Lack of care led to the deaths of three Devon hospital patients in an apparent suicide pact, an inquest jury has said.
The three died five hours after leaving the unit
Three patients died together when they jumped off a 200ft cliff at Salcombe Hill, Sidmouth two years ago.
They had all been voluntary psychiatric patients at the Cedars Unit of Wonford House Hospital in Exeter.
But staff failed to act on warning signs and did not raise the alarm for almost three hours after they left, the inquest was told.
The jury returned a verdict of suicide on shop worker Shaun Sheppard, 17, from Upton Pyne, Exeter, and student Jamie Hague, 19, from Cullompton.
It returned an open verdict on mother-of-three Anne Harris, 29, from Tiverton.
During the five-week inquest in Exeter, the jury heard how drugs and alcohol were freely used by patients at the unit and none of the three victims were prevented from leaving despite specific warnings of a suicide pact.
The inquest heard the trio ignored pleas to come back
Mr Sheppard and Mr Hague had both been drinking before the tragedy and Mr Sheppard was so drunk when he died that he could barely stand up.
Mr Hague, who had repeatedly threatened suicide, jumped moments before the other two leapt off together.
The unit failed to follow its own rules when the three went missing because they should have been reported to the police straight away. Instead there was a three-hour delay.
A policeman who tried to talk them down could only watch in horror as they went.
An independent inquiry later found that all three deaths could have been prevented by better risk assessments of the patients, security and procedures at the unit.
East Devon coroner Dr Elizabeth Earland said she would be asking the Devon Partnership Trust, which has responsibility for mental health care, and the Mental Health Commission to review supervision of patients.
After the inquest Dr Paul Cawthron, medical director of the trust said procedures had been tightened.