Recurring concern
Unreliable clinical review and authorisation of discharge decisions
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Request correctionFirst reported 2 Apr 2014•Latest report 11 Jan 2026
What this concern includes
Includes failures in the clinical review and authorisation of hospital, mental-health or ambulatory-care discharge decisions, including failure to reconsider discharge after a material change in presentation, failure to obtain required psychiatrist or senior clinician review, and decisions made or potentially made by non-clinical or otherwise unauthorised personnel.
Not included
- Excludes discharge timing, transport, accommodation, medication, information and post-discharge follow-up failures where the clinical review or authorisation of the discharge decision is not the deficient control.
- Excludes routine clinical disagreement with a discharge decision when the decision received appropriate, timely and accountable clinical review.
- Excludes generic clinical staffing, documentation or communication deficiencies unless they directly result in discharge decisions proceeding without required clinical review or authorisation.
- Excludes admission, transfer and treatment decisions that are not decisions about discharge.
- Reports
- 20
- Individual concerns
- 24
- Date range
- 2014–2026
- Stated actions
- 18
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
Pre-determined HTT discharge decisions before patient assessment
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.
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
Hold twice-weekly multidisciplinary discussions with community services about patient care, including planned Home Treatment Team discharges.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Provide senior Rapid Response clinical input to interface forums for clinically considered decisions and agreed safe discharge plans.
Stated by Kent and Medway Mental Health NHS Trust
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Concerns raised1
Failure to obtain cardiology review of discharge appropriateness
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
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Stated by NHS England
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Position
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Stated by NHS England
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Concerns raised2
Failure to obtain psychiatrist review before discharge
Discharge decisions falling to a senior psychiatric nurse
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 provide timely final medical review before formal discharge
This report raised 21 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 the Emergency Department adult-discharge SOP defining discharge responsibilities, documentation requirements, safety-netting, and safeguards for higher-risk patients.
Stated by The 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 discharge omissions were considered case-specific, not a systemic issue requiring wider policy or practice change.
Stated by The Trust
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Concerns raised1
Failure to take postoperative CRP results into account in discharge and scanning decisions
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
Provide existing guidance on postoperative CRP monitoring and CT investigation triggers.
Stated by The Association of Coloproctology of Great Britain and Ireland -
Action
Direct South East Clinical Quality colleagues to engage with the relevant ICB or Trust and seek assurance that learning from Lorraine’s case has been taken.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
Existing guidance on CRP monitoring and CT investigation makes further ACPGBI guidance unnecessary at this time.
Stated by The Association of Coloproctology of Great Britain and Ireland
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Position
ACPGBI is best placed to consider whether guidance is needed on recognising deterioration after bowel surgery.
Stated by Royal College of Surgeons of England -
Position
Existing NICE guidance, clinical judgement, local protocols and relevant professional guidance are relied upon instead of standalone CRP-based postoperative imaging guidance.
Stated by Department of Health and Social Care -
Position
NHS Trusts are responsible for ensuring staff competence and should review their clinical protocols following the case.
Stated by Department of Health and Social Care
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Concerns raised1
Unclear governance of safe discharge decisions from the neurosurgical ward
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.
Stated by NHS England
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Concerns raised2
Failure to resolve differing psychiatric team assessments before discharge
Failure to discuss CATT discharge and admission patients with the on-call psychiatrist
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.3
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Action
Remind crisis-assessment staff that they may request senior consultant discussion regardless of the proposed disposition.
Stated by West London NHS Trust -
Action
Embed trusted-assessment working between CATT and Psychiatric Liaison teams for joint admission and home-treatment decisions.
Stated by West London NHS Trust -
Action
Work with North West London partners to implement clinical escalation protocols for clinical disagreement.
Stated by West London NHS Trust
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Concerns raised2
Lack of policy or protocol governing discharge from the Ambulatory Care Unit without medical review
Failure to conduct an in-person medical review before discharge from the Ambulatory Care Unit
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
Existing policy requires medical authorisation for Ambulatory Care Unit discharge and prevents Physician Associates from discharging patients independently.
Stated by Manchester University NHS Foundation Trust
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Position
Consultant review of information supplied by a Physician Associate was considered sufficient; an in-person consultant assessment was not required.
Stated by Manchester University NHS Foundation Trust
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Concerns raised1
Lack of named or responsible consultant review before child discharge
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
Complete weekly assurance audits of clinical records across acute areas, covering sepsis assessment and related discharge and communication safeguards.
Stated by Doncaster and Bassetlaw Teaching Hospitals 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
Consultant handovers, case discussion and retrospective attendance-note review provide sufficient safeguards for children discharged without admission.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to learn from findings that a discharge or transfer should not take place
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.
Data last updated 7 September 2026