All three bodies were found at the bottom of the cliffs

Dr Paul Cawthron, medical director of the Devon Partnership NHS Trust, said "policies and procedures were not followed in the way I'd have expected".

The trust was responsible for the care of Anne Harris, 29, Jamie Hague, 19, and Shaun Sheppard, 17.

Dr Cawthron was giving evidence at an Exeter inquest into the 2002 deaths.

Suicide pact

The three were informal patients at the Cedars Unit of Wonford House Hospital in Exeter.

Mother-of-two Mrs Harris, from Tiverton, Mr Sheppard, from Upton Pyne, and Mr Hague, from Cullompton, all died on 12 June, 2002.

They plunged to their deaths from 200ft cliffs at Salcombe Hill in Sidmouth, about five hours after leaving the unit.

The inquest had heard the trio left the unit at 1345 BST, a fact soon known to nursing staff.

But the missing patient procedure was not operated until about 1600 BST, after talk of a suicide pact among the patients was passed on to staff.

External report

Coroner Dr Elizabeth Earland asked Dr Cawthron in cross-examination whether it was his view the alarm should have been raised as soon as a nurse told staff the three had gone from the unit.

"I believe the missing person procedure should have been implemented at that point," said Dr Cawthron.

He confirmed that would have been in accordance with policy at that time.

Professor Donald Grubin, who compiled an external report for Devon and Cornwall Police into events leading to the deaths, told the inquest earlier that, had staff searched for the patients right away, they may have been discovered before they travelled far.