First reported 30 Jan 2013•Latest report 10 Jun 2026
Definition
What this concern includes
Includes failures in hospital discharge planning, readiness decisions, multidisciplinary or receiving-service coordination, safety planning, execution and directly required follow-up.
Not included
Inter-hospital patient transfer where no discharge from hospital care occurs
Failures in treatment after a safe and complete discharge
Generic care coordination unrelated to a hospital discharge process
Delays in admission or movement within hospital before discharge is being planned
Reports
273
Distinct published reports
Individual concerns
406
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
524
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 Care48
NHS England20
University Hospitals Sussex NHS Foundation Trust9
Essex Partnership University NHS Foundation Trust8
Manchester University NHS Foundation Trust8
Barts Health NHS Trust7
Care Quality Commission7
Greater Manchester Mental Health NHS Foundation Trust7
NHS Greater Manchester Integrated Care Board6
Tameside and Glossop Integrated Care NHS Foundation Trust6
Betsi Cadwaladr University LHB5
Kent and Medway Mental Health NHS Trust5
Pennine Care NHS Foundation Trust5
Royal London Hospital5
Stockport NHS Foundation Trust5
NHS trust183
Ministerial department51
Healthcare site43
Executive non-departmental public body24
Integrated care board13
Local health board12
English county council10
Type not available8
Health and social care service regulator7
Multi-service care provider6
Private limited company6
English metropolitan district council5
English unitary authority5
London borough council5
Independent healthcare provider4
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.
Manchester South
Concerns raised1
Failure to make safe discharge decisions based on clinical findings
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.
Nottingham and Nottinghamshire
Concerns raised3
Delays or failures in delivery of ED discharge summaries
Failure to supply ED discharge summaries to patients
Inadequate information in ED discharge summaries
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.5
Action
Develop and publish a patient information leaflet explaining pneumonia follow-up requirements and their importance.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026.
Action
Complete pharmacy feedback and update the agreed ED discharge-letter template to improve medicines documentation.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026.
Action
Implement system updates to auto-generate a full clinician summary for appropriate patients discharged directly from ED.
Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 August 2026.
Action
Provide medical-documentation training, including discharge-summary requirements, through Foundation Doctor induction and Resident Doctor teaching.
Stated by Nottingham University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Action
Review and update medical-documentation training materials to emphasise robust follow-up arrangements before October 2026 delivery.
Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 August 2026.
Essex
Concerns raised2
Failure to resolve unmet discharge conditions and escalated self-harm concerns before discharge
Failure to verify service acceptance and agree an appropriate discharge care plan
This report raised 17 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.3
Action
Recruit a Community and Inpatient Liaison Practitioner CPN to coordinate inpatient communication and safer discharge planning.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Action
Hold weekly ward discharge-planning meetings with key care workers and community leads, documenting complex-discharge actions.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Action
Ensure Home First Home Team staff attend inpatient MDT meetings and ward reviews to coordinate discharge interventions.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Discharge to community mental health services was considered appropriate and proportionate based on multidisciplinary risk assessment and the patient’s clinical presentation.
Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Discharge planning meetings may proceed without a community team member because records and multidisciplinary notes remain accessible to all relevant staff.
Stated by Essex Partnership University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Failure to accurately record changes in mental health diagnosis in discharge summaries
This report raised 7 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.
Cumbria
Concerns raised1
Failure to provide Flow Coordinators with information about patient vulnerabilities when arranging discharge
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
Review the Band 4 Flow Coordinator role and associated discharge processes, including responsibilities, risk-information flow, escalation and multidisciplinary clinical leadership.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2026.
Action
Implement clinical-risk information sharing during discharge coordination and multidisciplinary discharge processes, including updated documentation and mental-health referral prompts.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Contemporaneous staff accounts did not indicate that explicit hanging suicide intent was escalated immediately before discharge.
Stated by North Cumbria Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner South London
Concerns raised1
Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Suffolk
Concerns raised3
Inadequate recording of important discharge advice
Absence of an assurance mechanism to identify and remedy discharge advice errors
Provision of wrong advice to patients on 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 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.5
Action
Use a standardised discharge-summary process with pre-approved #tag advice to reduce variation and inaccurate instructions.
Stated by West Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Train junior doctors during induction to use standardised discharge-summary #tags.
Stated by West Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Assign consultants ownership of discharge processes and require checking and challenging draft discharge letters.
Stated by West Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2026.
Action
Rectify digital barriers and implement digital enablers for producing discharge letters.
Stated by West Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.
Action
Monitor discharge-letter compliance through Clinical Directors and Clinical Leads and discuss the data in governance meetings.
Stated by West Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Manchester South
Concerns raised1
Failure of discharge-safety assessment processes to accurately assess patient mobility
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.3
Position
There was no discrepancy between the discharge referral information and the patient’s function at discharge, so mobility was not unrealistically represented.
Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing discharge planning, equipment provision and continuing mobility reviews were considered appropriate and sufficient under usual practice.
Stated by Stockport NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The discharge information accurately reflected the patient’s function, and the discharge was appropriately planned within usual expectations.
Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
County Durham and Darlington
Concerns raised1
Failure to ensure patients can consistently complete a flight of stairs without assistance before discharge
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
Deliver SOAP note training to Community Physiotherapy, Occupational Therapy and Assistant staff within six weeks, and remaining Physiotherapy and Occupational Therapy staff within four months.
Stated by County Durham and Darlington NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Repeating stair assessments is not always necessary where a patient previously completed one safely and has no additional risk factors.
Stated by County Durham and Darlington NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Suffolk
Concerns raised2
Failure to ensure that oncology discharge criteria are known and followed
Unavailability of on-call oncology support for cancer patient discharge planning during weekends and out of hours
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 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
Share targeted communication with ward teams reinforcing oncology advice and safe discharge requirements for complex out-of-hours and weekend discharges.
Stated by SNEE ICB and West Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A formal out-of-hours consultant oncology service cannot be provided because additional consultant capacity and resources are unavailable.
Stated by SNEE ICB and West Suffolk NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures in hospital discharge planning, readiness decisions, multidisciplinary or receiving-service coordination, safety planning, execution and directly required follow-up.
