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
Reliance of delayed-discharge protocols on home-team engagement
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 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.
Exeter and Greater Devon
Concerns raised1
Failure of discharge summaries to clearly communicate target fluid intake
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
Use Epic’s Hospital Course function to build discharge summaries from clinicians’ real-time inpatient documentation.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
Action
Use bespoke discharge-summary templates for complex patient groups to clarify pertinent information and follow-up instructions.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
Action
Maintain a four-day junior-doctor rota in Medicine to reduce cross-cover and improve staffing consistency for discharge documentation.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
Action
Review use of the After Visit Summary across inpatient and outpatient services through an established working group.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
Action
Produce guidance and standard operating procedures for ward teams following the After Visit Summary review.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
Action
Review community-hospital staffing to develop a more robust, consistent medical team with specialty-doctor and Advanced Clinical Practitioner oversight.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2023.
Action
Relaunch the Trust-wide discharge-summary working group with primary-care representation to refine discharge processes and communication.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust considers reviewing every discharge letter by a consultant infeasible because of resource demands, unclear responsibility, delays and risks of error.
Stated by Royal Devon University Healthcare NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Gateshead and South Tyneside
Concerns raised2
Inconsistency between hospital and community teams about post-discharge procedures and points of access
Absence of documented discharge advice on points of access for concerns or complications
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.6
Action
Liaise with Newcastle Trust to confirm the correct procedure for community teams to contact vascular services about post-discharge concerns.
Stated by Gateshead Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 September 2023.
Action
Share inquest findings with District Nurses, reiterating ward contact routes, contact-information access, and warning signs after femoral endarterectomy.
Stated by Gateshead Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 September 2023.
Action
Develop a professional information leaflet for District Nurses covering post-operative risks, escalation requirements, and intervention following femoral endarterectomy.
Stated by Gateshead Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 September 2023.
Action
Provide patients and community clinicians with written post-discharge wound information, contact points, escalation advice and urgent bleeding instructions.
Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 September 2023.
Action
Operate a 24-hour vascular call-triage pathway directing wound concerns to specialist nurses or the on-call vascular registrar.
Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 September 2023.
Action
Standardize documentation of wound calls, discharge advice and ward reviews, including changes communicated to community teams.
Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing procedures and collaboration with Newcastle Trust adequately address post-discharge communication and escalation following vascular surgery.
Stated by Gateshead Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North Yorkshire and York
Concerns raised3
Failure to provide discharge medications
Lack of discharge notes
Safety hazard associated with evening hospital discharges
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 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
Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Amend the electronic discharge-note template to include required discharge information and advice.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Update and disseminate clinical record-keeping guidance to clinical staff.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.
Action
Disseminate discharge-advice guidance and train registered nurses in its use.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.
Action
Operate a quality-improvement collaborative supporting earlier ward discharges and monthly tracking of discharge performance and EDAN provision.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Manchester City
Concerns raised1
Lack of a thorough procedure or legal test for assessing nearest relative discharge applications
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.
Derby and Derbyshire
Concerns raised1
Lack of protocols ensuring safe and appropriate multi-party discharge arrangements
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.
Cumbria
Concerns raised3
Failure to involve family or carers in discharge processes
Failure to plan follow-up after discharge
Delays in sending discharge notifications to GPs
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.
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
Monitor caregiver inclusion in safety and discharge planning through daily MDT review, audits and supervisory checks.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 June 2023.
Action
Continue rolling out carer-awareness and Getting To Know You training, including one-to-one training for new staff.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 June 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The investigation concluded that identified family-involvement issues were not causative or contributory to the death.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The discharge included planned follow-up, with ongoing support from the Cumbria East Crisis Team and planned referrals to other services.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes
Concerns raised1
Failure to plan discharge from hospital
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.
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
Provide a full-time heart-centre discharge coordinator using a multidisciplinary approach for discharge planning.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Manchester South
Concerns raised1
Failure to conduct an in-person medical review before discharge from the Ambulatory Care Unit
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
Consultant review of information supplied by a Physician Associate was considered sufficient; an in-person consultant assessment was not required.
Stated by Manchester University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing policy requires medical authorisation for Ambulatory Care Unit discharge and prevents Physician Associates from discharging patients independently.
Stated by Manchester University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North Northumberland and South Northumberland
Concerns raised2
Failure to coordinate inpatient discharge with family and other agencies
Failure of the care coordinator to establish direct contact and a relationship with the service user before discharge
This report raised 11 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.
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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.
