Recurring concern
Failure to ensure discharge information is accessible and understood by patients and carers
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Request correctionFirst reported 20 Aug 2013•Latest report 3 Jun 2026
What this concern includes
Includes failures within the patient- and carer-facing discharge communication process, including accessible discharge instructions or summaries, confirmation of understanding, alternative communication formats, and communication of follow-up arrangements.
Not included
- Excludes failures concerning the clinical content or quality of discharge summaries when the issue is not their accessibility to or understanding by patients or carers.
- Excludes communication of discharge information solely between professionals, such as notifying GPs or transferring information to another service.
- Excludes general communication, literacy, training or documentation deficiencies not specifically tied to discharge information for patients or carers.
- Excludes failures to coordinate whether a receiving service or care home can accept a patient, where the concern is discharge logistics rather than patient- or carer-facing discharge information.
- Reports
- 17
- Individual concerns
- 19
- Date range
- 2013–2026
- Stated actions
- 16
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 supply ED discharge summaries to 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
Develop and publish a patient information leaflet explaining pneumonia follow-up requirements and their importance.
Stated by Nottingham University Hospitals NHS Trust
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Concerns raised1
Lack of structured local support for interpreting neurodivergent parental communication
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.3
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Action
Run monthly multidisciplinary simulation sessions covering paediatric abdominal pain, neurodivergence, communication and escalation.
Stated by George Eliot Hospital NHS Trust -
Action
Develop and deliver a communications campaign promoting Hospital Passports and “All About Me” tools.
Stated by George Eliot Hospital NHS Trust -
Action
Establish neurodivergent champion roles across GEH and SWFT with a dedicated training programme.
Stated by George Eliot Hospital NHS Trust
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Concerns raised1
Lack of guidance on contacting the secondary care team after recurrent seizures
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 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 written and family-shared bleeding-risk advice for direct oral anticoagulant medication
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
Create and implement a generic anticoagulant discharge leaflet covering bleeding risks, warning signs and when to seek medical attention.
Stated by East Kent Hospitals University NHS Foundation Trust
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Concerns raised2
Failure to inform family supporters of discharge
Failure to notify vulnerable service users’ parents of discharge
This report raised 9 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.1
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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 Trust
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Concerns raised1
Failure to ensure discharge instructions are accessible and understood by patients
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 admission and discharge documentation across the Trust to identify required changes.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Amend admission and discharge documentation to include literacy checks, support requirements and signposting to the admissions booklet.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Launch and cascade the amended documentation through ward managers at the Clinical Leaders Event.
Stated by James Paget University Hospitals NHS Foundation Trust
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Action
Audit compliance with the amended admission and discharge documentation monthly, beginning with results available at the end of October.
Stated by James Paget University Hospitals NHS Foundation Trust
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Concerns raised1
Failure to provide clear discharge follow-up advice and guidance
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 assess and communicate night-time falls risk at discharge
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.4
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Action
Use care-planning documentation to record identified risks, mitigation, equipment, training requirements and available community support.
Stated by Barts Health NHS Trust -
Action
Monitor discharge-checklist completion through Ward Manager oversight.
Stated by Barts Health NHS Trust -
Action
Reassess changed care needs through a senior professional and identify risks requiring further intervention.
Stated by Barts Health NHS Trust
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Action
Include reviewed carer guidelines in discharge information and provide accessible onward-referral and joint-planning contact details.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to provide discharge information in a form the patient could comprehend and retain
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.
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 communicate AES discharge instructions and correct use
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026