It's a wake-up call for Southern Health. That's the coroner's view after a woman fell to her death from a motorway bridge.
74-year-old Marion Munns from Southampton was under the care of the troubled NHS Trust at the time. Her family say they could see her mental health state deteriorating but no-one listened.
In a letter obtained by ITV News Meridian, the then chief executive - Katrina Percy - apologised and said the death WAS preventable.
Sally Simmonds has the story.
The MP for Fareham, Suella Fernandes, has been following events at the Southern Health Trust on behalf of her constituents in Hampshire.
The politician raised her concerns about the organisation in the House of Commons earlier this year. ITV Meridian presenter Sangeeta Bhabra asked the MP about her reaction to the resignation of Southern Health's Chief Executive Katrina Percy.
The Chief Executive of the Southern Health NHS Trust has given in to pressure and resigned from her post.
Katrina Percy was criticised for her lack of leadership at the trust which failed to properly investigate the unexpected deaths of hundreds of vulnerable patients in its care.
It has taken more than a year of repeated calls for her to go - from MPs, to charities and Southern Health governors themselves. But she will not leave empty-handed, she'll move to another role in the same health trust, and keep her salary of more than £180,000.
Today, the mother of Connor Sparrowhawk - a young man from Oxfordshire who died whilst in Southern Health's care - gave her reaction. Kate Bunkall has our report.
A damning report has highlighted how the Southern Health NHS Foundation Trust failed its patients and is still not doing enough to protect them.
Concerns were originally raised two years ago, about the organisation, which cares for people with mental health and learning disabilities across much of the South. The concerns were prompted by the death of Conor Sparrowhawk in Oxford, he drowned in the bath after having a seizure - he was not being supervised.
The Care Quality Commission report, released today highlights that most of the failings are down to poor leadership, but tonight the head of Southern Health - Katrina Percy is still in the job. The first person Rachel Hepworth speaks to in her report is Sara Ryan, Connor's mother.