Failure to ensure safe post-discharge arrangements for vulnerable patients and residents
First to latest report 26 Nov 2013 — 14 Apr 2026
Reports that mention this concern
34
Times this concern has been raised
44
Stated actions linked to this concern
53
What this concern includes
Includes failures in discharge or return arrangements for vulnerable, challenging or clinically dependent patients and residents where responsible services do not reliably establish, coordinate or communicate the support and protective arrangements needed after discharge, including required advice from social services or comparable care functions.
What is not included
Excludes routine discharge delays or unsuitable discharge timing where post-discharge safety arrangements are not the deficient condition.
Excludes failures confined to a named mental-health, hospital-to-care-home, prison-release or other specialised discharge pathway when that pathway provides the more specific supported boundary.
Excludes failures in care or treatment after safe discharge arrangements have been established.
Excludes generic communication, staffing or documentation deficiencies unless they directly leave a vulnerable person without safe post-discharge arrangements.
Trends
Reports over time
Reports mentioning this concern, 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.
Department of Health and Social Care4
Kent County Council2
North Cumbria Integrated Care NHS Foundation Trust2
Worcestershire County Council2
Aneurin Bevan University LHB1
Barts Health NHS Trust1
Care Quality Commission1
Central London Community Healthcare NHS Trust1
Chesterfield Royal Hospital1
City of Doncaster Council1
Cornwall Council1
County Durham and Darlington NHS Foundation Trust1
Cumbria County Council1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Grasmere Surgery1
NHS trust19
Healthcare site6
English county council5
Ministerial department4
English metropolitan district council3
London borough council3
Private limited company2
Type not available2
Domiciliary care provider1
English district council1
English unitary authority1
Health and social care service regulator1
Health-system partnership1
Local health board1
Multi-service care provider1
Reports and published responses 34 reports
See individual reports that have raised this concern, and the actions taken in response
Cumbria
Concerns raised1
Failure to provide Flow Coordinators with information about patient vulnerabilities when arranging discharge
Linked response
North Cumbria Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
North Cumbria Integrated Care NHS Foundation Trust
Review the Band 4 Flow Coordinator role and associated discharge processes, including responsibilities, risk-information flow, escalation and multidisciplinary clinical leadership.
North Cumbria Integrated Care NHS Foundation Trust
Implement clinical-risk information sharing during discharge coordination and multidisciplinary discharge processes, including updated documentation and mental-health referral prompts.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
North Cumbria Integrated Care NHS Foundation Trust
Contemporaneous staff accounts did not indicate that explicit hanging suicide intent was escalated immediately before discharge.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
County Durham and Darlington
Concerns raised1
Failure to ensure patients can consistently complete a flight of stairs without assistance before discharge
Linked response
County Durham and Darlington NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
County Durham and Darlington NHS Foundation Trust
Deliver SOAP note training to Community Physiotherapy, Occupational Therapy and Assistant staff within six weeks, and remaining Physiotherapy and Occupational Therapy staff within four months.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
County Durham and Darlington NHS Foundation Trust
Repeating stair assessments is not always necessary where a patient previously completed one safely and has no additional risk factors.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Worcestershire
Concerns raised1
Failure to provide a careline/lifeline pendant before discharge home for a person at high risk of falls
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Worcestershire County Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Worcestershire County Council
Review the hospital discharge policy and procedures to ensure assistive technology needs and safe discharge decisions are explicit.
Worcestershire County Council
Consider assistive technology needs and associated risks before every hospital discharge.
Worcestershire County Council
Remind staff to identify risks requiring mitigation through assistive technology before discharge.
Worcestershire County Council
Share necessary assistive technology requirements with acute colleagues and the person or representative, and arrange provision before discharge.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Worcestershire County Council
The discharge triage process sufficiently identifies when assistive technology is essential for safe discharge, so it need not always be provided beforehand.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Worcestershire County Council
Always providing assistive technology before discharge is not feasible because it would significantly delay discharges where it is not essential.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Worcestershire
Concerns raised1
Failure to provide a careline/lifeline pendant before discharge home for a person at high risk of falls
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to rearrange required care before arranging transportation home
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Dudley Group NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
the Dudley Group NHS Foundation Trust
Review and update the discharge-planning SOP, including care-agency confirmation, failed-discharge escalation and documentation requirements.
the Dudley Group NHS Foundation Trust
Train discharge-team staff on accurate clinical-record documentation and required care-agency contact details.
Inner South London
Concerns raised1
Failure to complete accurate discharge passports containing patients’ clinical, therapy, equipment and home-environment needs
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Lewisham and Greenwich NHS Trust
London Borough of Lewisham
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Lewisham and Greenwich NHS Trust and London Borough of Lewisham
Strengthen multidisciplinary discharge-passport completion, checking, approval, electronic-record updating and daily validation before discharge.
Lewisham and Greenwich NHS Trust and London Borough of Lewisham
Develop standards, role definitions, guidance and staff teaching for prescribing pressure-care equipment and hospital beds.
Lewisham and Greenwich NHS Trust and London Borough of Lewisham
Progress the Occupational Therapy Policy through Trust governance approval.
Lewisham and Greenwich NHS Trust and London Borough of Lewisham
Perform additional electronic-record checks for last-minute changes in condition or discharge support needs under an embedded discharge protocol.
South Yorkshire (Eastern)
Concerns raised1
Failure to provide recommended safety equipment in the home
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
City of Doncaster Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
City of Doncaster Council
Follow up delays in providing recommended aids and equipment for service users.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
City of Doncaster Council
Relevant professionals, rather than social care staff, must assess risks and recommend or order aids and equipment.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cheshire
Concerns raised1
Failure to establish whether care at home could be safely provided
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised1
Failure to provide pain relief and consider a care package at discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
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.2
the Princess Alexandra Hospital NHS Trust
No analgesia was considered necessary because neither the patient nor her daughter requested it at discharge and shoulder pain was not subsequently reported.
No action considered necessaryThe respondent said that no further action was needed.
the Princess Alexandra Hospital NHS Trust
A care package was not considered necessary because the assessment found that the patient did not meet the relevant threshold.
No action considered necessaryThe respondent said that no further action was needed.
Cumbria
Concerns raised1
Failure to notify support services of vulnerable patients' discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
North Cumbria Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
North Cumbria Integrated Care NHS Foundation Trust
Update Symphony’s discharge screen to record discharge discussions and identify notifications or vulnerable-adult support needed before patients go home.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
North Cumbria Integrated Care NHS Foundation Trust
The Emergency Department was not informed of any request or requirement to notify the Housing Officer about discharge.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.