When Annie got the call on a Friday afternoon in March this year, she was on her way to pick up her daughter from school.
Her son, in his early twenties, was being discharged, with immediate effect from the mental health unit Wotton Lawn in Gloucester, where he had been sectioned in the psychiatric intensive care unit.
“You are being discharged as homeless,” the staff member said, while Annie listened in.
Annie told them she was recording the call, and pleaded to keep him in, warning that this course of action would be potentially fatal for her son.
She was told he had allegedly assaulted another patient. He denied it.
But for several days leading up to this moment the hospital had warned his mother it was time for him to leave.
The young man, we will call ‘John,’ indicated that he was having suicidal thoughts. His confused response to what was happening was that he wanted “euthanasia”.
Annie warned staff she couldn’t get there to pick him up, but they pressed on with the discharge.
The staff member told John: “We are going to formally discharge you at half past four this afternoon. So, you won’t be a patient on this ward at half past four.
“And if you do refuse to leave you will be trespassing and the police will be removing you.”
After the discharge time had elapsed, Annie called her son again.
There was no reply – until eventually a member of the public answered the phone.
A woman told Annie that her son was badly injured and being treated by paramedics having thrown himself off a bridge.
“So, he’d basically been told to get out of the mental hospital and two minutes later, he’s on the tracks,” says Annie. “He just walked out of the door, jumped headfirst off a bridge.
“He smashed his skull, his face, had a brain haemorrhage, smashed his arms and legs and punctured his spleen.”
Incredibly, he survived.
That evening Wotton Lawn staff members left some of John’s belongings outside for Annie to collect.
She says no one spoke to her.
In the weeks leading up to this moment, Annie had already been talking to Sky News because she felt her son was not getting proper treatment or care at Wotton Lawn.
She said despite him being sectioned under the Mental Health Act, he was frequently going missing from the hospital.
She says she was unable to see his care plan and that doctors discouraged her from communicating with them.
She claims one consultant even said he would block her emails, after she told him she wanted to put her concerns in writing.
In that period, we collected the stories of several other families and patients who had recently been in the hospital and their experiences echoed Annie’s.
Staff gave tablets to patient despite overdose risk
Heidi Hanks was in Wotton Lawn for a period of eight weeks in late 2022 into 2023.
Her husband John says he had no contact with the hospital while she was in their care.
He said: “I’ve never seen her care plan, never spoken to a doctor. I called the hospital to say, ‘what’s the progress, what’s going on?’
“I never got anything back over the whole time she was there.”
Heidi would go missing from the premises and was once found by a member of the public walking down train tracks.
She says when she returned, no one asked her about what had happened.
Heidi says she too was discharged too soon.
She returned the next day pleading to be readmitted because voices were telling her to take an overdose.
She says despite this, she was told to go home and handed the very tablets she had said she was going to take an overdose with.
She swallowed the pills, just outside the hospital, and her husband collected her and took her to A&E.
Staff photographed asleep in their chairs
Sky News has obtained photographs of several staff members asleep in their chairs in different parts of the hospital.
These pictures have been taken by patients who say those staff members should have been alert and keeping an eye on the people in their care.
Another patient, who we will call ‘Jamie’, says he wasn’t properly watched and despite supposedly having round-the-clock care, was able to get onto the roof of the hospital and jump off it.
‘I wasn’t in a safe place’
Jamie told Sky News: “I broke both my legs, my wrists, my arm my back and my pelvis.
“I was hearing voices and I should have been in a safe place, where I can’t get out and there are no roofs I could jump off.
“But I wasn’t in a safe place at all.”
He says he was mostly looked after by inexperienced agency or ‘bank’ staff and was isolated from his family.
A Care Quality Commission report on the hospital found the psychiatric intensive care units had a 32% vacancy rate and “high rates of bank and agency staff”.
The service rated overall as ‘good’.
But they also found most relatives “had not been given information or been involved in decisions about their relative”.
