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Welland Centre 2021-01-01 Person 1 5 0

My son took his own life whilst a patient on the Avocet Ward, he was allowed out unescorted despite being high risk and when he failed to return the Missing Persons Policy was not implemented. The British Transport Police came to my house to inform me that my son was dead. (Appalling) We were assured that he would be safe and looked after in the unit. Three nurses were disciplined and staff failings were admitted. Communication between the Consultant in charge and staff was poor as was completion of important paperwork. The public need to be aware that this is not a safe unit as patients regularly go AWOL and this was not the first suicide to happen here. Lessons are not being learned because this continues to happen in mental health units up and down the country. I would welcome an independent enquiry when such incidents occur and perhaps then families will get answers to all the questions they have. Myself and my family are devastated by the loss of our son and our lives will never be the same. This was completely preventable and avoidable and steps need to be taken to prevent such a tragedy occurring ever again.