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

Distinct published reports

Individual concerns
47

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
74

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.

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.

  1. Brighton and Hove

    AI-generated summary

    Derek LEE · 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

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    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

    Incomplete mental-capacity documentation at discharge

    Wider context from the report

    “(2) Re: Admission Documentation – Mental capacity was not properly assessed and when Mr Lee was discharged from the ward after three weeks on the 17th May the paperwork in that respect was still incomplete. ”

    Source location

    Derek LEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Inner North London

    AI-generated summary

    Nuala Seddon · 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

    Nuala Seddon developed a hypoxic brain injury after a cardiac arrest on 27 November 2014, following her transfer from ITU to ward-based care, and died on 7 April 2016 after developing pneumonia. The report raised concern that a lack of available telemetry could expose patients discharged from ITU to significant risk of unrecognised deterioration.

    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

    Lack of documentation of significant discharge decisions

    Wider context from the report

    “(1) It seems clear that a decision was made to transfer Mrs Seddon from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff. The lack of documentation regarding this significant decision is concerning and leaves open the possibility that future discharges could be based on non-clinical need or inappropriate decision-making which is not subsequently able to be scrutinised because of a lack of documentation. ”

    Source location

    Nuala Seddon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Manchester West

    AI-generated summary

    Colin Garth · 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

    Colin Garth was diagnosed with colon cancer on 5 May 2016, underwent surgery and Hickman line insertion, was readmitted on 18 June, and died at Royal Bolton Hospital on 19 June 2016. The medical cause of death included sepsis, Hickman line infection and pneumonia, and disseminated colonic carcinoma. Concerns included inadequate written guidance for patients discharged with Hickman or central lines, insufficient staff knowledge of relevant policy, and a syringe driver that failed to alarm when blocked and was reconnected rather than referred for repair or replacement.

    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

    Lack of written discharge guidance for monitoring, cleaning and flushing Hickman or central lines

    Wider context from the report

    “A. During the course of the evidence I was told that when patients are discharged from the hospital with a Hickman or central line in situ, they are not furnished with any guidance booklet or sheet as to how the said line should be monitored, cleaned, flushed etc. It is clearly desirable that they should be as well informed as possible and I therefore consider that the provision of such written advice should be considered. ”

    Source location

    Colin Garth · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Rutland and North Leicestershire

    AI-generated summary

    Anthony John Preston · 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

    Anthony John Preston was admitted to The Priory Hospital in October 2013, discharged home on 11 November 2013, and was admitted to The Bradgate Unit four days later after becoming extremely anxious and depressed. He hanged himself in May 2014. Concerns included the lack of robust documentary evidence that his discharge had been communicated to the Leicestershire Crisis Team, the absence of immediate follow-up, and the resulting lack of support for him and his main carer when he was considered at high risk; the report states that no causal connection was suggested between his death and the discharge arrangements.

    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 documentary proof of discharge notification calls

    Wider context from the report

    “(2) The system for discharge of patients, whereby a nurse makes contact with (in this case) the Leicestershire Crisis Team does not appear to have been robust. There was no documentary proof of the telephone call. ”

    Source location

    Anthony John Preston · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Birmingham and Solihull

    AI-generated summary

    Terence Henry Stilges · 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

    Terence Henry Stilges was admitted to hospital after collapsing, was discharged before an outstanding troponin result was available, and was readmitted with severe shortness of breath and chest pain. He was diagnosed with an acute myocardial infarction and died following a cardiac arrest; the principal concern was that advance preparation of discharge summaries and incorrect discharge instructions could lead to patients being discharged before tests were complete.

    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 document outstanding test results and required follow-up in discharge records

    Wider context from the report

    “(1) A discharge summary was prepared several days in advance for this patient. This summary did not mention the need for a further troponin result before the patient was discharged home. In addition the medical records wrongly specified that he should be discharged home. Therefore the patient was incorrectly sent home before the second troponin result was available. I heard that there was a practice of writing discharge summaries in advance despite tests results being outstanding. I am concerned this could result in other patients being discharged before their tests are complete. ”

    Source location

    Terence Henry Stilges · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  6. North Wales (East and Central)

    AI-generated summary

    Laura Beth Newlands · 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

    Laura Beth Newlands was known to Denbighshire Social Services because of concerns about self-harm related to difficult home circumstances. After her case was closed, a delay in arranging a professionals’ meeting meant that further support was not provided before she took her own life by overdose four days before the scheduled meeting. The report identified concerns about incomplete safety-plan input, delays in responding to risk, and the decision to close and not reopen the case.

    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

    Insufficient DSS input into discharge safety plans

    Wider context from the report

    “1. Although a “safety plan” is prepared by CAMHS at the time of discharge from hospital, there does not appear to be sufficient input to this document by DSS with the result that those caring for a young person at risk may have incomplete written information available to them to properly ensure the safety of the young person. ”

    Source location

    Laura Beth Newlands · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. Norfolk

    AI-generated summary

    NICOLA ANNE TWEEDY · 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

    Mrs Tweedy underwent elective varicose vein surgery as a day-case patient on 27 March 2014 and was found collapsed and died at home on 29 March 2014. The inquest recorded pulmonary embolism following recent varicose vein surgery. Concerns included incomplete thromboprophylaxis risk assessment, missing procedure and aftercare leaflets, and incomplete discharge checks and documentation.

    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

    Incomplete nursing discharge notes covering required pre-discharge checks

    Wider context from the report

    “Nursing notes on discharge did not fully cover all the factors required to be checked before a patient is discharged. ”

    Source location

    NICOLA ANNE TWEEDY · 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

    Review the day-case discharge process outside the Day Procedure discharge pathway for consistency.