All the relatives or carers who spoke to the CQC said “they had not been given the opportunity of providing feedback”.
One patient ‘able to access hospital roof for years’
Another patient, Nicky Davis, is currently in Wotton Lawn.
She has taken photographs of herself on the roof of the hospital on numerous occasions.
She says she’s been able to access it by the same route “for years” having been in and out of the hospital over a six-year period.
Even when on the hospital’s most secure psychiatric ward for the most at-risk patients, Nicky says she was able to access the roof through a window, and on one occasion attempted suicide.
Nicky says the high use of agency staff means patients don’t form a relationship with their carers but the thing that upsets her most is sleeping staff and claims this is widespread and it’s not just at night, but more often on the afternoon into evening shift.
‘I’ve actually seen patients walk out of the hospital’
Her mother Joanna Davis, and stepfather Darren Watts, say the level of care is inadequate.
Joanna said: “I’ve seen staff asleep. I’ve seen staff when she’s been escorted to the hospital fall asleep.
“I’ve seen the chair on the door empty so that patients are able to abscond.
“I’ve actually seen patients walk out of the hospital and Nicky have to say to a member of staff, ‘that patient is not allowed leave’.”
Nicky’s twin sister Laura committed suicide after she stayed at Wotton Lawn.
An inquest at Cheshire’s Coroner’s Court completed in February 2023 found Wotton Lawn failed to pass on crucial information about Laura to another hospital, leading to a fatal mistake.
The inquest states: “The information transferred from Wotton Lawn Hospital to Arbury Court Hospital about Laura was deficient, in that it did not include anything about a recent incident.”
It goes on to describe how she had tried to commit suicide in Wotton Lawn and then used the same method successfully because staff hadn’t realised a particular object posed a risk.
‘People can abscond from the psychiatric hospital’
Joy Higgins, from the local Gloucester charity Suicide Crisis, is a former patient at Wotton Lawn.
She says she has spent months examining inquests which have shown failures at Wotton Lawn and other hospitals and the lessons are not being learned.
“I think in particular, where patients have been able to access harmful items on the ward and that’s something that we have seen at more than one inquest, tragically.
“And so that suggests very strongly that the learning has not been taken from the inquest and that it is simply repeating.
“And what we have seen in inquest after inquest is the frequency with which people can abscond from the psychiatric hospital when they are assessed as being at high risk of suicide.”
She added: “It’s a repeated issue that’s been going on not just for months, but for years, where patients are being able to simply leave.
“It’s a requirement that the exit doors are monitored to prevent patients leaving. But too often there are no staff there.
“And so, for me, it’s a management issue and ultimately a senior management issue. The leadership of the trust.”
Trust admits ‘we do not always get things right’
Gloucestershire Health and Care NHS Foundation Trust, which runs Wotton lawn, said: “We are really disappointed to hear these reports and apologise to anyone who hasn’t had good experience of our care.
“Our hospital at Wotton Lawn is a therapeutic environment and, while two of the wards in the hospital are classed as secure, the majority of general hospital patients are allowed to leave the premises when appropriate and this is managed carefully on a case by case basis.
“Our colleagues work hard, often in very difficult circumstances, to support our patients to recover and be safely discharged every day, and we receive regular positive feedback.
“We know, however, that we do not always get things right.
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“While we cannot respond with specific details, context and facts due to patient confidentiality, we were already aware of the cases detailed and have reviewed them fully.
“We take the allegations of staff sleeping on duty very seriously and will investigate further once full details are shared with us.
“We are constantly reviewing our processes and procedures, and will continue to speak to patients and families about improvements they would like to see within the hospital and improve our services based on their feedback.”
But national charities such as SANE and MIND have expressed growing concerns about the state of mental health services across the UK.
Wotton Lawn seems to be another example where patients are being failed.
:: Anyone feeling emotionally distressed or suicidal can call Samaritans for help on 116 123 or email jo@samaritans.org in the UK. In the US, call the Samaritans branch in your area or 1 (800) 273-TALK.