Three mentally-ill patients who jumped to their deaths from a Devon cliff should not have been allowed out on their own, according to a report.

The bodies were recovered from the foot of Salcombe Hill cliffs at Sidmouth, east Devon, on 12 June.

Jamie Hague, 19, from Cullompton; Shaun Shephard, 17, from Upton Pyne near Exeter; and mother-of-three Anne Harris, 29, from Tiverton, were voluntary patients at The Cedars Unit in Exeter.

An interim report published by the Devon Partnership NHS recommended 19 changes at the Cedars and said that staffing levels must be reviewed.

Suicide pact

All three patients had signed themselves out of the unit at 1345 BST on the day of their deaths, but staff did not contact police until 1630 BST to tell them of their concerns.

At 1900 BST a local officer checking cliffs at Salcombe Hill, 14 miles from Exeter, saw three people on top of the cliff on the far side of a chain link fence.

They fell to their deaths minutes later as part of a suicide pact.

Design faults

Loose ceiling tiles should be permanently fixed in place Bedroom doors should be fitted with observation windows The external security camera should be upgraded The "signing in and out book" should be moved from the lobby area

According to the report, one of the three had been identified as being at greater risk than the others and should have been accompanied by what the Trust described as a "responsible adult".

Although the report says there were no breaches in the Trust's policies regarding the incident, it outlines a number of key recommendations including higher staffing levels and tighter security at the unit.

Sue Simmons, the Trust's director of nursing and chair of the review group, said: "We are recommending that staffing on the ward is increased to a minimum of four staff on early and late shifts and a senior member of staff working from 0900 BST to 1700 BST.

Staff training

"We are also recommending that staffing levels are compared against other acute inpatient units around the country."

The report also recommended that more training should be made available to staff dealing with the difficult balance between families and patients.

Ms Simmons said: "In the case of two of the families, the patients said at particular points that they did not wish their families to be given information.

"This can place staff in a difficult position and we feel that channels of communication with the families could have been kept open."

The Trust had hoped to complete its internal review before its Board meets on Tuesday but it is expected the report will be completed by the end of October and not finally closed until after the inquests are held.