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 ensure safe oxygen saturation levels before discharge
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 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.1
Position
Oxygen saturation readings of 90–92% were generally considered adequate for a patient who smoked, although the 89% reading was not adequately documented.
Stated by BMI The Alexandra HospitalDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Exeter and Greater Devon
Concerns raised1
Failure to send discharge letters to GPs documenting dangerous treatment side effects
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.
Birmingham and Solihull
Concerns raised1
Failure to ensure that the electronic medication administration chart mirrors the discharge medication documentation
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.7
Action
Amend the nursing discharge checklist to remind staff to check the PEPMAC.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 June 2015.
Action
Improve and standardise yellow-card discharge documentation to provide optimal information for safe prescribing and administration.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 June 2015.
Action
Obtain governance approval and pilot the revised yellow-card documentation within palliative care.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 June 2015.
Action
Make a final decision on extending the revised discharge documentation process to intermediate-care discharges after piloting and feedback review.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 June 2015.
Action
Check available MAC charts and TTOs for medication discrepancies.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 June 2015.
Action
Remind all pharmacists about the importance of identifying medication discrepancies between MAC charts and TTOs.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 June 2015.
Action
Review existing pharmacy SOPs to ensure they are robust and fit for purpose.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 June 2015.
Brighton and Hove
Concerns raised3
Failure to involve patients and families in discharge decisions
Inadequate discharge planning
Failure to provide accurate discharge lounge information
This report raised 16 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.
North London
Concerns raised1
Failure to ensure doctor assessment before discharge from the Minor Injuries Unit
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.
South Yorkshire (Eastern)
Concerns raised1
Inadequacy of guidance incorporating the ethos and workings of the early discharge plan
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.
North West Wales
Concerns raised1
Failure to detect a defective surgical anastomosis before hospital 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
Implement a pre-discharge checklist for all patients leaving the Colo-Rectal Ward.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 29 April 2015.
Action
Require all other Glan Clwyd surgical wards to develop and implement appropriate discharge checklists.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 29 April 2015.
Mid Kent and Medway
Concerns raised1
Failure to identify scheduled investigations before hospital 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 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 (West)
Concerns raised1
Lack of assessment of patients’ ability prior to 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.
County Durham and Darlington
Concerns raised1
Lack of formal policy or written guidance for safe late-at-night discharge decisions
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
Amend the Trust’s Going Home Policy to specify Emergency Department discharge procedures, including discharges after 22:00.
Stated by County Durham and Darlington NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 March 2015.
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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.
