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.
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.
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.1
Position
The discharge protocol was implemented by Mid Yorkshire Hospitals NHS Trust, so this respondent will not respond to that concern.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustOutside 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.
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
Launch a patient-designed discharge safety-netting leaflet after final approval and printing.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Launch and weekly-audit a two-month Emergency Department discharge helpline pilot.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
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.
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.3
Action
Review safe and appropriate discharge arrangements for people with complex needs across Greater Manchester with localities.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2021.
Action
Continue complex-needs and discharge scoping through the Learning Disabilities Complex Needs Programme.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2021.
Action
Publish and update the Hospital Discharge Service policy and operating model guidance for NHS trusts and care home providers.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 29 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Hospital discharge guidance predominantly applies to admitted patients, and this case did not appear to involve hospital admission.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Developing policy and procedures for integrated care and communication is outside the regulator’s direct remit.
Stated by Care Quality CommissionOutside 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.
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
Update CPA and Acute Care Services policies to require a pre-discharge CPA meeting for every homeless inpatient.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Use the SystmOne risk-assessment node to support structured, evidence-based risk assessments.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2021.
Action
Deliver training on risk assessment, risk factors, care-plan links and use of the SystmOne risk-assessment tool.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2021.
Action
Recruit and deploy a Lead Nurse for Quality and Practice to improve inpatient care plans and risk assessments.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 April 2021.
Action
Add weekly audits of discharge checklists to verify completion and close the learning loop.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Review the Risk Assessment and Management Policy to guide staff in risk assessment and management.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
A policy cannot prevent vulnerable patients from being discharged into homelessness because discharge depends on circumstances beyond the Trust’s control.
Stated by Surrey and Borders Partnership NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
District and Borough Housing Departments are responsible for finding settled accommodation following the Trust’s statutory referral of homeless patients.
Stated by Surrey and Borders Partnership NHS Foundation TrustRedirects 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.
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
Create a task and finish group of relevant clinicians to strengthen application of CPA policy and care coordinator practice.
Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
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.
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.
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.
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
Reduce required post-discharge follow-up contact from seven days to three days under the Care Programme Approach policy.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 March 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The Lead Practitioner was aware of the planned discharge and was notified, contrary to the concern that she was unaware.
Stated by Sussex Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing Care Programme Approach policy and multidisciplinary discharge arrangements were considered sufficient for Lead Practitioner involvement and follow-up.
Stated by Sussex Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
No further action was considered necessary on family involvement because confidentiality and consent governed information sharing, with contact attempted where consent permitted.
Stated by Sussex Partnership NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
Position
Accommodation access and organisation were considered the Local Authority’s responsibility, although Trust staff assisted with referrals and discharge planning.
Stated by Sussex Partnership NHS Foundation TrustRedirects 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.
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.
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.
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.
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.
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
Share the response at the Divisional Surgery Governance Meeting and discuss the importance of checking medical records during handover completion.
Stated by Oldham Care OrganisationStated plannedThe respondent said that this action was planned when they made their response on 9 February 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Directly communicating cancer diagnoses to GPs at discharge is not standard; supported outpatient disclosure is considered best practice.
Stated by Oldham Care OrganisationExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Communicating a cancer diagnosis to the GP at discharge is not standard practice because it could disclose the diagnosis without appropriate patient support.
Stated by Oldham Care OrganisationDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
