It should have been a fine day out for Anne Harris, a 29-year-old mother, and teenagers Jamie Hague and Shaun Sheppard. After a shopping trip in Exeter, the friends took a taxi for the nine-mile journey to a Devon beauty spot overlooking the sea.
After reaching the top of Salcombe Hill cliffs at Sidmouth, however, one of the trio shouted that he was going to jump. Nineteen-year-old Hague turned from his two companions and plunged to his death - to be followed seconds later by the others, linked arm-in-arm.
All three were voluntary in-patients at a psychiatric unit and had walked out under the noses of staff at the centre, just outside Exeter. Harris reportedly had been talked out of a suicide attempt at the same cliffs only a week before. The appalling deaths, in June, have highlighted the lack of safeguards for voluntary patients who may be contemplating suicide, or self-harm, and mental health experts say that all patients must, as a matter of urgency, have a risk assessment carried out and a care plan drawn up.
In the first of a series of inquiries into the highly unusual triple tragedy, recommendations have been made for improvements in hospital security. But this raises fundamental questions about the status of voluntary patients and the freedom they should be given: should they be supervised 24 hours a day, or be able to come and go as they please?
An interim report by the Devon Partnership NHS trust, which runs the Cedars unit where the friends were being treated, has found that one of the three - who is not identified - had been under "close observation" and should not have been allowed out unless accompanied by a member of staff. The report recommends clearer guidance on when patients can leave the hospital, improved signing-out procedures and higher staffing levels on wards.
The report calls also for installation of CCTV with recording facilities at hospital exits and, most controversially, observation windows to be inserted in all bedroom doors.
Harris, 19-year-old Hague and 17-year-old Shaun Sheppard were strangers when they were admitted to the unit at Wonford House hospital. All were being treated for severe depression. They signed out of the unit at 1.45pm on the day they died, staff noting their absence "very quickly", according to the report, and concluding that there was "no immediate concern". At 4pm, however, the nursing team received information that prompted a review of the level of risk, a search of the building and a call to the police at 4.15pm. Just after 7pm, the three ignored the pleas of a police officer on the cliffs and fell to their deaths.
The improved security systems recommended in the report are being introduced immediately. But mental health charity Mind says these are by no means a full response and warns that patients will be left at risk while gaps in care remain.
The charity admits that hospitals have a difficult role, as they have no legal powers to hold voluntary patients but do have a duty to care and respect the welfare of individuals. There are currently 300,000 patients on acute mental health units - 270,000 of whom are there informally and can, in theory, walk out at any time
Simon Foster, Mind's principal legal officer, says: "People in psychiatric units have a right to the fullest life possible. By definition, they are vulnerable members of the community and the hospital has a duty to take reasonable care of them. This can be difficult and it's a balance that needs to be struck between taking care of them and their human rights."
Putting observation windows in patients' bedroom doors has to be balanced with the need for privacy, according to the charity. It believes the way forward lies in making care plans mandatory for both detained and voluntary patients. These plans should include regular risk assessment and spell out what leave could be granted. They would include contingency plans, if necessary including "sectioning" or compulsory detention, should patients decide to walk out without permission.
Mind believes also that it is important to have proper handover notes when staff change shifts. And it says alarm bells should ring among hospital staff if a group of patients walk out without permission.
The need for clearer guidance on agreed leave plans and observation levels has been recognised by the Devon Partnership trust, which plans later this year to publish a full report on the triple deaths. In future, the trust says, any patient will be expected to discuss with a nurse any proposed leave from the Cedar unit.
