Recurring concern
Unreliable hospital discharge processes
Pin
Get email alerts
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.
-
Concerns raised2
Failure to communicate changes in discharge timings to the ambulance service
Failure to discharge patients within the required timing when they are unable to manage independently at home
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 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
-
Action
Develop and progress the Out of Hours Discharge Avoidance SOP through MRI governance ratification for operational use.
Stated by Manchester University NHS Foundation Trust -
Action
Share the draft Out of Hours Discharge Avoidance SOP with Wythenshawe Hospital and North Manchester General Hospital teams.
Stated by Manchester University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
Existing ward contact before evening discharges will safeguard patients until the hospital’s discharge policy is received.
Stated by East Midlands Ambulance Service NHS Trust
-
Position
The second concern relates to Manchester City Council, so MFT will not provide a response.
Stated by Manchester University NHS Foundation Trust
-
Concerns raised1
Failure to audit the sufficiency of detail in discharge summaries
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 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.
-
Concerns raised2
Failure to provide pain relief and consider a care package at discharge
Failure to communicate identified fractures in discharge information
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 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
-
Action
Reviewed the emergency department's process for subsequent image review to assess its robustness and alignment with national practice.
Stated by the Princess Alexandra Hospital NHS Trust -
Action
Launch a comprehensive electronic health record to reduce risks arising from clinicians using multiple systems.
Stated by the Princess Alexandra Hospital NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Position
No analgesia was considered necessary because neither the patient nor her daughter requested it at discharge and shoulder pain was not subsequently reported.
Stated by the Princess Alexandra Hospital NHS Trust
-
Position
A care package was not considered necessary because the assessment found that the patient did not meet the relevant threshold.
Stated by the Princess Alexandra Hospital NHS Trust -
Position
The existing process of subsequent emergency-department consultant image review was considered as robust as possible and consistent with national practice.
Stated by the Princess Alexandra Hospital NHS Trust
-
Concerns raised2
Failure to ensure a robust safety plan upon discharge
Failure to determine whether discharge or step-down should be delayed until a place of safety is identified
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
-
Position
Existing clinical review, discharge documentation and policy-based follow-up arrangements were considered sufficient to address discharge safety concerns.
Stated by County Durham and Darlington NHS Foundation Trust
-
Position
Discharge need not normally be delayed for homeless patients when capacity, medical and mental-health fitness, signposting, and community support are in place.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust
-
Concerns raised1
Failure of hospital discharge documentation to provide warnings on NSAID prescribing considerations and risk factors
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 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
-
Action
Work with the Trust and safety lead to develop systems promoting safer NSAID prescribing after hospital discharge.
Stated by NHS Lincolnshire Integrated Care Board -
Action
Resend a reminder about co-prescribing PPIs with NSAIDs through the discharge prescribing safety work.
Stated by NHS Lincolnshire Integrated Care Board
-
Concerns raised1
Failure to provide accurate and complete discharge information
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 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.5
-
Action
Develop and implement the 5P discharge process for communicating significant pressure damage.
Stated by East Sussex Healthcare NHS Trust -
Action
Develop and publish a District Nurse referral flow chart specifying information required for fast-track discharge.
Stated by East Sussex Healthcare NHS Trust -
Action
Develop and pilot a flow chart for recognising end-of-life patients and selecting appropriate care pathways.
Stated by East Sussex Healthcare NHS Trust
-
Action
Share the end-of-life recognition flow chart throughout the hospitals after piloting.
Stated by East Sussex Healthcare NHS Trust -
Action
Conduct quality documentation and discharge-checklist audits to identify and correct communication failures.
Stated by East Sussex Healthcare NHS Trust
-
Concerns raised1
Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty
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 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
-
Position
The Integrated Care Board is expected to respond to concerns about the specific care provided.
Stated by Department of Health and Social Care
-
Concerns raised1
Failure to notify support services of vulnerable patients' 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 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
-
Action
Update Symphony’s discharge screen to record discharge discussions and identify notifications or vulnerable-adult support needed before patients go home.
Stated by North Cumbria Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The Emergency Department was not informed of any request or requirement to notify the Housing Officer about discharge.
Stated by North Cumbria Integrated Care NHS Foundation Trust
-
Concerns raised1
Lack of appropriate community care packages for patients fit for discharge
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
-
Action
Invest £1 billion through the Discharge Fund to commission discharge care packages and improve discharge processes.
Stated by Department of Health and Social Care -
Action
Launch a £40 million fund for local authorities facing significant urgent and emergency care pressures.
Stated by Department of Health and Social Care
-
Concerns raised1
Lack of appropriate community care causing medically fit patients to remain on hospital wards
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.2
-
Action
Improve discharge processes and capacity modelling to support appropriate commissioned community care capacity.
Stated by NHS England -
Action
Undertake programmes improving admissions avoidance and discharge flow to reduce patients remaining in acute medical beds without criteria to reside.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Responsibility for responding to the report’s concerns rests with NHS England, so no duplicate response will be provided.
Stated by Department of Health and Social Care
Data last updated 7 September 2026