Recurring concern
Failure to involve families and carers in discharge planning and decisions
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Request correctionFirst reported 30 Jan 2013•Latest report 7 Nov 2025
What this concern includes
Includes failures in the discharge process to identify appropriate families or carers, seek and consider their views or information, involve them in complex discharge planning and decisions, and communicate material arrangements or risks to them where involvement is appropriate.
Not included
- Excludes failures in family or carer involvement outside discharge planning or discharge decisions.
- Excludes communication solely between professionals, services or receiving organisations where family or carer involvement is not the unsafe condition.
- Excludes failures limited to the clinical suitability of a discharge, housing, care-package provision or equipment unless the report also identifies exclusion of relevant families or carers from the discharge process.
- Excludes mental-health care-planning involvement where discharge is not materially part of the asserted concern.
- Reports
- 35
- Individual concerns
- 40
- Date range
- 2013–2025
- Stated actions
- 36
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to involve the patient’s cohabiting carer in discharge planning
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Request and develop IT record changes to distinguish carers from next of kin.
Stated by East Kent Hospitals University NHS Foundation Trust -
Action
Audit identification of carers and their support needs among patients aged 70 or over.
Stated by East Kent Hospitals University NHS Foundation Trust -
Action
Establish and operate a Carer Champion post supporting carer identification and involvement in discharge discussions.
Stated by East Kent Hospitals University NHS Foundation Trust
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Action
Re-audit progress on carer identification and support in February, March and April.
Stated by East Kent Hospitals University NHS Foundation Trust
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Concerns raised1
Failure to engage family members effectively in discharge planning
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Implement family and carer engagement changes using the triangle of care model in the Psychiatric Intensive Care Unit.
Stated by The Trust
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Concerns raised1
Failure to communicate diagnosis, treatment options, rationale and discharge plans with family representatives
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Allocate a multidisciplinary team member on ward rounds to update families about all aspects of patient care.
Stated by County Durham and Darlington NHS Foundation Trust -
Action
Conduct regular retrospective clinical-record audits to monitor compliance with family communication standards.
Stated by County Durham and Darlington NHS Foundation Trust
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Concerns raised1
Failure to further explore a patient's decision not to involve a relevant family member in discharge notification
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to liaise with family to establish discharge suitability and safety
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Assign Family Ambassadors to support family engagement, information sharing and recording family information for multidisciplinary consideration.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Assign a registered nurse to coordinate each patient’s safe-discharge preparation, travel, support, follow-up and crisis-contingency plans.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Mobilise the new inpatient operating model and its implementation plan for proactive, safe and effective discharge across adult and older-adult wards.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to communicate identified fractures in discharge information
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Reviewed the emergency department's process for subsequent image review to assess its robustness and alignment with national practice.
Stated by the Princess Alexandra Hospital NHS Trust -
Action
Launch a comprehensive electronic health record to reduce risks arising from clinicians using multiple systems.
Stated by the Princess Alexandra Hospital NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The existing process of subsequent emergency-department consultant image review was considered as robust as possible and consistent with national practice.
Stated by the Princess Alexandra Hospital NHS Trust
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Concerns raised1
Failure to complete and consider a pre-discharge family assessment
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide families with deterioration warning signs and actions at discharge
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Develop and provide patients and carers with a postoperative sepsis-awareness information card.
Stated by South Tees Hospitals NHS Foundation Trust
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Concerns raised2
Failure to involve family or carers in discharge processes
Failure to involve family in discharge processes
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Monitor caregiver inclusion in safety and discharge planning through daily MDT review, audits and supervisory checks.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust -
Action
Continue rolling out carer-awareness and Getting To Know You training, including one-to-one training for new staff.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The investigation concluded that identified family-involvement issues were not causative or contributory to the death.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
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Concerns raised2
Failure to coordinate inpatient discharge with family and other agencies
Failure to hold a multidisciplinary pre-discharge meeting for future planning
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026