Failure to provide timely and adequate follow-up after discharge
First to latest report 30 Jan 2013 — 23 Oct 2025
Reports that mention this concern
55
Times this concern has been raised
66
Stated actions linked to this concern
56
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 55 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked responses
NHS England
the Shrewsbury and Telford Hospital NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
the Shrewsbury and Telford Hospital NHS Trust
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
the Shrewsbury and Telford Hospital NHS Trust
Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.
the Shrewsbury and Telford Hospital NHS Trust
Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.
the Shrewsbury and Telford Hospital NHS Trust
Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
the Shrewsbury and Telford Hospital NHS Trust
Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Redirects 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.
Linked response
County Durham and Darlington NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
County Durham and Darlington NHS Foundation Trust
Use a discharge process requiring follow-up appointments when needed and documenting confirmation in patient records.
County Durham and Darlington NHS Foundation Trust
Conduct regular ward audits to monitor compliance with the follow-up appointment process.
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.
Linked response
Priory Group
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Priory Group
A 48-hour follow-up call is not required where a confirmed NHS community appointment exists within 72 hours of discharge.
Existing 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.
Linked response
Leicestershire Partnership NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Leicestershire Partnership NHS Trust
Discharge to primary care is considered appropriate for many patients when supported by a collaboratively formulated crisis and contingency plan with 24-hour access.
Existing 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.
Linked responses
Cornwall Council
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Department of Health and Social Care
Publish statutory guidance for discharge from mental health and learning disability and autism inpatient settings, including patient, carer and family involvement in discharge planning.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Cornwall Council
No further difficulties need to be overcome in the referral pathway into secondary mental health services.
No action considered necessaryThe respondent said that no further action was needed.
Department of Health and Social Care
The Integrated Care Board is expected to respond to concerns about the specific care provided.
Redirects 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.
Linked responses
Care Quality Commission
City Health Care Partnership CIC
Hull University Teaching Hospitals NHS Trust
NHS England
St Andrews Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Care Quality Commission
Share the review findings with CQC’s Primary and Community Care operations team for consideration in its regulatory response.
Hull University Teaching Hospitals NHS Trust
Finalize and roll out an electronic nursing discharge pro forma prompting community-nursing referral consideration and recording referral recipients.
Hull University Teaching Hospitals NHS Trust
Discuss the appropriate level of information about community-nursing referrals for inclusion in medical discharge summaries.
City Health Care Partnership CIC
Explore enabling external SystmOne users to send referrals directly into CHCP’s SystmOne system.
City Health Care Partnership CIC
Share referral criteria, available services and referral instructions regularly with GPs and other healthcare organisations.
St Andrews Surgery
Implement mandatory use of SystmOne task functionality for structured communication, monitored task handling, and patient-record traceability.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Hull University Teaching Hospitals NHS Trust
Concerns about points 2 and 3 relate to primary care rather than the Trust’s responsive responsibilities.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
Providers involved in Linda’s care should address the specific care concerns, provide further information, and identify related learning.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Care Quality Commission
Oversight of the GP practice is assigned to the integrated care board, while findings inform CQC’s regulatory response.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Hull University Teaching Hospitals NHS Trust
The material risk arose from missed community nursing referrals at discharge, not insufficient information in the immediate discharge summary.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
City Health Care Partnership CIC
Feedback on the concerns cannot be provided because no referral was made to Community Nursing, and the referral hub manages all CHCP referrals.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Care Quality Commission
Routine monitoring and risk-based inspections are considered sufficient to identify and address further concerns about the services.
Existing 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.
Linked response
Ministry of Defence
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Ministry of Defence
The report may reflect an incomplete understanding of MOD medical history and support because MOD was not an interested person.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Ministry of Defence
Existing mental health services mean there is no immediate need to change MOD policies.
Existing 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.
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.
Linked response
Leeds Teaching Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Leeds Teaching Hospitals NHS Trust
Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
Leeds Teaching Hospitals NHS Trust
Amend the electronic discharge-note template to include required discharge information and advice.
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.
Linked response
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
The discharge included planned follow-up, with ongoing support from the Cumbria East Crisis Team and planned referrals to other services.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.