No-one was to blame for the deaths of three psychiatric patients in Devon, according to a report.

Mother-of-three Anne Harris, 29, 17-year-old Shaun Sheppard and 19-year-old Jamie Hague fell to their deaths from 200 ft high cliffs at Salcombe Hill, near Sidmouth, in June.

They were voluntary patients at the Cedars Hospital at Wonford House in Exeter.

The review, carried out by the Devon Partnership NHS Trust, did, however, make a number of recommendations to improve security and observation at the unit.

The report's recommendations include:

Improve patient care guidelines Better risk assessment Increase staffing on the ward Review nursing duties Tighter security at unit Re-introduction of a regular ward community meeting

The six-month investigation was launched into care and conditions at the unit following the deaths.

But the report stressed that no single factor was to blame for the tragic deaths.

Trust director of nursing and review chairwoman Sue Simmons said: "There was no individual action, policy or activity that led to this tragedy.

"But the themes highlighted in the report are things we can work on, improve and learn from."

Among the recommendations were improved patient care guidelines and better risk assessment of patients.

More staff on ward rounds, the release of nurses from menial tasks to concentrate on care, and better security cameras were also listed.

Ms Simmons said about half of the recommendations, many of which were in line with national guidance, had already been implemented.

Greater risk

Mr Sheppard, from Upton Pyne near Exeter, Mr Hague, from Cullompton, and Ms Harris, from Tiverton, signed themselves out of the unit on 12 June.

The report said that one of the three patients 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".

But the three were all informal in-patients, which meant they were not forced to stay overnight and could leave with permission.

No dates have yet been set for the inquests into the deaths of the three patients.