Ahead of a report into scandal-hit Southern Health, the BBC has uncovered new failings at the mental health trust.
The BBC has learned 12 patients have jumped off the roof of a hospital run by Southern Health, while another has escaped twice and is currently missing.
Problems at Melbury Lodge, which treats people with severe mental health problems, have been known about for years but it is only in recent weeks - following a Care Quality Commission (CQC) inspection - that remedial action has been taken.
The revelations come as the chair of Southern Health announced his resignation and ahead of a CQC report to be published on Friday.
Southern Health said managing the risks posed by patients was difficult.
Of the 12 Melbury Lodge patients who managed to gain access to the roof and jump off it over the past five years, two did so in the last six months.
Neither of those two men died, but one was seriously injured.
Patients at Melbury Lodge, many of whom are detained for the safety of themselves or others, have been accessing the roof or absconding from the unit for years as a combination of staffing problems and the physical layout of the building has led to repeated problems.
Work is now under way to secure the building after the CQC demanded improvements following the inspection earlier this year.
The patient who is currently missing was sectioned under the Mental Health Act but managed to escape and flee to France.
He was discovered by police and brought back to Melbury Lodge in Winchester - only to escape again.
Concerns about Southern Health's ability to improve patient services across the trust were first raised by the regulator in 2011, according to a letter seen by BBC News.
Monitor, the precursor to NHS Improvement, hauled the management and board of Southern Health to London over concerns that the trust "may not have the leadership and management expertise within its mental health services" to make sufficient improvements while ensuring safe and effective services.
Around the same time, one director wrote to the board and management expressing concern that a "blame culture" was developing at the trust, quoting staff as feeling that: "We are reverting to carrot and stick in style and that you're either in the tent or outside."
The trust is under intense scrutiny after an official investigation found it had failed to investigate hundreds of unexpected deaths.
The CQC issued a warning notice last month and an external director has been placed at the trust by NHS Improvement.
The full CQC report is expected to severely criticise the leadership of the trust.
An official review of deaths at the trust published before Christmas blamed leadership and governance failures for the problems.
Despite mounting pressure from dozens of families, and the extent of failings at Southern Health, chief executive Katrina Percy has refused to resign.
It's understood she continues to have the support of both NHS England and NHS Improvement.
In a statement to BBC News, Southern Health said: "At all our units there is a balance to be struck between providing effective security and a therapeutic environment for our service users.
"Our staff are the most important safety feature we have, and they assess any risks associated with the building alongside understanding the risks associated with individual patients.
"These daily decisions are very challenging and occasionally we may not get it right, which is why continuous learning is so vital to how we operate."
On the issues identified in the internal documents, the trust said: "A culture of blame or 'carrot and stick' is not one that we recognise in our organisation."