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 raised1
Absence of formal documented s.117 discharge plans agreed by all responsible care and treatment providers
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.1
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Action
Use a standardized Rio form covering all relevant s.117 meeting areas and remind acute-care staff to complete it.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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 is better placed to respond to concerns about the absence of a requested Section 117 plan.
Stated by NHS England
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Concerns raised1
Failure to provide clear oxygen-therapy discharge planning and referral information
This report raised 18 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 hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS England
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Concerns raised1
Failure to involve the patient’s cohabiting carer in discharge planning
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.4
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Action
Request and develop IT record changes to distinguish carers from next of kin.
Stated by East Kent Hospitals University NHS Foundation Trust -
Action
Audit identification of carers and their support needs among patients aged 70 or over.
Stated by East Kent Hospitals University NHS Foundation Trust -
Action
Establish and operate a Carer Champion post supporting carer identification and involvement in discharge discussions.
Stated by East Kent Hospitals University NHS Foundation Trust
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Action
Re-audit progress on carer identification and support in February, March and April.
Stated by East Kent Hospitals University NHS Foundation Trust
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Concerns raised1
Failure to obtain cardiology review of discharge appropriateness
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.2
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Position
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Stated by NHS England
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Position
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Stated by NHS England
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Concerns raised1
Failure to complete discharge care plans, risk assessment and procedures
This report raised 12 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
Introduce structured handovers and shared care plans accessible to involved health, care-home and social-care professionals.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Address the importance of recording information in care-plan sections through staff meetings, supervision and audit.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Discuss professional curiosity with teams, remind staff to review care-home paperwork and consult carers, and provide support sessions on asking appropriate questions.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to undertake a sepsis screen before Emergency Department discharge
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
Existing triage, NEWS assessment and consultant review are considered sufficient; sepsis screening need not be repeated before Emergency Department discharge.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to check CT scan outcomes before patient discharge
This report raised 11 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 provide a careline/lifeline pendant before discharge home for a person at high risk of falls
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 the hospital discharge policy and procedures to ensure assistive technology needs and safe discharge decisions are explicit.
Stated by Worcestershire County Council -
Action
Consider assistive technology needs and associated risks before every hospital discharge.
Stated by Worcestershire County Council -
Action
Remind staff to identify risks requiring mitigation through assistive technology before discharge.
Stated by Worcestershire County Council
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Action
Share necessary assistive technology requirements with acute colleagues and the person or representative, and arrange provision before discharge.
Stated by Worcestershire County Council
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 triage process sufficiently identifies when assistive technology is essential for safe discharge, so it need not always be provided beforehand.
Stated by Worcestershire County Council
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Position
Always providing assistive technology before discharge is not feasible because it would significantly delay discharges where it is not essential.
Stated by Worcestershire County Council
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Concerns raised1
Failure to provide a careline/lifeline pendant before discharge home for a person at high risk of falls
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 maintain adequate discharge handover information
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.2
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Action
Operate a Trust-wide action group to improve discharge processes and report to the Patient Safety Review Group.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Operate a Trust-wide action group to drive discharge-process quality improvement and report to the Patient Safety Review Group.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Data last updated 7 September 2026