning said: "With thanks to my predecessors we have achieved much in the past 3 years. Improving welfare provision through new facilities, more staff, and improved communication and processes. Developing an effective culture by rewarding the right behaviours and upskilling the staff and Officer Cadets. There is more to do; we are determined to produce the best possible leaders for our Army and the nation."
The inquest into the death of Olivia Perks is due to start next week.