Recurring concern
Failure to ensure patients receive the correct prescribed medication at hospital discharge
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Request correctionFirst reported 4 Sep 2013•Latest report 17 Oct 2023
What this concern includes
Includes failures in the hospital discharge medication process that prevent the patient receiving the correct prescribed medication before or at discharge, including transfer, dispensing, availability, reconciliation and escalation failures dedicated to discharge medication safety.
Not included
- Excludes failures to administer medication during an inpatient stay when they are not connected to discharge.
- Excludes prescribing, clinical selection or dose-assessment failures that do not concern supplying or transferring medication at discharge.
- Excludes generic discharge communication failures involving summaries, results or other information without a medication-supply failure.
- Excludes medication-access or dispensing risks outside hospital discharge.
- Reports
- 13
- Individual concerns
- 13
- Date range
- 2013–2023
- Stated actions
- 13
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 dispense prescribed dalteparin 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.
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Concerns raised1
Failure to prescribe or dispense medication before self-discharge against medical advice patients leave the Hospital
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.3
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Action
Complete a Trust-wide review of self-discharge against medical advice policies and procedures.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Develop, ratify and implement a single Trust-wide self-discharge procedure with a checklist, senior clinical review, capacity and risk assessments, detention consideration, documentation and medication supply requirements.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Disseminate the ratified procedure to Care Groups and staff through the intranet and junior-doctor induction.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Failure to provide discharge medications
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 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.2
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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 Trust -
Action
Amend the electronic discharge-note template to include required discharge information and advice.
Stated by Leeds Teaching Hospitals NHS Trust
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Concerns raised1
Failure to transfer prescribed medication to the community hospital
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 send prescribed anticipatory medication with the person at 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.
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
Re-circulate the discharge Standard Operating Procedure to staff, including staff on the discharge ward.
Stated by Northern Care Alliance NHS Foundation Trust
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Concerns raised1
Failure to provide prescribed antibiotics 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 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 ensure an adequate supply of prescribed medication during hastily arranged discharges
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of a protocol for patients self-discharging from hospital without necessary medication
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.1
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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
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Concerns raised1
Failure to ensure prescribed antibiotics are supplied to patients on 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.3
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Action
Complete a retrospective audit of emergency-department discharge prescriptions and evidence that medications were dispensed and communicated in line with policy.
Stated by Manchester University NHS Foundation Trust -
Action
Remind emergency-department and clinical-decisions-unit staff to supply prescribed medications, communicate instructions to patients and carers, and document this in clinical records.
Stated by Manchester University NHS Foundation Trust -
Action
Commence a regular emergency-department audit programme monitoring compliance with medication-supply and documentation policy.
Stated by Manchester University NHS Foundation Trust
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Concerns raised1
Failure to maintain syringe-driver medication delivery during hospital-to-hospice transfer
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