Wotton Lawn psychiatric unit subject of 4,600 police calls

Almost 100 people were reported missing from Wotton Lawn in the space of two years

Families have shared their concerns about a mental health unit that was the subject of more than 4,600 phone calls to police over a two-year period.

The BBC has spoken to families about staff reportedly sleeping on shift and poison being used by a patient at Wotton Lawn Hospital in Gloucester.

A spokesman for the hospital's trust apologised and said the issues raised had been "thoroughly investigated".

In March last year, a patient absconded from the unit and killed his parents.

William Warrington, 43, killed his mother Valerie and his father Clive at their respective homes in Whiteshoots Hill, Bourton-on-the-Water and Sherborne Place in Cheltenham.

He left Wotton Lawn at 22:00 BST in a taxi on 1 March 2022, but it was two hours before staff realised he was missing.

Valerie Warrington and her ex-husband Clive Warrington were stabbed to death by their son

Although a report was made to police, his family were not told he had escaped, despite the hospital being sent 11 emails about the risk he posed to them.

Requests under the Freedom of Information Act by the BBC have revealed Gloucestershire Police received 97 reports of patients missing from Wotton Lawn between 1 January 2021 and 31 December 2022.

Over the same period, it received 4,611 phone calls relating to the unit.

The force has yet to respond to requests setting out how many times officers were sent to the hospital over the same time frame. However, according to the Gloucestershire Health and Care NHS Foundation Trust (GHC), staff called police on 299 occasions and officers attended on 171 occasions.

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Patients have the right to have a mobile phone in the unit, and many of the calls would have been made by those being treated there.  

It is understood the calls relate to all incidents where the location is given as Wotton Lawn, which may or may not be serious. 

In some cases, the calls may relate to incidents that occurred outside of the hospital, but the caller has given their address as Wotton Lawn. 

One father told the BBC his daughter had repeatedly been able to access high-risk items such as cannulas, plastic bags, medication and aerosols while in the unit.

'Patients at risk'

Darren Watts claimed staff monitoring doors frequently fell asleep while on duty.

"Every single time a member of staff falls asleep, doesn't do their job properly and misses their observations, every single patient in that ward is at risk," Mr Watts said.

"The trust's response is they firstly deny there's a problem, they will say 'we don't believe there are people falling asleep. There's no evidence'."

Mr Watts said patients would be penalised for taking photos of sleeping staff.

Patients and their family members said staff had frequently fallen asleep on duty

"Then they'll turn on the member of staff rather than recognising this is a management and leadership issue," he added.

"There is no structure to monitor and make sure people get the right training, that people's behaviour is corrected to be what is required.

"When we spoke to the board level the response we got was 'it's the agency's job to make sure the member of staff is fit for duty,'.

"By abdicating the trust's responsibility, they create this culture which encourages people not to write accurate records, it encourages people that they won't be held to account."

Darren Watts said patients would be penalised for taking photos of sleeping staff

Patients have also escaped over the garden walls of the unit and climbed onto the roof, Mr Watts said.

"We had to tell staff patients were stashing a ladder around the back so they could just get it out, climb out and climb back in later on.

"Those patients were not noticed as being missing," Mr Watts added.

John Trevains, director of nursing, therapies and quality at GHC, told the BBC: "We constantly seek to make improvements to make things better and safer for our patients.

"A lot of our patients have the rights and the freedoms to be able to come and go and leave the ward while reporting to staff what they are doing.

"So it's a very difficult balance to achieve, and we work very hard to maintain safety as best we can within that."

Poison delivery

Rochelle Ravenscroft took her own life at Wotton Lawn in March 2020 after being admitted as a voluntary patient.

She ordered a poisonous substance and had it delivered to the facility.

Her father Warren Rose said she would frequently be out all day and there would be little monitoring of her whereabouts unless she missed her medication.

Mr Rose said his daughter had told them about ordering the substance, but her level of risk was never reassessed by clinicians and no attempt was made to find the substance.

"During various conversations with the psychiatrist, Rochelle told them she had been onto a website and had the perfect plan of how to end her life.

"She told them she had ordered that and it was on the way," Mr Rose said.

He continued: "There was no more supervision than she had at any other time, even though there was at least a week or 10 days between her telling them she had the product and actually using it.

"To jump on (Wotton Lawn's) side, there's no guarantee she wouldn't have done it somewhere else, some other time, but that's not the point - the point is she was sent there as a place of safety.

"She was put there by Gloucester crisis team to protect her, because she was going through a really bad patch."

William Warrington

William Warrington pleaded guilty to the manslaughter of his parents at a hearing on 15 November last year on the grounds of diminished responsibility.

Passing sentence, Mrs Justice Eady ordered Warrington be detained in a secure psychiatric hospital indefinitely under Sections 37 and 41 of the Mental Health Act.

Justice Eady said the case raised questions about Wotton Lawn.

William Warrington absconded from Wotton Lawn in a taxi

She told Warrington: "I have not heard from those with responsibility for you at Wotton Lawn, and can make no findings as to the adequacy of the arrangements there.

"What is clear, however, is the events that unfolded on 1 and 2 March 2022 raise very serious questions for those involved, particularly given the concerns that had been communicated by your family."

The findings of a review into the deaths of Mr and Mrs Warrington have yet to be published.