Recurring concern

Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPs

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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

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.

  1. Leicester City and South Leicestershire

    AI-generated summary

    Margaret Mary Dempsie · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Margaret Mary Dempsie, who had advanced dementia and frailty, was admitted to hospital for treatment of infected leg ulcers, later deteriorated with sepsis, and died two days after discharge for end-of-life care. The discharge letter contained inaccurate and incomplete clinical information, including an incorrect reference to aspiration pneumonia and omission of pyelonephritis, raising concerns that vulnerable patients could receive inappropriate care based on incorrect discharge information.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure accurate and complete discharge information is communicated to primary care teams

    Wider context from the report

    “The discharge letter from the University Hospitals of Leicester NHS Trust addressed to the primary care team contained inaccuracies. It stated that Mrs Dempsie had been suffering from aspiration pneumonia when no pneumonia had been identified and did not mention pyelonephritis, which had been present. The Consultant who was looking after Mrs Dempsie was not surprised and admitted in the inquest that the Discharge Letters for patients were being completed with mistakes by the Junior Doctors, that this was something that happens and that GP's regularly have to phone the hospital to ascertain the correct facts. He said that sometimes the junior doctors who complete the discharge letters have never seen the patient. This situation was also confirmed by the General Practitioner who was also present at the inquest. I have concerns that the wrong information is being passed on to primary carers who are then, of course, obliged to act upon the information they are furnished with in the Discharge Letter and that this could lead to serious mistakes being made in the care of vulnerable patients newly discharged from hospital. ”

    Source location

    Margaret Mary Dempsie · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use a standardised discharge-letter template covering admission reasons and discharge diagnoses.

    Verbatim wording from the response

    “Whilst we strive to ensure that all discharge letters contain all relevant and accurate information, we recognise that we do not get this right on every occasion. To minimise the risk of inaccurate information being provided to GP’s, the Trust has developed a standardised template for discharge letters which detail the reason for admission and main diagnosis at discharge. Additionally the Trust provides an e-learning package for junior doctors to reinforce the importance of providing accurate information to GP’s.”

    Source location

    2016-0374-Response-by-University-of-Leicester-NHS-Trust
    Page 2 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide junior doctors with e-learning reinforcing accurate information in discharge letters to GPs.

    Verbatim wording from the response

    “Whilst we strive to ensure that all discharge letters contain all relevant and accurate information, we recognise that we do not get this right on every occasion. To minimise the risk of inaccurate information being provided to GP’s, the Trust has developed a standardised template for discharge letters which detail the reason for admission and main diagnosis at discharge. Additionally the Trust provides an e-learning package for junior doctors to reinforce the importance of providing accurate information to GP’s.”

    Source location

    2016-0374-Response-by-University-of-Leicester-NHS-Trust
    Page 2 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Request GP feedback and conduct regular audits of discharge-letter information quality.

    Verbatim wording from the response

    “In addition, the Trust has for some time requested individualised feedback from GP’s regarding any poor or inaccurate information received from the Trust and undertakes regular audits to provide assurance on the quality of the information provided in Discharge Letters. These audits show an improvement in the quality of the information that we provide to GP’s.”

    Source location

    2016-0374-Response-by-University-of-Leicester-NHS-Trust
    Page 2 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Increase the frequency of discharge-letter audits for each monthly QMG cycle.

    Verbatim wording from the response

    “1. The frequency of internal audits for discharge letters will be increased for each QMG every month with immediate effect and our Head of Outcomes and Effectiveness will lead on this.”

    Source location

    2016-0374-Response-by-University-of-Leicester-NHS-Trust
    Page 2 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Extend GP feedback collection, review findings, discuss necessary actions, report to the Executive Quality Board, and repeat the audit at intervals.

    Verbatim wording from the response

    “2. Our Chief Medical Information Officer and Head of Services for GP’s will encourage GP’s to provide individualised and patient specific feedback concerning poor discharge letters throughout December 2016 to assess the level of inaccuracies and perception of poor Discharge letters. Our Chief Medical Information Officer will then review any feedback and discuss necessary actions with the doctors involved and the GP dependant upon the findings. He will report on this matter to the Executive Quality Board in March 2017. Our Head of Services for GP’s will promote the opportunities to feedback errors on discharge letters directly to her in the December GP Newsletter. This extended audit will then be repeated at regular intervals, depending on the findings.”

    Source location

    2016-0374-Response-by-University-of-Leicester-NHS-Trust
    Page 2 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Discuss the case with the consultant involved to encourage reflective learning.

