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
Lack of a protocol for patients self-discharging from hospital without necessary medication
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.1
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Action
Continue communicating self-discharge policy requirements to clinical and nursing staff through bulletins, meetings, induction, briefings and read-and-sign materials.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to ensure food or essential provisions are available after discharge for patients with diabetes
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
Lack of guidelines or protocols for discharging challenging patients
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.1
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Action
Produce and disseminate guidance to assist staff managing such cases.
Stated by Cornwall Council
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Concerns raised1
Failure to assess home circumstances and available observation when discharging patients following head injury
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.
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
Operational improvements to head injury assessment and discharge are the responsibility of the involved NHS trust.
Stated by Department of Health and Social Care
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Concerns raised2
Lack of appropriate arrangements to ensure residents' safety and welfare after discharge
Lack of a system requiring residential home managers to seek Social Services advice before discharging residents
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
Change the Discharge Pack to include a procedure for managing unanticipated discharges.
Stated by GREENLANE CARE HOMES LIMITED
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Concerns raised1
Failure to independently check oxygen apparatus function before hospital departure
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.1
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Action
Implement an oxygen-therapy ward-exit checklist verifying clinical stability, cylinder operation, parental equipment competence, cylinder duration, and saturation-monitor readiness.
Stated by Leeds Teaching Hospitals NHS Trust
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Concerns raised1
Lack of detailed assessment of likely functional performance in home circumstances after discharge
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 ensure appropriate care is in place at home before discharge
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 raised2
Lack of formal assessment of the patient’s abilities, home environment and carer’s ability to provide care
Lack of a formal policy or procedure for risk assessing early-hours discharge of frail elderly patients to home
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.2
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Action
Complete the multidisciplinary review and finalise a clear policy for assessing elderly patients presenting after a fall.
Stated by Chesterfield Royal Hospital NHS Foundation Trust -
Action
Provide the ratified policy to the coroner.
Stated by Chesterfield Royal Hospital NHS Foundation Trust
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Concerns raised1
Failure to ensure clear and consistent discharge instructions
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