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.
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
Reports and published responses 273 reports
See individual reports that have raised this concern, and the actions taken in response
West Yorkshire Western Division
Concerns raised1
Failure to adhere to the hospital discharge protocol for self-discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
South West Yorkshire Partnership Teaching NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
South West Yorkshire Partnership Teaching NHS Foundation Trust
The discharge protocol was implemented by Mid Yorkshire Hospitals NHS Trust, so this respondent will not respond to that concern.
Outside remitThe respondent said that this matter was outside its role or authority.
East London
Concerns raised1
Absence of safety-netting advice for patients leaving the hospital
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Barking, Havering and Redbridge University Hospitals 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.2
Barking, Havering and Redbridge University Hospitals NHS Trust
Launch a patient-designed discharge safety-netting leaflet after final approval and printing.
Barking, Havering and Redbridge University Hospitals NHS Trust
Launch and weekly-audit a two-month Emergency Department discharge helpline pilot.
Manchester South
Concerns raised1
Lack of guidance on ensuring a care home can accept a person back after discharge
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
Department of Health and Social Care
NHS Greater Manchester Integrated Care Board
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
NHS Greater Manchester Integrated Care Board
Review safe and appropriate discharge arrangements for people with complex needs across Greater Manchester with localities.
NHS Greater Manchester Integrated Care Board
Continue complex-needs and discharge scoping through the Learning Disabilities Complex Needs Programme.
Department of Health and Social Care
Publish and update the Hospital Discharge Service policy and operating model guidance for NHS trusts and care home providers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
Hospital discharge guidance predominantly applies to admitted patients, and this case did not appear to involve hospital admission.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Care Quality Commission
Developing policy and procedures for integrated care and communication is outside the regulator’s direct remit.
Outside remitThe respondent said that this matter was outside its role or authority.
Surrey
Concerns raised4
Failure of pre-discharge risk assessments to be sufficiently rigorous and evidence based
Failure to prevent discharge of vulnerable patients into homelessness through adequate housing and discharge planning
Premature discharge before the effectiveness of prescribed medication is adequately observed
Failure to undertake and record formal pre-discharge risk assessments
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Surrey and Borders Partnership NHS Foundation 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.6
Surrey and Borders Partnership NHS Foundation Trust
Update CPA and Acute Care Services policies to require a pre-discharge CPA meeting for every homeless inpatient.
Surrey and Borders Partnership NHS Foundation Trust
Use the SystmOne risk-assessment node to support structured, evidence-based risk assessments.
Surrey and Borders Partnership NHS Foundation Trust
Deliver training on risk assessment, risk factors, care-plan links and use of the SystmOne risk-assessment tool.
Surrey and Borders Partnership NHS Foundation Trust
Recruit and deploy a Lead Nurse for Quality and Practice to improve inpatient care plans and risk assessments.
Surrey and Borders Partnership NHS Foundation Trust
Add weekly audits of discharge checklists to verify completion and close the learning loop.
Surrey and Borders Partnership NHS Foundation Trust
Review the Risk Assessment and Management Policy to guide staff in risk assessment and management.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Surrey and Borders Partnership NHS Foundation Trust
A policy cannot prevent vulnerable patients from being discharged into homelessness because discharge depends on circumstances beyond the Trust’s control.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey and Borders Partnership NHS Foundation Trust
District and Borough Housing Departments are responsible for finding settled accommodation following the Trust’s statutory referral of homeless patients.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Buckinghamshire
Concerns raised1
Failure to provide detailed CPA care plans that inform patients, families, care coordinators and community teams on discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Oxford Health NHS Foundation 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.1
Oxford Health NHS Foundation Trust
Create a task and finish group of relevant clinicians to strengthen application of CPA policy and care coordinator practice.
Sunderland
Concerns raised1
Failure to provide families’ contact details at hospital admission and discharge
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex
Concerns raised5
Failure to include and inform the primary support practitioner in discharge arrangements
Failure to inform family supporters of discharge
Failure to notify vulnerable service users’ parents of discharge
Failure to provide safe and therapeutic post-discharge accommodation
Failure to include and alert the primary lead practitioner in discharge arrangements
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sussex Partnership NHS Foundation 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.1
Sussex Partnership NHS Foundation Trust
Reduce required post-discharge follow-up contact from seven days to three days under the Care Programme Approach policy.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Sussex Partnership NHS Foundation Trust
The Lead Practitioner was aware of the planned discharge and was notified, contrary to the concern that she was unaware.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Sussex Partnership NHS Foundation Trust
Existing Care Programme Approach policy and multidisciplinary discharge arrangements were considered sufficient for Lead Practitioner involvement and follow-up.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Sussex Partnership NHS Foundation Trust
No further action was considered necessary on family involvement because confidentiality and consent governed information sharing, with contact attempted where consent permitted.
No action considered necessaryThe respondent said that no further action was needed.
Sussex Partnership NHS Foundation Trust
Accommodation access and organisation were considered the Local Authority’s responsibility, although Trust staff assisted with referrals and discharge planning.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to prevent discharge into unsupervised parental care despite professional concerns
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Mid Kent and Medway
Concerns raised2
Failure to complete recommended home assessments before discharge
Failure to inform families of discharge home when care is required
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Failure to communicate pathology reports to general practitioners at hospital discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Oldham Care Organisation
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Oldham Care Organisation
Share the response at the Divisional Surgery Governance Meeting and discuss the importance of checking medical records during handover completion.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Oldham Care Organisation
Directly communicating cancer diagnoses to GPs at discharge is not standard; supported outpatient disclosure is considered best practice.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Oldham Care Organisation
Communicating a cancer diagnosis to the GP at discharge is not standard practice because it could disclose the diagnosis without appropriate patient support.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.