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
Failure to ensure that service users and carers receive follow-up appointment details on discharge
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
Implement enhanced discharge documentation requiring written follow-up details, contact numbers, and agreed information for patients and carers.
Stated by Northern Health and Social Care Trust
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Concerns raised2
Failure to make formal post-discharge referral or contact with community mental health services and general practitioner
Lack of post-discharge community aftercare
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.
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 notify relevant support services and contacts after patient self-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.
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
Continue communicating self-discharge policy requirements to clinical and nursing staff through bulletins, meetings, induction, briefings and read-and-sign materials.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust -
Action
Use the electronic hospital information system to provide ward managers with daily lists of missing discharge summaries and promptly rectify failures or delays in sending them to GPs.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust -
Action
Assign self-discharge codes and conduct monthly audits to verify that discharge letters are sent to patients’ GPs, urgently rectifying omissions.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
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Action
Develop a more sophisticated audit of hospital information system records to assess information quality and identify discharge-summary failures or delays in real time.
Stated by Wrightington, Wigan and Leigh Teaching 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
The existing self-discharge policy and electronic discharge system require GP discharge letters for all patients, addressing discharge communication.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to tailor discharge support to the patient’s reported lack of benefit from crisis-team care
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 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
Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.
Stated by Royal Free London 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
CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.
Stated by Royal Free London NHS Foundation Trust
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Concerns raised1
Failure to arrange mandatory post-discharge reviews
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 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
Implement a central referrals inbox for communicating hospital discharge plans to CMHT staff, with daily administrative review and senior oversight.
Stated by East London NHS Foundation Trust -
Action
Extend seven-day post-discharge follow-up to everyone discharged from hospital, not only people under the Care Programme Approach.
Stated by East London NHS Foundation Trust -
Action
Require Senior Practitioners to allocate and monitor discharge-plan actions, using duty workers when care coordinators are unavailable.
Stated by East London 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
Implemented CMHT systems are considered sufficient to address concerns about monitoring care coordinators.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure to ensure follow-up appointments are booked before 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
Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.
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
Existing discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to provide follow-up after community mental health assessment
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.2
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Position
The assessment found low suicide risk and sufficiently detailed needs assessment, so discharge after one consultation was considered the right decision.
Stated by Midlands Partnership University NHS Foundation Trust
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Position
Existing self-help resources, GP referral routes and CMHT re-referral contacts were considered sufficient without ongoing CMHT follow-up.
Stated by Midlands Partnership University NHS Foundation Trust
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Concerns raised3
Failure to make telephone contact between discharge and first appointment review
Reliance on individuals to proactively manage their rehabilitation after discharge
Failure to provide fixed post-discharge appointments after detoxification
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.1
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Action
Participate in a trial of more assertive follow-up for alcohol-dependent patients before discharge, including arranging a GP appointment.
Stated by King'S College Hospital NHS Foundation Trust
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
Expanding telephone follow-up would require additional funding for the Trust’s alcohol dependency service.
Stated by King'S College Hospital NHS Foundation Trust
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Position
Existing motivational models and pre-discharge links to appropriate third-sector services are preferred over fixed hospital follow-up appointments.
Stated by King'S College Hospital NHS Foundation Trust
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Concerns raised1
Failure to make further referrals back to the Mental Health Liaison Service after hospital discharge
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 visit and re-engage people who do not respond to appointment contacts
Failure to arrange follow-up appointments before discharge
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