Since it opened in December 1985, there have been at least 31 suicides by in-patients or recently discharged patients, a sudden death of a patient last July, and two killings and other violent attacks by patients on the public and staff, including Georgina Robinson.
Originally hailed as a model of the Government's community care policy, the 58-bed acute psychiatric unit, attached to Torbay district general hospital in Torquay, was built to cater for patients from the Exminster long-stay psychiatric hospital in Exeter which closed in December 1986.
The first suicide of a patient from the new unit happened the next month.
The closure of the Exminster hospital, a Victorian asylum, was masterminded by David King, then district general manager for Exeter Health Authority and now head of the Government's mental health task force. Mr King told the Independent that resources were distributed to the local authorities and he had no involvement in the planning or design of the Edith Morgan Centre.
In late 1989, the first of three inquiries was held after the South Devon coroner, Hamish Turner, highlighted 10 deaths of patients and recently discharged patients between June 1988 and June 1989.
Gethin Morgan, Professor of Psychiatry at Bristol University, who conducted the inquiry, doubted the number of suicides was significantly different from other psychiatric services but recommended training in suicide prevention and improved communications.
Problems continued and late in 1993 the South Devon Healthcare Trust commissioned Sir Louis Blom-Cooper QC and Professor Elaine Murphy, chairman and vice-chairwoman of the Mental Health Act Commission, to review mental health services purchased by Plymouth and Torbay Health Authority.
Their report, published in April 1994, made 41 recommendations including the closure of the unit in the longer term.
Its design, the authors said, was "reminiscent of a disused bus station" and was "seriously prejudicial to patient care". Senior management was described as "confused" and "lacking professional leadership".
The second Blom-Cooper report, published yesterday, was prompted by the stabbing in September 1993 of Georgina Robinson, who died five weeks later. The public inquiry also examined the death of Stephen Hext, a patient who suffered from paranoid schizophrenia, who committed suicide in December 1993 after being allowed leave from the unit - against the specific instructions of his doctors and in breach of the law.
Mr Hext jumped from the roof of an eight-storey car park in Torquay, days after he told a nurse he heard voices in his head saying he was going to die by throwing himself from a multi-storey car park.
The trust has admitted that leave was in clear breach of the Mental Health Act, which states that a detained patient shall not be granted leave without the permission of his Responsible Medical Officer. After an internal inquiry, the management admitted the decision by Mr Hext's key worker to let him go out "contributed to his death".
In July 1994, David Falconer, 23, a schizophrenic patient who became agitated, died after being pinned down and restrained by four nurses for 45 minutes until a doctor arrived.
A post-mortem examination showed the cause of death was cardiac arrest during agitated state and traumatic asphyxia due to restraining.
Last month an inquest jury in Torquay returned a verdict of misadventure to which neglect contributed due to the fact that there was no resident doctor at the unit.Reuse content