First reported 14 Jan 2014•Latest report 3 Jun 2026
Definition
What this concern includes
Includes dedicated failures of the hospital discharge-summary process that affect the accuracy, completeness, finalisation, quality assurance or timely transmission of summaries to GPs.
Not included
Excludes generic IT, staffing, training or documentation deficiencies not explicitly tied to the hospital discharge-summary process.
Excludes failures concerning other clinical documents or information-sharing processes that are not discharge summaries.
Excludes downstream failures by GPs or other recipients to review or act on a discharge summary after it has been received.
Reports
26
Distinct published reports
Individual concerns
32
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
54
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.
Tameside and Glossop Integrated Care NHS Foundation Trust2
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Barts Health NHS Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Care Quality Commission1
Department of Health and Social Care1
Dudley Integrated Health and Care NHS Trust1
Epsom and St Helier University Hospitals NHS Trust1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Hampshire Hospitals NHS Foundation Trust1
Imperial College Healthcare NHS Trust1
Isle of Wight NHS Trust1
Kent and Medway Mental Health NHS Trust1
King's College Hospital1
King'S College Hospital NHS Foundation Trust1
NHS trust23
Healthcare site4
Executive non-departmental public body2
English metropolitan district council1
Health and social care service regulator1
Ministerial department1
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.
Isle of Wight
Concerns raised1
Failure to provide timely Discharge Summaries to GPs
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.
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.6
Action
Establish a Medical Director-led workstream to improve the quality and timeliness of discharge summaries.
Stated by Isle of Wight NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2019.
Action
Conduct an in-depth review of discharge summaries and communications to GPs following relevant mental health contacts.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Map communication processes with staff groups and develop a standard operating procedure or flowchart.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Audit discharge-summary quality, including admission reasons, care received, and medication reviews or changes.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Use formal teaching sessions with junior doctors to embed learning from the discharge-summary audit.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Present discharge-summary audit outcomes at Trust quality forums to share learning.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Surrey
Concerns raised1
Insufficient detail in discharge letters for GPs
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.
Surrey
Concerns raised1
Omission of blood test results from discharge summaries
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 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
Including hospital blood results in discharge summaries is not considered necessary because GPs can access those results through Telepath.
Stated by Epsom and St Helier University Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised2
Failure to accurately transcribe significant individual results into discharge letters
Failure to include a complete set of blood results in discharge letters
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.
Surrey
Concerns raised1
Failure of hospital discharge-summary procedures to provide accurate and consistent prescribed-medication information
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 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.1
Action
Amend the discharge-letter template to consolidate medication information and instruct junior doctors to keep medication instructions in that section.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.
Black Country
Concerns raised1
Failure to communicate previous tramadol overdose information to the General Practitioner on the hospital discharge letter
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 standards for discharge communications.
Stated by Dudley Integrated Health and Care NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
Action
Reiterate to medical staff the importance of including necessary incidents and risk factors in discharge letters.
Stated by Dudley Integrated Health and Care NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
Action
Agree required audit frequency and standards for discharge communication, then communicate them to medical teams.
Stated by Dudley Integrated Health and Care NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
Manchester South
Concerns raised1
Delays in dispatching discharge summaries
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 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
Deploy additional resources to clear the discharge-summary backlog and restore timely completion.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2017.
Action
Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2017.
Action
Strengthen discharge-summary governance through designated clinical and operational leadership, reiterated consultant accountability, compliance monitoring and ward-level safety-net alerts.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner South London
Concerns raised1
Failure to document significant findings and required follow-up investigations in discharge information
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.4
Action
Send formal discharge notifications to GPs after self-discharge, including relevant tests, assessments and follow-up arrangements.
Stated by King'S College Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2017.
Action
Implement mandatory suspected and confirmed diagnoses, author and senior clinician fields on Emergency Department discharge letters to GPs.
Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017.
Action
Develop a Trust-wide best-practice guide for discharge notifications and clinic letters, including self-discharge requirements, with local CCG collaboration.
Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017.
Action
Upgrade the Emergency Department tracking system to distinguish completed, booked and pending investigations on GP discharge notifications.
Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The concerns raised did not cause or contribute to the death, and the inquest found no failures of care contributed to it.
Stated by King'S College Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to provide discharge summaries to GPs after emergency department attendance
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 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.7
Action
Deploy additional resource to clear the discharge-summary backlog.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
Action
Assign divisional operational leadership for improving discharge-summary completion.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
Action
Reiterate consultants’ responsibility for ensuring every patient receives a discharge summary.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
Action
Monitor discharge-summary compliance through governance, clinical and operational management arrangements.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
Action
Develop bespoke software for electronic Emergency Department casualty cards and automated discharge-summary generation.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2017.
Action
Roll out the new electronic Emergency Department casualty-card process from October 2017.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 August 2017.
Action
Introduce dashboard monitoring of discharged Emergency Department patients awaiting discharge summaries and follow-up investigations.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 August 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for ensuring every patient has a discharge summary rests with the consultant responsible for that episode of care.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Portsmouth and South East Hampshire
Concerns raised1
Failure to email endoscopy discharge summaries to GP practices
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 dedicated failures of the hospital discharge-summary process that affect the accuracy, completeness, finalisation, quality assurance or timely transmission of summaries to GPs.
