Recurring concern
Unreliable hospital discharge processes
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Request correctionFirst reported 30 Jan 2013•Latest report 10 Jun 2026
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
- Individual concerns
- 406
- Date range
- 2013–2026
- Stated actions
- 524
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 raised2
Failure to coordinate hospital discharge with the receiving care home
Discharge of patients with medicines that the receiving care home cannot administer
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.
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 Trust disputes that Mr Yemm was discharged without warning or without arrangements for insulin administration and supervision.
Stated by Norfolk and Norwich University Hospitals NHS Foundation Trust
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Concerns raised1
Delays in transmitting discharge letters when timely GP involvement is required
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
Inaccurate wording in discharge notices about GP referral as an alternative to hospital admission
Failure to include clinically relevant information in discharge notices
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 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
Complete refresher training for crew members on documentation standards, checking EPR entries and obtaining signatures for non-conveyance cases.
Stated by West Midlands Ambulance Service University 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
The discharge form advised contacting or attending the GP; it did not indicate that the patient had been referred.
Stated by West Midlands Ambulance Service University NHS Foundation Trust
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Position
A discharge sheet provided safety-netting information, so it was not correct that no relevant information or consultation outcome was left.
Stated by West Midlands Ambulance Service University NHS Foundation Trust
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Concerns raised1
Failure to communicate required follow-up arrangements to GPs at 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.
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
Current practice and guidelines did not indicate that the Trust should recommend home blood glucose monitoring to the GP.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Position
The system remains robust, so no further action is proposed regarding home blood glucose monitoring advice.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Concerns raised2
Lack of quality assurance of discharge summary letters
Discharge summary letters failing to communicate significant clinical risks and incidents
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.5
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Action
Check and discuss new trainees’ admission and discharge summaries during their first month, with senior-doctor review before discharge.
Stated by Pennine Care NHS Foundation Trust -
Action
Incorporate documentation review into trainees’ weekly supervision.
Stated by Pennine Care NHS Foundation Trust -
Action
Audit the revised admission and discharge summary process.
Stated by Pennine Care NHS Foundation Trust
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Action
Provide all new medical trainees with training on admission and discharge summary standards and processes.
Stated by Pennine Care NHS Foundation Trust -
Action
Issue new trainees laptops and require admission and discharge summaries to be maintained as live documents throughout patients’ admissions.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Delays in putting care packages in place for medically optimised patients
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
Make £1.3 billion available and confirm £588 million to support enhanced hospital-discharge arrangements over winter.
Stated by Department of Health and Social Care -
Action
Adopt and implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, discharge medication, testing, PPE and next-day follow-up processes.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Create additional community discharge capacity, including reablement support, domiciliary care and community beds.
Stated by NHS Greater Manchester Integrated Care Board
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Action
Review community-based capacity to ensure discharge pathways have the correct types of capacity.
Stated by NHS Greater Manchester Integrated Care Board
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
NHS providers and local partners, including social services, are responsible for timely discharge planning and post-discharge care.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to assess the safety or suitability of the home and appliances as part of hospital discharge planning
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.2
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Action
Ensure the multidisciplinary team and Social Services are informed when concerns about a vulnerable patient’s home safety are raised or suspected.
Stated by Recipient name withheld -
Action
Prompt the Care Navigator or Social Worker at monthly multidisciplinary meetings to ensure appropriate fire-safety checks are implemented.
Stated by Recipient name withheld
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
Responsibility for environmental risk assessments after discharge lay with the Reablement Team within the London Borough of Tower Hamlets.
Stated by East London NHS Foundation Trust
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Position
Hospital discharge planning, including functional assessment before discharge, is the hospital team’s responsibility; primary care is not involved.
Stated by Recipient name withheld -
Position
Occupational therapy assesses functional safety in the home but does not assess the safety or adequacy of electrical appliances.
Stated by Recipient name withheld -
Position
No further GP occupational therapy referral was needed because the patient was already under an integrated care arrangement including the local-authority reablement team.
Stated by Recipient name withheld
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Concerns raised1
Failure to ensure discharge instructions are accessible and understood by patients
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
Review admission and discharge documentation across the Trust to identify required changes.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Amend admission and discharge documentation to include literacy checks, support requirements and signposting to the admissions booklet.
Stated by James Paget University Hospitals NHS Foundation Trust -
Action
Launch and cascade the amended documentation through ward managers at the Clinical Leaders Event.
Stated by James Paget University Hospitals NHS Foundation Trust
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Action
Audit compliance with the amended admission and discharge documentation monthly, beginning with results available at the end of October.
Stated by James Paget University Hospitals NHS Foundation Trust
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Concerns raised1
Delays in discharge via Adult Social Care
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.2
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Action
Maintain cross-system work to improve hospital discharge.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Operate the Greater Manchester Discharge Pathway and Discharge to Assess system.
Stated by NHS Greater Manchester Integrated Care Board
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 local authority had potential provision and appears to have offered it, disputing that discharge was delayed solely by a lack of suitable placement.
Stated by NHS Greater Manchester Integrated Care Board
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Concerns raised3
Inadequate discharge plan communicated to GP
Failure to take and consider relevant patient history before discharge
Failure to properly assess suicidal symptoms and risks before discharge
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
Require primary care teams to send comprehensive letters to general practitioners covering referral issues, assessment outcomes and treatment advice.
Stated by Oxleas NHS Foundation Trust
Data last updated 7 September 2026