    Verbatim wording from the response

    “Our Action Plan on this case explained that whilst this issue was covered by the existing Day Procedure (DPD) discharge checklist, the process applying to day-case patients outside the DPD was to be reviewed to ensure that this was consistent.”

    Source location

    2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
    Page 4 · response
    Published 12 March 2015

    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’s implemented Action Plan was considered to have addressed the reported care concerns, with learning and improvement demonstrated.

    Verbatim wording from the response

    “I note that you have sent your report to the Norfolk and Norwich University Hospital NHS Foundation Trust. My officials have liaised with the Foundation Trust about your report and I understand that it has fully considered and responded to each of your concerns relating to the care of Mrs Tweedy. I can report that a recent independent external inspection found that the Foundation Trust had implemented an Action Plan, to address the issues raised by this case, and that this demonstrated that learning and improvement had taken place.”

    Source location

    2015-0095-Response-by-Department-of-Health
    Page 1 · response
    Published 12 March 2015

    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

    Professional regulatory bodies are responsible for investigating registrants’ alleged failures to meet standards and taking necessary safeguarding action.

    Verbatim wording from the response

    “Lastly, as some of the actions of medical and nursing staff are subject to criticism in your report, I wish to take this opportunity to remind you of the role of the professional regulatory bodies and their fitness-to-practise processes.”

    Source location

    2015-0095-Response-by-Department-of-Health
    Page 2 · response
    Published 12 March 2015

    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 Department cannot become involved in or comment on individual cases.

    Verbatim wording from the response

    “health and well-being of the public. The Department cannot get involved with or comment on individual cases.”

    Source location

    2015-0095-Response-by-Department-of-Health
    Page 3 · response
    Published 12 March 2015

    Open published response
  8. Bedfordshire and Luton

    AI-generated summary

    Simon Robert ALLISTON · 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

    Simon Robert ALLISTON lived alone and was found deceased in his flat after neighbours had not seen him for approximately a week; paramedics confirmed his death. The concerns included his discharge from mental health services without a formal handover, despite the Community Team considering that he still needed support, with no recorded reason for discharge and no formal Serious Incident Investigation after his 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 record the reason for discharge

    Wider context from the report

    “(3) That the reason for discharge was never recorded. ”

    Source location

    Simon Robert ALLISTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. Brighton and Hove

    AI-generated summary

    Graham Harold WATTS · 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

    Graham Harold Watts was discharged from Princess Royal Hospital to his nursing home, where he arrived hypothermic, hypotensive, oedematous and sleepy. The report raised concerns about a flawed discharge process, blank paperwork and a lack of communication with the nursing home and his son. It also recorded evidence that, had he not fractured his hip in a fall, he would not have died when he did.

    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 complete discharge paperwork

    Wider context from the report

    “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge. (2) The discharge paperwork was effectively blank. (3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy. (4) It is acknowledged and accepted that a change of environment increases the risks of fall. ”

    Source location

    Graham Harold WATTS · 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 ward nurses with refresher training on discharge processes, required documentation and Do Not Attempt Cardio-pulmonary Resuscitation forms.

    Verbatim wording from the response

    “The ward nurses have all had refresher training on the processes they are expected to go through, including but not limited to the related documentation, before any patient is discharged from the ward. This has included a reminder of the correct procedure to be followed with any “Do Not Attempt Cardio-pulmonary Resuscitation” form. The Trust deeply regrets that this form did not accompany Mr Watts on his discharge as it should have done.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 3 April 2014

    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

    Emphasize completion of nurse-to-nurse discharge summaries for patients transferred to or returning to residential or nursing home care.

    Verbatim wording from the response

    “The senior nursing staff agree that it is essential that a nurse to nurse discharge summary is completed for any patient leaving the hospital to go to, or return to, residential or nursing home care. They have emphasized the importance of this to the ward nurses. As part of the programme for developing the skills of junior nurses, the ward is placing increased emphasis on shadowing senior colleagues, to equip these junior staff with the skills needed to make robust decisions and to give them role models to assist with their communication skills.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 3 April 2014

    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

    Conduct monthly snapshot audits of ward medical records to monitor discharge-documentation standards.

    Verbatim wording from the response

    “Each month a snapshot audit is being done of 10 sets of medical records from the ward to ensure that they reflect an acceptable standard of discharge documentation. For this ward, the April review of discharge documentation showed 100% compliance with the requirement for documentation in the discharge planner, and also on the provision of information about discharge plans to relatives.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 3 April 2014

    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

    Review the forms used for discharge planning.

    Verbatim wording from the response

    “The Trust has reviewed the forms currently used for discharge planning and is devising new paperwork which is intended to facilitate timely documentation, and to encourage daily consideration of each in-patient’s progress towards discharge.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 3 April 2014

    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 new discharge-planning paperwork to facilitate timely documentation and daily consideration of patients’ progress toward discharge.

    Verbatim wording from the response

    “The Trust has reviewed the forms currently used for discharge planning and is devising new paperwork which is intended to facilitate timely documentation, and to encourage daily consideration of each in-patient’s progress towards discharge.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 3 April 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 discharge process was not fundamentally flawed; shortcomings arose from inadequate implementation on this occasion.

    Verbatim wording from the response

    “The Trust acknowledges and apologises that there were significant shortcomings in the discharge planning process for Mr Watts, arising from failures by staff to complete thoroughly all the steps necessary to ensure safe and timely discharge for each patient. The Trust does not accept that the process itself was deeply flawed, but acknowledges that it was not implemented adequately on this occasion.”

    Source location

    2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 3 April 2014

    Open published response
  10. 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