Recurring concern
Failure to ensure safe post-discharge arrangements for vulnerable patients and residents
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Request correctionFirst reported 26 Nov 2013•Latest report 14 Apr 2026
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.
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.
- Reports
- 34
- Individual concerns
- 44
- Date range
- 2013–2026
- Stated actions
- 53
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 provide Flow Coordinators with information about patient vulnerabilities when arranging discharge
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
Review the Band 4 Flow Coordinator role and associated discharge processes, including responsibilities, risk-information flow, escalation and multidisciplinary clinical leadership.
Stated by North Cumbria Integrated Care NHS Foundation Trust -
Action
Implement clinical-risk information sharing during discharge coordination and multidisciplinary discharge processes, including updated documentation and mental-health referral prompts.
Stated by North Cumbria Integrated Care 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
Contemporaneous staff accounts did not indicate that explicit hanging suicide intent was escalated immediately before discharge.
Stated by North Cumbria Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to ensure patients can consistently complete a flight of stairs without assistance before discharge
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
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.
Stated by County Durham and Darlington 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
Repeating stair assessments is not always necessary where a patient previously completed one safely and has no additional risk factors.
Stated by County Durham and Darlington NHS Foundation Trust
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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.
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
Review the hospital discharge policy and procedures to ensure assistive technology needs and safe discharge decisions are explicit.
Stated by Worcestershire County Council -
Action
Consider assistive technology needs and associated risks before every hospital discharge.
Stated by Worcestershire County Council -
Action
Remind staff to identify risks requiring mitigation through assistive technology before discharge.
Stated by Worcestershire County Council
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Action
Share necessary assistive technology requirements with acute colleagues and the person or representative, and arrange provision before discharge.
Stated by Worcestershire County Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The discharge triage process sufficiently identifies when assistive technology is essential for safe discharge, so it need not always be provided beforehand.
Stated by Worcestershire County Council
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Position
Always providing assistive technology before discharge is not feasible because it would significantly delay discharges where it is not essential.
Stated by Worcestershire County Council
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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.
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 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.
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
Review and update the discharge-planning SOP, including care-agency confirmation, failed-discharge escalation and documentation requirements.
Stated by the Dudley Group NHS Foundation Trust -
Action
Train discharge-team staff on accurate clinical-record documentation and required care-agency contact details.
Stated by the Dudley Group NHS Foundation Trust
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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.
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
Strengthen multidisciplinary discharge-passport completion, checking, approval, electronic-record updating and daily validation before discharge.
Stated by Lewisham and Greenwich NHS Trust and London Borough of Lewisham -
Action
Develop standards, role definitions, guidance and staff teaching for prescribing pressure-care equipment and hospital beds.
Stated by Lewisham and Greenwich NHS Trust and London Borough of Lewisham -
Action
Progress the Occupational Therapy Policy through Trust governance approval.
Stated by Lewisham and Greenwich NHS Trust and London Borough of Lewisham
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Action
Perform additional electronic-record checks for last-minute changes in condition or discharge support needs under an embedded discharge protocol.
Stated by Lewisham and Greenwich NHS Trust and London Borough of Lewisham
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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.
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
Follow up delays in providing recommended aids and equipment for service users.
Stated by City of Doncaster Council
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
Relevant professionals, rather than social care staff, must assess risks and recommend or order aids and equipment.
Stated by City of Doncaster Council
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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.
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 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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
No analgesia was considered necessary because neither the patient nor her daughter requested it at discharge and shoulder pain was not subsequently reported.
Stated by the Princess Alexandra Hospital NHS Trust
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Position
A care package was not considered necessary because the assessment found that the patient did not meet the relevant threshold.
Stated by the Princess Alexandra Hospital NHS Trust
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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.
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
Update Symphony’s discharge screen to record discharge discussions and identify notifications or vulnerable-adult support needed before patients go home.
Stated by North Cumbria Integrated Care 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 Emergency Department was not informed of any request or requirement to notify the Housing Officer about discharge.
Stated by North Cumbria Integrated Care NHS Foundation Trust
Data last updated 7 September 2026