    Verbatim wording from the response

    “4. Our Medical Director will ensure that this case is discussed with the Consultant involved before the end of December 2016 to encourage reflective learning. ████████ has met with the junior doctor who wrote the discharge”

    Source location

    2016-0374-Response-by-University-of-Leicester-NHS-Trust
    Page 2 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Strengthen the Letters Policy to clarify discharge-letter procedures and senior medical oversight.

    Verbatim wording from the response

    “5. Our Head of Outcomes and Effectiveness will strengthen our “Letters Policy” to ensure that there is clarity concerning the process for discharge letters and the importance of senior medical oversight. This should go to the Policy and Guideline Committee Meeting in January 2017.”

    Source location

    2016-0374-Response-by-University-of-Leicester-NHS-Trust
    Page 3 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue joint work through the LLR-wide discharge group to address IT barriers to electronic transfer of discharge letters to primary care.

    Verbatim wording from the response

    “This CCG and our two commissioning partners in Leicestershire and Rutland recognise that the provision of accurate and timely discharge information is a prerequisite for safe and high quality patient care. We have been working together with University Hospitals of Leicester (UHL) to address this and have taken a number of concrete actions:-”

    Source location

    2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
    Page 1 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Report monthly discharge-letter audit results to the CCGs’ Contract team for formal oversight.

    Verbatim wording from the response

    “• UHL undertakes an audit of a sample of discharge letters on a monthly basis, assessing their content and timeliness, with feedback directly to the clinician concerned. The trust reports that they have seen an improvement in both the quality and the accuracy of letters since this started. This monthly audit will continue, and the results will now be reported into the CCGs Contract team for formal overview.”

    Source location

    2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
    Page 1 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a process for obtaining timely GP feedback on inaccurate discharge letters and supporting rapid correction and clinician learning.

    Verbatim wording from the response

    “• Getting accurate feedback from GPs whenever there is a problem with Discharge letters is a key part of improving performance. We are currently in discussion with UHL and our GP Colleagues about how this can best be done, probably through a dedicated email contact point. The intention is to get feedback within 24 to 36 hours of receipt of the letter, with rapid contact with the relevant junior doctor both to increase their learning but also to ensure the provision of a corrected an accurate discharge letter where necessary. We are exploring the feasibility of this over the coming weeks.”

    Source location

    2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
    Page 2 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Include a discharge-letter quality indicator in the 2017–2018 UHL contract and formally monitor and report it, with corrective-action discussions if improvements are not sustained.

    Verbatim wording from the response

    “• To ensure there is an ongoing focus on the quality of Discharge letters, the 2017 / 2018 contract with UHL will include a quality indicator within the contract which will be formally monitored and reported to the contract team. This will include discussions around corrective action should the necessary improvements not be sustained. The contracts are due to be agreed by the 23rd of December 2016.”

    Source location

    2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
    Page 2 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Include in the junior doctors’ induction programme an item emphasising accurate, timely information for primary care.

    Verbatim wording from the response

    “• The CCGs are currently in discussion with UHL about the content of their junior doctors Induction programme. We will ensure that an item is included within this programme which highlights the importance of getting accurate information out to primary care colleagues as soon as possible to ensure the appropriate delivery of care to patients.”

    Source location

    2016-0374-Response-by-Leicester-City-Clinical-Commissioning-Group
    Page 2 · response
    Published 24 October 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for commissioning services and providing assurance on mitigation actions rests with the Leicester City Clinical Commissioning Group.

    Verbatim wording from the response

    “I have reviewed your report in detail and I have identified that the Leicester City Clinical Commissioning Group (“CCG”) is responsible for commissioning services from the University Hospitals of Leicester NHS Trust. I have therefore asked the CCG to respond and provide assurance regarding actions they have taken in order to mitigate the risk identified within your report. A copy of their response is enclosed with this letter.”

    Source location

    2016-0374-Response-by-NHS-England
    Page 1 · response
    Published 24 October 2016

    Open published response
  2. Brighton and Hove

    AI-generated summary

    Marion Rose HOWES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marion Rose HOWES died before the inquest concluded on 3 February 2016; the circumstances are referred to in the Record of Inquest. The concerns included failures in discharge communication, coordination and continuity of care, two failed discharges, inadequate communication of a cancer diagnosis, and failure to recognise that she was dying, which was said to have resulted in an undignified and uncomfortable death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to send hospital discharge summaries electronically to GPs on the day of discharge

