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 raised2
Failure to complete pre-discharge risk assessments
Inadequacy of discharge summaries for ongoing care risk assessments
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
Relevant frailty and mobility information is provided through the TARF, which was appropriately completed and submitted for social care risk assessment.
Stated by Hull University Teaching Hospitals NHS Trust
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Concerns raised2
Failure of out-of-area and private providers to coordinate effectively with local discharge arrangements
Failure to establish a clear discharge plan understood by all involved in care
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.
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
Publish statutory guidance for discharge from all mental health inpatient settings.
Stated by Department of Health and Social Care
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Concerns raised2
Failure to physically assess the patient by a doctor before discharge
Failure to provide families with deterioration warning signs and actions at discharge
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.
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
Develop and provide patients and carers with a postoperative sepsis-awareness information card.
Stated by South Tees Hospitals 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
Records and the discharge checklist indicate that a doctor saw the patient before discharge, although staff roles may not have been made clear.
Stated by South Tees Hospitals NHS Foundation Trust
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Concerns raised2
Unclear governance of safe discharge decisions from the neurosurgical ward
Failure to follow and understand the VTE policy for discharge risk reduction
This report raised 7 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
Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.
Stated by NHS England
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Concerns raised1
Failure of discharge planning to consider ongoing anticoagulant prophylaxis for patients with restricted mobility
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.6
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Action
Review NICE guidance and update the Trust pharmacological VTE prophylaxis guideline, including discharge advice and VTE-risk documentation.
Stated by North Cumbria Integrated Care NHS Foundation Trust -
Action
Share the Regulation 28 recommendation with Matrons to raise awareness of discharge VTE documentation requirements.
Stated by North Cumbria Integrated Care NHS Foundation Trust -
Action
Discuss implementation with Digital Systems to add VTE discharge documentation to the nursing checklist.
Stated by North Cumbria Integrated Care NHS Foundation Trust
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Action
Audit the nursing discharge checklist for compliance with VTE documentation requirements.
Stated by North Cumbria Integrated Care NHS Foundation Trust -
Action
Progress training, discharge-summary amendments and ownership guidance for documenting VTE assessment and ongoing prophylaxis at discharge.
Stated by North Cumbria Integrated Care NHS Foundation Trust -
Action
Amend the ward-round proforma to prompt daily VTE review and a discharge VTE-risk plan.
Stated by North Cumbria Integrated Care NHS Foundation Trust
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Concerns raised1
Lack of clarity about VTE risk-assessment responsibilities at hospital-to-community discharge
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
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Action
Review the guideline for updates covering continuation of VTE prophylaxis and anticoagulation after discharge to community settings.
Stated by National Institute for Health and Care Excellence -
Action
Consider providing implementation support on VTE risk assessments and discharge planning, focusing on anticoagulation.
Stated by National Institute for Health and Care Excellence
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Concerns raised1
Failure to dispense prescribed dalteparin before discharge
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 record discharge and non-admission decisions concerning oxygen monitoring and remedial oxygen therapy
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.
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 ensure adequate and up-to-date risk assessments and care plans during discharge or transfer between care facilities
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
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Action
Hold weekly Transfer of Care Hub audits and reflective discussions about hospital discharges and required improvements.
Stated by Nottinghamshire County Council -
Action
Implement and use a referral and assessment process for Assessment Flat admissions, recording care needs, risks and medical information and sharing them with providers.
Stated by Nottinghamshire County Council
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Concerns raised1
Failure of ED discharge summaries to clearly identify diagnoses and actions expected from GPs
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.3
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Action
Require ED clinicians to document significant findings and matters requiring GP attention under a separate heading in discharge summaries.
Stated by Hampshire Hospitals NHS Foundation Trust -
Action
Update the junior doctors’ induction programme to include the revised discharge-process requirements.
Stated by Hampshire Hospitals NHS Foundation Trust -
Action
Re-audit a random sample of discharge letters at three and six months to monitor the impact of the changes.
Stated by Hampshire Hospitals NHS Foundation Trust
Data last updated 7 September 2026