Recurring concern
Unreliable hospital discharge documentation
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Request correctionFirst reported 30 Jan 2013•Latest report 27 May 2026
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
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
Incomplete and inaccurate discharge nursing documentation
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 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 keep contemporaneous documentation of self-discharge and detention decision-making rationale
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 raised2
Failure to retain discharge documentation
Failure to provide clear discharge follow-up advice and guidance
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 transfer complete discharge documentation to the community hospital
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.
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Concerns raised1
Failure to provide an adequate discharge summary
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.3
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Action
Audit 50 CDU discharges over three months to assess whether discharge summaries were documented.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Introduce a discharge checklist to improve discharge documentation and reduce recurrence of discharge omissions.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Continue developing an electronic CDU discharge summary and put it in place within three months.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Incomplete discharge documentation for handover to doctors
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.
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
Appoint a discharge facilitator and refocus a band 7 nursing role on admissions, discharges and complete discharge-planning documentation.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Revise the discharge-planner template to clarify recording of key information.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Use documentation audits to review discharge-documentation quality.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Lack of standard patient discharge information materials
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.
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Concerns raised1
Failure to include falls in hospital discharge information
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
Require significant inpatient falls to be recorded in discharge summaries.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Coordinate an audit of discharge summaries with external auditors.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Address findings from the discharge-summary audit.
Stated by University Hospitals of North Midlands NHS Trust
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Concerns raised1
Gaps in clinical record keeping hindering treatment coordination and discharge accountability
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.5
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Action
Establish strategic patient-flow leadership and review admission and discharge procedures.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Require formal discharge care plans, risk assessments and consultant oversight for high-risk discharges.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Introduce the approved PARIS electronic clinical record system across Manchester services.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Action
Deliver rolling record-keeping training for Manchester healthcare professionals incorporating lessons from the death.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Include record-keeping standards in ongoing clinical-staff audit supervision.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Failure to maintain accurate records of care, fluid intake, diet, nutrition, hospital discharge arrangements and aftercare instructions
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.
Data last updated 7 September 2026