Recurring concern

Unreliable hospital discharge documentation

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First reported 30 Jan 2013•Latest report 27 May 2026

Definition

What this concern includes

Includes failures to create, complete, retain or make available hospital discharge documentation, including the reason for discharge, discharge decisions, follow-up or advice, and other material information needed for continuity and safe review.

Not included

Excludes failures in the clinical suitability or timing of discharge where discharge documentation is not itself deficient.
Excludes medication-supply, discharge-summary-to-GP and patient-accessibility failures where the specific unsafe condition is a separate named discharge-information process.
Excludes failures to implement post-discharge care after complete and available discharge documentation has been provided.
Excludes generic clinical-record deficiencies unrelated to documenting or retaining hospital discharge information.

Reports: 43
Individual concerns: 47
Date range: 2013–2026
Stated actions: 74

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care6

NHS England4

University College London Hospitals NHS Foundation Trust3

Barts Health NHS Trust2

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust2

Essex Partnership University NHS Foundation Trust2

Greater Manchester Mental Health NHS Foundation Trust2

Pennine Care NHS Foundation Trust2

University Hospitals Sussex NHS Foundation Trust2

Betsi Cadwaladr University LHB1

Bolton NHS Foundation Trust1

Brunswick Ward at Lindridge1

Central and North West London NHS Foundation Trust1

Central London Community Healthcare NHS Trust1

Cornwall Council1

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.

12 Dec2013
South Yorkshire (Eastern)
Concerns raised1
1. Failure to maintain complete and accurate records of discharge decisions and timing
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

ROSEMARY BRONWYN FERGUSON · 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

ROSEMARY BRONWYN FERGUSON, who had a long-standing history of epilepsy, was admitted after a head injury from a fall and was assessed as unfit for discharge because of risks associated with further falls. Despite recommendations that she remain in hospital, she was discharged to the care of a friend and was found deceased alone at home on 11 March 2013; the medical cause of death was recorded as sudden unexpected death in epilepsy. The principal concerns were that Social Services were not notified of the discharge, the friend’s expected role was unclear, and hospital records did not adequately document key communications and the date 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 to maintain complete and accurate records of discharge decisions and timing
Wider context from the report
“(3) The Hospital Notes were scanty and there appear to be material omissions to record important decisions such as a detailed note of the telephone call between ████████ and the clinician, properly timed and recording clearly what was intended. Further, it was difficult to trace from the Notes, the actual day of discharge, the clinician believing it to be the 8th March and ████████ believing it was the 9th March. Some computer records were presented to the Court suggestive of a discharge on the 8th March, but this information appears to be missing from the actual hand-written Notes. I am concerned that such problems with communication can lead to misunderstandings to the detriment of all concerns. ”
Source location
ROSEMARY BRONWYN FERGUSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Oct2013
Liverpool
Concerns raised2
1. Failure to provide written post-operative discharge information and advice
2. Failure to provide a discharge summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Provide procedure-specific written discharge advice to patients undergoing laparoscopic and hiatus hernia surgery.
  Stated by Liverpool University Hospitals NHS Foundation TrustStated completed
2. Action
  Implement generic discharge-information leaflets for all Trust inpatients where procedure-specific information is unavailable.
  Stated by Liverpool University Hospitals NHS Foundation TrustStated in progress
3. Action
  Develop and implement individualized discharge-information sheets for specialties requiring them.
  Stated by Liverpool University Hospitals NHS Foundation TrustStated in progress
AI-generated summary

Rosa ANDERSON · 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

Rosa Anderson underwent laparoscopic repair of a diaphragmatic hernia, during which her oesophagus was inadvertently damaged. The resulting mediastinitis compromised her breathing and led to cardiac arrest and hypoxic brain injury; concerns included that she was discharged without a discharge summary, written information about the operation, advice contact numbers, or warnings about when to seek urgent medical assistance.

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 provide written post-operative discharge information and advice
Wider context from the report
“During the course of the Inquest it was evident that Mrs Anderson was not given a discharge summary when discharged on 30th April 2013. Further, she was given no written information about her recent laparoscopic operation, contact telephone numbers for advice, nor were matters highlighted that required urgent medical assistance. ”
Source location
Rosa ANDERSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 provide a discharge summary
Wider context from the report
“During the course of the Inquest it was evident that Mrs Anderson was not given a discharge summary when discharged on 30th April 2013. Further, she was given no written information about her recent laparoscopic operation, contact telephone numbers for advice, nor were matters highlighted that required urgent medical assistance. ”
Source location
Rosa ANDERSON · 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
Provide procedure-specific written discharge advice to patients undergoing laparoscopic and hiatus hernia surgery.

Verbatim wording from the response
“I can confirm that there is now a discharge advice sheet in place, appropriate for these laparoscopic procedures and this is provided to all relevant patients prior to discharge. This discharge advice is generic for patients undergoing short stay surgery. There is also a separate patient information leaflet for patients having hiatus hernia surgery and this is given to patients pre-operatively. This also includes discharge advice for that specific group of patients.”

Source location
2013-0263-Response-by-Aintree-University-Hospital
Page 1 · response
Published 17 October 2013
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
Implement generic discharge-information leaflets for all Trust inpatients where procedure-specific information is unavailable.

Verbatim wording from the response
“Action is also being taken to ensure that appropriate written advice is provided to all inpatients of the Trust (both Surgical and Medical) prior to discharge. A number of generic leaflets have been produced intending to cover all patients on discharge where a procedure specific information leaflet is not available. This will be implemented by 1 January 2014.”

Source location
2013-0263-Response-by-Aintree-University-Hospital
Page 1 · response
Published 17 October 2013
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 and implement individualized discharge-information sheets for specialties requiring them.

Verbatim wording from the response
“In addition, a number of specialties are looking at developing their own individualised discharge information sheets and action is being taken to ensure that in such cases this is fully implemented by 1 March 2014. In the meantime, in such cases, the appropriate generic information leaflet will be provided to the patient.”

Source location
2013-0263-Response-by-Aintree-University-Hospital
Page 1 · response
Published 17 October 2013
Open published response
30 Jan2013
Manchester South
Concerns raised1
1. Delays in completing and sending the discharge summary
This report raised 12 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.
AI-generated summary

Gareth Mark Slater · 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

Gareth Mark Slater, who had a history of bipolar affective disorder and had been discharged from hospital into his own accommodation, was found in the River Medlock on 31 March 2013 after apparently falling from Bardsley Bridge. The Inquest concluded that he died from drowning and multiple injuries, with bipolar affective disorder recorded as a contributing condition, and found no evidence of an intention to end his life. Concerns included inadequate discharge planning, lack of a care plan and follow-up arrangements, insufficient assessment of his ability to live independently, and poor preparation of his accommodation.

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
Delays in completing and sending the discharge summary
Wider context from the report
“8. The discharge summary was not dictated and sent to his new outpatient Consultant until the 18th February over three months from his discharge from hospital. There were no follow up appointments in place for Gareth at the time of discharge. ”
Source location
Gareth Mark Slater · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to maintain complete and accurate records of discharge decisions and timing

Concerns raised2

Failure to provide written post-operative discharge information and advice

Failure to provide a discharge summary

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

Concerns raised1

Delays in completing and sending the discharge summary

Actions described in response 3