First reported 30 Jan 2013•Latest report 23 Oct 2025
Definition
What this concern includes
Includes failures of the post-discharge process, including absent or delayed follow-up care, appointments, referrals, contact, treatment plans, monitoring, or community support where these are needed after discharge.
Not included
Excludes failures confined to pre-discharge assessment or the discharge decision unless they directly concern arranging continuing post-discharge care.
Excludes missed-appointment follow-up where no discharge or post-discharge care process is involved.
Excludes generic staffing, communication, documentation or community-care deficiencies unless they directly cause or form part of inadequate follow-up after discharge.
Excludes unrelated care transitions that do not concern follow-up after discharge.
Reports
55
Distinct published reports
Individual concerns
66
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
56
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 Care8
NHS England5
Pennine Care NHS Foundation Trust4
Care Quality Commission3
Midlands Partnership University NHS Foundation Trust3
NHS Greater Manchester Integrated Care Board3
Black Country Healthcare NHS Foundation Trust2
East London NHS Foundation Trust2
Greater Manchester Health and Social Care Partnership2
Leicestershire Partnership NHS Trust2
South London and Maudsley NHS Foundation Trust2
Tameside and Glossop Integrated Care NHS Foundation Trust2
Aneurin Bevan University LHB1
Barts Health NHS Trust1
Betsi Cadwaladr University LHB1
NHS trust37
Healthcare site14
Ministerial department9
Integrated care board7
Executive non-departmental public body5
Local health board5
English metropolitan district council3
Health and social care service regulator3
Health-system partnership2
Community interest company1
Company limited by guarantee1
Coronial office1
Domiciliary care provider1
English county council1
English unitary authority1
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.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to arrange cardiology follow-up after discharge
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
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Stated by the Shrewsbury and Telford Hospital NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
County Durham and Darlington
Concerns raised1
Failure to arrange follow-up appointments after discharge
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.
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.2
Action
Use a discharge process requiring follow-up appointments when needed and documenting confirmation in patient records.
Stated by County Durham and Darlington NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 June 2025.
Action
Conduct regular ward audits to monitor compliance with the follow-up appointment process.
Stated by County Durham and Darlington NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.
Manchester North
Concerns raised1
Failure to make a 48-hour post-discharge follow-up call
This report raised 13 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
A 48-hour follow-up call is not required where a confirmed NHS community appointment exists within 72 hours of discharge.
Stated by Priory GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Rutland and North Leicestershire
Concerns raised1
Lack of planned post-discharge support
This report raised 8 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
Discharge to primary care is considered appropriate for many patients when supported by a collaboratively formulated crisis and contingency plan with 24-hour access.
Stated by Leicestershire Partnership NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cornwall and Isles of Scilly
Concerns raised1
Absence of a planned route back to mental health assessment
This report raised 10 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
Publish statutory guidance for discharge from mental health and learning disability and autism inpatient settings, including patient, carer and family involvement in discharge planning.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
No further difficulties need to be overcome in the referral pathway into secondary mental health services.
Stated by Cornwall CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
The Integrated Care Board is expected to respond to concerns about the specific care provided.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East Riding and Hull
Concerns raised2
Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments
Failure to make post-discharge referrals for patients needing district nursing care
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.6
Action
Share the review findings with CQC’s Primary and Community Care operations team for consideration in its regulatory response.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
Action
Finalize and roll out an electronic nursing discharge pro forma prompting community-nursing referral consideration and recording referral recipients.
Stated by Hull University Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2024.
Action
Discuss the appropriate level of information about community-nursing referrals for inclusion in medical discharge summaries.
Stated by Hull University Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2024.
Action
Explore enabling external SystmOne users to send referrals directly into CHCP’s SystmOne system.
Stated by City Health Care Partnership CICStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2024.
Action
Share referral criteria, available services and referral instructions regularly with GPs and other healthcare organisations.
Stated by City Health Care Partnership CICStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Implement mandatory use of SystmOne task functionality for structured communication, monitored task handling, and patient-record traceability.
Stated by St Andrews SurgeryStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
Concerns about points 2 and 3 relate to primary care rather than the Trust’s responsive responsibilities.
Stated by Hull University Teaching Hospitals NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Providers involved in Linda’s care should address the specific care concerns, provide further information, and identify related learning.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Oversight of the GP practice is assigned to the integrated care board, while findings inform CQC’s regulatory response.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The material risk arose from missed community nursing referrals at discharge, not insufficient information in the immediate discharge summary.
Stated by Hull University Teaching Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Feedback on the concerns cannot be provided because no referral was made to Community Nursing, and the referral hub manages all CHCP referrals.
Stated by City Health Care Partnership CICUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Routine monitoring and risk-based inspections are considered sufficient to identify and address further concerns about the services.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Difficult access to mental health support for service personnel with severe PTSD during service and following discharge
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.2
Position
The report may reflect an incomplete understanding of MOD medical history and support because MOD was not an interested person.
Stated by Ministry of DefenceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing mental health services mean there is no immediate need to change MOD policies.
Stated by Ministry of DefenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Delays in community mental health team follow-up
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.
North Yorkshire and York
Concerns raised1
Failure to arrange follow-up appointments at discharge
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 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.2
Action
Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Amend the electronic discharge-note template to include required discharge information and advice.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Cumbria
Concerns raised1
Failure to plan follow-up after discharge
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The discharge included planned follow-up, with ongoing support from the Cumbria East Crisis Team and planned referrals to other services.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures of the post-discharge process, including absent or delayed follow-up care, appointments, referrals, contact, treatment plans, monitoring, or community support where these are needed after discharge.
