Recurring concern

Unreliable hospital discharge processes

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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
Individual concerns: 406
Date range: 2013–2026
Stated actions: 524

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

9 Sep2013
Mid Kent and Medway
Concerns raised1
1. Failure to put a care plan in place to establish needs before early 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ricky Anderson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ricky Anderson was admitted to hospital with command hallucinations and suicidal thoughts, was discharged, and was later found suspended from a tree at Chatham Cemetery on 21 May 2012. Concerns included failures to inform his GP of his hospital admissions, reliance on family information when assessing his wellbeing after discharge, and the lack of contact with the Access team and a care plan before his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to put a care plan in place to establish needs before early discharge
Wider context from the report
“Mr. Anderson's discharge from hospital occurred at an earlier stage than had been planned as he wished to leave and was deemed safe to do so. As a consequence, a care plan had not been put in place to establish his needs. I heard evidence that following Mr. Anderson's death procedures have been put in place to ensure that this situation does not reoccur ”
Source location
Ricky Anderson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
4 Sep2013
Leicester City and South Leicestershire
Concerns raised1
1. Failure to provide prophylactic antibiotic medication 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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Explore ward-based technicians’ knowledge of prophylactic antibiotics required after splenectomy.
  Stated by University Hospitals of Leicester NHS TrustStated planned
2. Action
  Discuss systems and processes across all three Trust sites for flagging and communicating medicines that must continue after discharge.
  Stated by University Hospitals of Leicester NHS TrustStated planned
3. Action
  Remind the junior doctors involved to fully consider patients’ pre-admission medication.
  Stated by University Hospitals of Leicester NHS TrustStated planned
AI-generated summary

Karen Lesley SUTTON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Karen Lesley Sutton, who had primary antibody deficiency disorder and had undergone a splenectomy, was readmitted on 11 October 2012 with severe sepsis and died that evening after cardiac arrest. Concerns included the Immunology team not being notified of her hospital admissions, discontinuation of her prophylactic antibiotics on discharge, and inadequate arrangements for follow-up and communication between departments.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide prophylactic antibiotic medication at discharge
Wider context from the report
“(1) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge. (2) Mrs Sutton was discharged home without prophylactic antibiotic medication (3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that ████████ was able to see her after the day of discharge, 4th October 2012. (4) ████████ was unaware of any Trust policy to share admissions between departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide. ”
Source location
Karen Lesley SUTTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Explore ward-based technicians’ knowledge of prophylactic antibiotics required after splenectomy.

Verbatim wording from the response
“In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

Source location
2013-0223-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 4 September 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Discuss systems and processes across all three Trust sites for flagging and communicating medicines that must continue after discharge.

Verbatim wording from the response
“In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

Source location
2013-0223-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 4 September 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Remind the junior doctors involved to fully consider patients’ pre-admission medication.

Verbatim wording from the response
“In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

Source location
2013-0223-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 4 September 2013
Open published response
30 Jan2013
Manchester South
Concerns raised4
1. Delays in completing and sending the discharge summary
2. Failure to involve family in discharge planning
3. Lack of a discharge care plan
1. Failure to hold a Section 17 discharge planning meeting
This report raised 9 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.
AI-generated summary

Gareth Mark Slater · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Gareth Mark Slater, who had a history of bipolar affective disorder and had been discharged from hospital into his own accommodation, was found in the River Medlock on 31 March 2013 after apparently falling from Bardsley Bridge. The Inquest concluded that he died from drowning and multiple injuries, with bipolar affective disorder recorded as a contributing condition, and found no evidence of an intention to end his life. Concerns included inadequate discharge planning, lack of a care plan and follow-up arrangements, insufficient assessment of his ability to live independently, and poor preparation of his accommodation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in completing and sending the discharge summary
Wider context from the report
“8. The discharge summary was not dictated and sent to his new outpatient Consultant until the 18th February over three months from his discharge from hospital. There were no follow up appointments in place for Gareth at the time of discharge. ”
Source location
Gareth Mark Slater · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to involve family in discharge planning
Wider context from the report
“4. There was no attempt to involve Gareth’s family in the discharge of Gareth. ”
Source location
Gareth Mark Slater · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a discharge care plan
Wider context from the report
“1. The discharge planning in relation to Mr Slater was overshadowed by the impasse in clinical opinion and the length of time it took to resolve this. No doubt because of the difficulties to resolve Gareth’s situation there was a failure to actually carry out the important task of discharge planning. No care plan was in place for Gareth, merely a recognition of the conditions of his Community Treatment Order. ”
Source location
Gareth Mark Slater · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to hold a Section 17 discharge planning meeting
Wider context from the report
“2. There was no Section 17 discharge planning meeting. ”
Source location
Gareth Mark Slater · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to put a care plan in place to establish needs before early discharge

Concerns raised1

Failure to provide prophylactic antibiotic medication at discharge

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

Concerns raised4

Delays in completing and sending the discharge summary

Failure to involve family in discharge planning

Lack of a discharge care plan

Failure to hold a Section 17 discharge planning meeting

Actions described in response 3