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.
London (East)
Concerns raised1
Failure to provide an appropriately trained pre-discharge asthma review
This report raised 23 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.1
Action
Review national asthma policy and existing clinical guidelines, including the National Review of Asthma Deaths report, to determine appropriate national and local actions.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 May 2019.
South Wales Central
Concerns raised1
Lack of updated and documented pain scores 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 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
Develop a corrective Action Plan for Improvement addressing the concerns identified in the Regulation 28 report.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2018.
West London
Concerns raised1
Failure to require senior clinical reference before discharge by very junior doctors
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.3
Action
Audit discharge records to examine whether senior doctors or Consultants participated in discharge decisions.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2019.
Action
Provide learning to Consultant Psychiatrists about senior involvement in discharge decisions.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2019.
Action
Provide junior doctors with discharge-related teaching during Trust induction.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 April 2019.
Isle of Wight
Concerns raised1
Failure to provide timely Discharge Summaries to GPs
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.6
Action
Establish a Medical Director-led workstream to improve the quality and timeliness of discharge summaries.
Stated by Isle of Wight NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2019.
Action
Conduct an in-depth review of discharge summaries and communications to GPs following relevant mental health contacts.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Map communication processes with staff groups and develop a standard operating procedure or flowchart.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Audit discharge-summary quality, including admission reasons, care received, and medication reviews or changes.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Use formal teaching sessions with junior doctors to embed learning from the discharge-summary audit.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Present discharge-summary audit outcomes at Trust quality forums to share learning.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Surrey
Concerns raised1
Inadequate communication with families about treatment decisions and discharge
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 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.
West London
Concerns raised1
Failure of the Discharge Medication Summary and 7-Day Follow-Up to provide an adequate format
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.
Milton Keynes
Concerns raised1
Lack of a clear and agreed inter-agency protocol for discharge of patients brought in for assessment
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.
Leicester City and South Leicestershire
Concerns raised1
Lack of standard patient discharge information materials
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 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.
Kent (North-West)
Concerns raised1
Discharge of very unwell patients before required tests are carried out
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 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.
West Yorkshire Eastern
Concerns raised4
Failure to involve and inform families in complex discharge decisions
Failure to ensure an adequate supply of prescribed medication during hastily arranged discharges
Precipitous hospital discharges
Inadequate discharge preparation for wound care, pain control and required clinical skills
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
Coordinate frail older patients’ discharge plans with patients, families, representatives and relevant care providers, including capacity and safeguarding considerations.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2019.
Action
Reassess mobility and provide occupational therapy and physiotherapy assessments to identify discharge support needs.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2019.
Action
Operate the REACT multidisciplinary and multiagency service to support early assessment and safe discharge of elderly patients.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2019.
Action
Use daily multidisciplinary board rounds and safety huddles to review treatment, discharge plans, patient needs and emerging concerns.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2019.
Action
Provide dedicated discharge coordinators on each Care of the Elderly ward to facilitate safe, timely discharge.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2019.
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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.
