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
Delays in arranging suitable community care packages for 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.
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
Make £1.3 billion available through the NHS to fund follow-on care and support patients safely and quickly after hospital discharge during the pandemic.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 5 June 2020.
Action
Operate the adult discharge policy through integrated discharge support, multidisciplinary discharge reviews, timely referrals, and documented communication to reduce avoidable delays.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 June 2020.
Action
Provide Patient Flow Coordinator and Hospital Discharge Service support for complex discharge planning and identification of patients’ community support needs.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 June 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
NHS organisations and local partners, including social services, are responsible for timely discharge and ongoing care arrangements.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Discharge arrangements depend on In-reach, Local Authority, Social Care and other bodies undertaking assessments and providing community support.
Stated by Manchester University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust’s ability to progress discharge was limited because In-reach, Social Care and other bodies controlled necessary reviews and placement arrangements.
Stated by Manchester University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Failure to consider bespoke placements early for complex patients
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 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.
Manchester West
Concerns raised2
Failure to consider admission circumstances and current risks in self-discharge decisions
Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale
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.
Avon
Concerns raised1
Lack of a formal system for seeing patients who reattend unexpectedly after 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
Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.
Stated by Spire Bristol HospitalStated completedThe respondent said that this action was complete when they made their response on 27 December 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing admission and discharge procedures provided a formal process for managing patients who contacted or re-attended after discharge.
Stated by Spire Bristol HospitalExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cumbria
Concerns raised2
Failure to routinely involve agencies receiving discharged patients in the discharge process
Failure to routinely involve supportive families or friends in the discharge process
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
Carry out a learning review to identify best practice for involving significant clinicians and future-care providers in discharge meetings.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.
Action
Move from telephone dial-in to Skype facilities for discharge meetings where geographical restrictions exist.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 December 2019.
Action
Remind staff to use the discharge flow chart, including advance meeting arrangements and escalation where required attendance is unavailable.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.
Action
Hold weekly interface meetings to discuss complex cases and escalate discharge-meeting non-attendance to clinical leads and, where persistent, the Associate Director.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.
Action
Amend and use the safer-discharge audit across wards to monitor family attendance and other discharge requirements, with weekly clinical review and monthly quality reporting.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.
Cheshire
Concerns raised3
Lack of guidance for arranging and communicating critical post-discharge investigations
Failure to clearly define responsibilities and timings in the discharge process
Failure to demonstrate effective discharge communications
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.
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
Rewrite the national discharge policy to clarify multidisciplinary roles, responsibilities, discharge scenarios and arrangements for critical post-discharge investigations.
Stated by Nuffield HealthStated completedThe respondent said that this action was complete when they made their response on 22 November 2019.
Action
Test and roll out an electronic quality-management audit across hospitals to monitor discharge-process effectiveness and patient experience.
Stated by Nuffield HealthStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2019.
Action
Communicate consultants’ responsibilities for contemporaneous documentation and discharge-related communication with nursing staff and GPs.
Stated by Nuffield HealthStated completedThe respondent said that this action was complete when they made their response on 22 November 2019.
Action
Contact GPs by telephone, in addition to sending discharge summaries, when urgent action is required.
Stated by Nuffield HealthStated completedThe respondent said that this action was complete when they made their response on 22 November 2019.
Action
Use secure electronic discharge-summary delivery to provide GP surgeries with heightened assurance of receipt within 48 hours.
Stated by Nuffield HealthStated completedThe respondent said that this action was complete when they made their response on 22 November 2019.
Action
Advance a quality-improvement plan for standardised discharge systems, processes and collaborative working with GPs.
Stated by Nuffield HealthStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2019.
Inner South London
Concerns raised1
Failure to provide adequate post-operative discharge advice about warning symptoms
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
London (West)
Concerns raised2
Failure to provide detailed written clinical information and directions on discharge
Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC
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 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.
Manchester South
Concerns raised1
Failure of discharge planning to share risk information with GPs and families
This report raised 10 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.
Liverpool and the Wirral
Concerns raised1
Failure to send discharge letters to all current medical attendants
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Individual trusts remain responsible for discharge summaries and transferring medication information after discharge.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing legal and professional duties provide a sufficient framework for information sharing, so further data-sharing requirements are unnecessary.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
