Recurring concern
Unreliable hospital discharge processes
- Reports that mention this concern
- 273
- Times this concern has been raised
- 406
- Stated actions linked to this concern
- 524
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.
What is 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
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 273 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to verify the most recent clinical observations and PEWS score before discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Barts Health NHS Trust
Stated actions 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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Barts Health NHS Trust
Implement and use a two-hourly Paediatric SITREP to record, escalate and plan responses to staff concerns despite low PEWS.
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Barts Health NHS Trust
Provide ongoing teaching on paediatric gastroenteritis risks, deterioration despite low PEWS and communicating concerns.
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Barts Health NHS Trust
Auto-populate the latest clinical observations and blood results in records when clinicians make entries before discharge decisions.
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Concerns raised1
Lack of specific guidance for expediting discharge and considering alternative treatment methods for high-risk patients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Department of Health and Social Care
Existing NHS, NICE and UKHSA guidance was considered sufficient to address COVID-19 infection prevention and expedited discharge concerns.
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Department of Health and Social Care
CQC considered Trust assurances and ongoing monitoring sufficient, so it identified no need for further investigation of this specific case.
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Department of Health and Social Care
The Trust's existing vulnerable-patient risk-management process, shared learning and discharge focus were considered sufficient responsive arrangements.
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Concerns raised1
Lack of specific guidance for expediting discharge of patients at high risk of acquiring Covid-19
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to await blood test results before discharge
Linked response
- the Royal Wolverhampton NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
-
the Royal Wolverhampton NHS Trust
Incorporate proactive blood-result review into postgraduate induction training and disseminate the requirement to postgraduate staff.
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the Royal Wolverhampton NHS Trust
Use the ED clerking form’s investigations-and-results section to document blood-result review before discharge.
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the Royal Wolverhampton NHS Trust
Allocate consultant work-plan time to review blood results in the ICE system within 24 hours.
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the Royal Wolverhampton NHS Trust
Review and include the discharge blood-result process in ED policy and guidance.
-
Concerns raised1
Failure to consider and act on dangerously elevated creatinine results before discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Barts Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
-
Barts Health NHS Trust
Pilot a dedicated process for immediate VBG result sign-off, clinician review, ECG signing and resulting actions.
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Barts Health NHS Trust
Evaluate the VBG process and additional resources using quality improvement methodology.
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Barts Health NHS Trust
Examine whether electronic patient records can track VBGs and provide an audit trail and completion alert.
-
Barts Health NHS Trust
Brief staff to perform three safety checks of results at availability, referral or movement to SDEC, and discharge.
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Concerns raised4
Failure of collaborative working across organisations during hospital discharge
Failure to include relevant community care organisations in multidisciplinary discharge planning
Failure to ensure discharge accommodation is suitable for complex medical needs
Failure to notify relevant clinical professionals of patient discharges
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of clarity in multi-disciplinary team decision-making about discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring 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 define and identify carer breakdown before discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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 safe discharge of patients requiring administered Depot antipsychotic medication
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Insufficient discharge advice for potentially time-critical complaints
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026