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
Failure to exercise professional curiosity in high-risk discharge decisions
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 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 reconsider the care plan when night-time circumstances changed
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.1
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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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Concerns raised1
Failure to require senior clinical reference before discharge by very junior doctors
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.3
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Action
Audit discharge records to examine whether senior doctors or Consultants participated in discharge decisions.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Provide learning to Consultant Psychiatrists about senior involvement in discharge decisions.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Provide junior doctors with discharge-related teaching during Trust induction.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Discharge decisions made without involvement of a clinician responsible for the patient's care
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.
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 clinical staff make discharge decisions
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 raised2
Failure to medically review suitability for discharge
Poorly informed discharge decision-making
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 identified care concerns to identify required improvements and share learning with Respiratory Medicine staff.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Raise the discharge-related events through Directorate clinical governance meetings and staff training and awareness sessions.
Stated by University Hospitals Sussex 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
Automatic medical review after discharge decisions is unnecessary because board rounds, nurse escalation and existing discharge policies provide sufficient safeguards.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Lack of protocol or guidance for Mental Health Nurses on referring acute-hospital discharge decisions to a doctor after self-harm
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
Amend the Community Treatment Order Procedure to address the identified concerns.
Stated by North West Boroughs Healthcare NHS Foundation Trust -
Action
Communicate the amended Community Treatment Order Procedure to staff.
Stated by North West Boroughs Healthcare NHS Foundation Trust
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Concerns raised1
Failure to review discharge decisions after material changes in patient presentation
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 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
Review, update and ratify the discharge protocol and guidance for similar situations through the Acute Care Forum and governance process.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Lack of suitably senior psychiatric clinician attendance at discharge case reviews
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 medically reassess the patient before 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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026