    Wider context from the report

    “(1) Discharge summaries from the hospital These need to be sent electronically to the GP on the day of discharge for continuity of care and full handover to the community from the acute hospital. In addition, the patient must understand the significance and be given his or her copy so that if by any chance there is a delay or a sudden readmission the patient understands the significance of keeping his copy with him for a few days after discharge. ”

    Source location

    Marion Rose HOWES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Exeter and Greater Devon

    AI-generated summary

    Alec James MATHIAS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alec James Mathias developed drug-induced jaundice after receiving Flucloxacillin in 2008, but this reaction was not communicated to his GP or highlighted in the hospital records. He was prescribed Flucloxacillin again in 2014 for an infected finger and died after developing Flucloxacillin-induced cholestatic liver injury and liver failure. The principal concerns were failures to send discharge information to the GP and to record the drug sensitivity in the hospital notes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to send discharge letters to GPs documenting dangerous treatment side effects

    Wider context from the report

    “(1) Discharge letters have not been sent to the patients GP in a case where a dangerous side effect to treatment has been noted ”

    Source location

    Alec James MATHIAS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Shropshire, Telford and Wrekin

    AI-generated summary

    Martin Rowland HILL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Martin Rowland HILL died on 24 April 2014 after an abdominal x-ray taken during an A&E attendance showed small bowel obstruction, but the report was not seen by subsequent doctors and he was treated for constipation. The concerns included the failure to act on the radiology report, which might have led to surgical review and readmission, as well as medication not being provided on discharge and no discharge summary being sent to his GP.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to send discharge summaries to patients’ GPs

    Wider context from the report

    “(6) For completeness, and it is an issue which arose in an earlier Inquest, no discharge summary was sent to the patient’s GP. This appears to have been an exception to normal practice and an indication was given at the Inquest that this issue has already been addressed. Confirmation of this is sought. ”

    Source location

    Martin Rowland HILL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. Inner South London

    AI-generated summary

    Miss Abiola Dosunmu · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Abiola Dosunmu developed abnormal blood tests, proteinuria and symptoms that were treated as cellulitis, before rapidly deteriorating and being found dead at home on 24 August 2012. The report identified concerns about failures to communicate the proteinuria and abnormal results, inadequate follow-up and monitoring, and a missed opportunity to diagnose and treat SLE earlier.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to communicate discharge information and monitoring needs to primary care

    Wider context from the report

    “(3) The Trust failed to send the GP a discharge summary or communicate to the surgery the significance of the raised ESR and CK and the need for further monitoring. ”

    Source location

    Miss Abiola Dosunmu · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Produce discharge notifications for patients who self-discharge.

    Verbatim wording from the response

    “a) Failure to send a discharge summary: A discharge summary should have been completed when Abiola self-discharged. As a result of this case, the Trust conducted an audit which showed that it is not consistent practice to issue discharge summaries for self-discharging patients. This issue was”

    Source location

    2014-0209-Response-by-Kings-College-Hospital
    Page 1 · response
    Published 5 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Trust states that the GP was informed by telephone and received a discharge summary containing the abnormal results.

    Verbatim wording from the response

    “b) Failure to communicate the significance of the raised ESR and CK and need for further monitoring to Abiola’s GP: The Trust contacted the GP by telephone informing the GP that Abiola had self-discharged, recommending oral antibiotics and stressing the importance of IV antibiotics and need for her to attend ED if her condition deteriorated. The Trust also notes that ED generated, and the GP received, a 4 page discharge summary which included (because it was generated on 9 March 2013) the abnormal results identified during Abiola’s admission.”

    Source location

    2014-0209-Response-by-Kings-College-Hospital
    Page 2 · response
    Published 5 May 2014

    Open published response
  6. Manchester South

    AI-generated summary

    John Joseph Malone · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Joseph Malone suffered two falls at home, the second on 24 October 2013, which led to a subdural haematoma; the inquest concluded that he died an accidental death. Concern was raised that the hospital discharge letter was woefully short on detail and omitted vital information for his GPs, and that he fell within three days of discharge.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of discharge documentation to include vital admission and discharge information

    Wider context from the report

    “I took evidence from the two GP's caring for the deceased and they showed to me, inter alia, a discharge letter from your hospital dated 21st October 2013 a copy of which I append hereto. You will note that this document is woefully short on detail and has significant omissions of vital information for the GP's. On page one of the report there are no details given as to Admission date, admission ward, admission method, admission source, discharge destination or discharge date. The patient sustained a fall within 3 days of his discharge and this led to or exacerbated his subdural haemorrhage. ”

    Source location

    John Joseph Malone · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026