Recurring concern
Failure to provide timely and adequate follow-up after discharge
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Request correctionFirst reported 30 Jan 2013•Latest report 23 Oct 2025
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
- Individual concerns
- 66
- Date range
- 2013–2025
- Stated actions
- 56
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
Lack of a formal system for seeing patients who reattend unexpectedly after 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 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.1
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Action
Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.
Stated by Spire Bristol Hospital
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing admission and discharge procedures provided a formal process for managing patients who contacted or re-attended after discharge.
Stated by Spire Bristol Hospital
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Concerns raised2
Lack of guidance for arranging and communicating critical post-discharge investigations
Failure to ensure clear and unambiguous procedures for implementing post-discharge investigation decisions
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.1
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Action
Rewrite the national discharge policy to clarify multidisciplinary roles, responsibilities, discharge scenarios and arrangements for critical post-discharge investigations.
Stated by Nuffield Health
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Concerns raised1
Inadequate follow-up engagement and monitoring after discharge
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.
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 timely referrals for discharged patients requiring community nursing services
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.
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
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Action
Move all Trust referrals to District Nurses onto an electronic portal.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Tighten referral processes while migrating from fax machines to electronic communication systems.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Reinforce clinical incident reporting for missed referrals to support investigation, learning and training.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Action
Track missed-referral incidents and escalate identified trends or themes through divisional meetings for timely action.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Missed referrals are not considered common, based on team experience, incident review and evidence from the referral service.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to arrange psychiatric liaison assessment and professional follow-up after overdose
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.1
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Action
Use the Bristol Matrix to identify patients requiring psychiatric assessment, supported by established staff training.
Stated by Cardiff & Vale University LHB
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing Bristol Matrix procedures and established training are considered sufficient to identify patients requiring immediate psychiatric assessment.
Stated by Cardiff & Vale University LHB
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Position
Home treatment with frequent specialist input was considered appropriate, balancing admission risks and the patient's unwillingness to be admitted.
Stated by Cardiff & Vale University LHB
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Concerns raised1
Failure to provide timely mental health follow-up after hospital 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 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 emphasise review of post-operative prophylaxis after discharge home
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
NICE concluded that its VTE guidelines are appropriate and require no amendment at this time.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to provide follow-up after emergency department admissions for alcohol-related presentations
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 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.4
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Action
Maintain a 24-hour referral service and dedicated pathway with the Inclusion Service.
Stated by Hampshire Hospitals NHS Foundation Trust -
Action
Provide alcohol-service inpatient access through weekly and arranged ad hoc Inclusion inreach.
Stated by Hampshire Hospitals NHS Foundation Trust -
Action
Maintain telephone and onsite liaison with Inclusion regarding referrals and referred patients receiving inpatient care.
Stated by Hampshire Hospitals NHS Foundation Trust
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Action
Participate in a monthly multi-provider High Intensity User Group to identify further support for frequent attenders.
Stated by Hampshire Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing referral, liaison, follow-up and high-intensity-user arrangements are considered sufficient to address the reported concerns.
Stated by Hampshire Hospitals NHS Foundation Trust
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Concerns raised1
Discharge from hospital without 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 concernsEach 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
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Position
Discharge without follow-up was considered sufficient because the family knew how to access crisis support if required.
Stated by Oxleas NHS Foundation Trust
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Concerns raised2
Failure to arrange an outpatient appointment within 3 weeks of discharge
Failure to arrange weekly post-discharge x-rays to monitor fracture alignment
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 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.4
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Action
Formulate and implement guidelines for conservatively managed potentially unstable fractures, including follow-up and X-ray review timescales.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Create three daily hot-clinic slots to provide capacity for expedited post-discharge Trauma and Orthopaedic follow-up.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Add the date of X-ray performance and review to consultant handover documentation.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Action
Highlight to Trauma and Orthopaedic consultants the responsibility to arrange clear management plans and weekly X-rays for conservatively managed fractures.
Stated by University Hospitals Birmingham NHS Foundation Trust
Data last updated 7 September 2026