First reported 26 Nov 2013•Latest report 14 Apr 2026
Definition
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
Distinct published reports
Individual concerns
44
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
53
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.
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
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.
Inner North London
Concerns raised2
Failure to arrange pressure-relieving bed and mattress replacement before discharge
Omission of daily skin-integrity checking instruction from discharge assessment form
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 concerns
Each 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.17
Action
Improve discharge information for carers, including holistic care instructions and equipment needed to reduce pressure damage.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Complete manual-handling, mobility-equipment and environmental assessments before or during the initial visit.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Escalate equipment-related barriers to essential personal care and resolve them before staff leave the property.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Use a discharge checklist to verify equipment, district nurse involvement and care-agency briefing before discharge.
Stated by Westminster City CouncilStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Complete manual-handling, mobility-equipment and environmental assessments during initial visits.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Escalate equipment-related barriers to care coordinators and resolve them before staff leave the property.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Deliver pressure-ulcer training to therapists on causes, risk factors, and clear skin-care instructions in discharge-to-assess forms, completing Trust-wide training by June 2023.
Stated by University College London Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.
Stated by University College London Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Review hospital discharge information and discharge letters to identify care needs relevant to care delivery.
Stated by Kapital Care (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review organisational recording and documentation practices.
Stated by Kapital Care (UK) LimitedStatus unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2022.
Action
Obtain the relevant discharge notification form before starting hospital-discharge care packages.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Implement the Hospital Discharge Reablement Assessment Form with mandatory prompts for pressure care, manual handling and medication, and share it across agencies.
Stated by Westminster City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.
Stated by University College London Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
Stated by University College London Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester City
Concerns raised1
Failure to ensure safe discharge of patients requiring administered Depot antipsychotic medication
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North East Kent
Concerns raised1
Lack of multi-agency procedures for safe discharge of patients with concurrent care needs
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 concerns
Each 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
Action
Update the hospital discharge policy and operating model, supported by discharge guidance action cards defining responsibilities for key roles.
Stated by Kent County CouncilStated completedThe respondent said that this action was complete when they made their response on 19 August 2021.
Action
Establish named KCC hospital discharge leads to attend discharge management meetings and provide social care advice, guidance and escalation.
Stated by Kent County CouncilStated plannedThe respondent said that this action was planned when they made their response on 19 August 2021.
West Yorkshire Eastern
Concerns raised5
Failure to assess current medical needs before vulnerable people return home
Failure to check that premises have heating, running water and smoke alarms before vulnerable people return
Failure to check the availability and operation of personal alarm systems before vulnerable people return home
Failure to provide relevant information about the absence of an alarm before a person decides whether to return home
Lack of a checklist for assessing numerous issues before vulnerable people return 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 concerns
Each 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
Action
Develop and publish guidance for the Conversation Record pro-forma covering medical needs, equipment and referrals, risk assessment, mitigation plans, service-user views, and documented capacity decisions.
Stated by Leeds City CouncilStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
Action
Establish a task-and-finish group to develop a discharge checklist covering utilities, safety equipment, environmental and occupational therapy assessments, and discharge-day home visits where indicated.
Stated by Leeds City CouncilStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
Action
Develop and deliver lessons-learned training for Mental Health Unit staff covering telecare, discharge planning, equipment checks, capacity recording and related safety processes.
Stated by Leeds City CouncilStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
Manchester South
Concerns raised2
Lack of guidance on ensuring a care home can accept a person back after discharge
Lack of guidance on acute trust action when attempts to contact a care home are unsuccessful
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 concerns
Each 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
Action
Review safe and appropriate discharge arrangements for people with complex needs across Greater Manchester with localities.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2021.
Action
Continue complex-needs and discharge scoping through the Learning Disabilities Complex Needs Programme.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2021.
Action
Publish and update the Hospital Discharge Service policy and operating model guidance for NHS trusts and care home providers.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 29 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Hospital discharge guidance predominantly applies to admitted patients, and this case did not appear to involve hospital admission.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Developing policy and procedures for integrated care and communication is outside the regulator’s direct remit.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
West Sussex
Concerns raised1
Failure to inform family supporters of discharge
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Position
No further action was considered necessary on family involvement because confidentiality and consent governed information sharing, with contact attempted where consent permitted.
Stated by Sussex Partnership NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
Mid Kent and Medway
Concerns raised2
Failure to complete recommended home assessments before discharge
Absence of a bed in the home
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Lack of a clear safeguard ensuring vulnerable patients are discharged to the correct address
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 concerns
Each 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
Action
Require discharge-lounge staff to confirm transport destinations, escalate discrepancies, and record the confirmation in electronic medical records.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 October 2020.
Action
Review transport safeguarding processes and amend them according to the review findings.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 October 2020.
East London
Concerns raised2
Failure to provide falls-management equipment before discharge
Insufficient care support for a safe discharge home
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Ensure essential discharge equipment is provided and installed before discharge, with provision checked through the discharge checklist.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Monitor discharge-checklist completion through Ward Manager oversight.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Use care-planning documentation to record identified risks, mitigation, equipment, training requirements and available community support.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Require acceptance by an appropriate community team and clear risk mitigation before discharging patients requiring 24-hour supervision.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsive community care was unavailable at the time because stroke Early Supportive Discharge provision for Redbridge residents was limited.
Stated by Barts Health NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Coventry
Concerns raised1
Failure to ensure care needs are assessed before discharge to the care 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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
