Staffing review at psychiatric unit after three patients die

Staffing levels at a Devon psychiatric unit are to be reviewed
after an internal report was published into the events which led to
the deaths of three ‘informal’ patients, writes Clare

Anne Harris and two teenagers Jamie Hague, aged 19, and Shaun
Sheppard, aged 17, were all patients at the Cedars Unit in Exeter.
They died after falling from Salcombe cliffs at Sidmouth last

An internal review was set up by Devon Partnership NHS Trust
following the incident, and an interim report makes 19

Chairperson of the review group Sue Simmons 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 9am–5pm, which will be particularly important on
ward round days.”

Staffing levels should also be compared against other acute
inpatient units around the country, she added.

The review also revealed design faults in the Cedars Unit and
recommends loose ceiling tiles are fixed in place, all bedroom
doors are fitted with observation windows and the external security
camera is upgraded to provide a better picture quality.

“None of the factors noted should be seen to be causes of this
tragic event,” the report says. “Nevertheless, the review team
feels that they are themes which should be addressed as they do
individually and collectively influence the quality of service

It is expected the full report will be completed by October, but
not finally closed until inquests into the deaths are held.









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