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
Lack of an overarching supportive care plan on 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Bedfordshire and Luton
Concerns raised1
Failure to include housing in hospital discharge planning
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 local NHS is responsible for reviewing the case circumstances and taking necessary action to ensure services are safe and high quality.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Worcestershire
Concerns raised1
Failure to retain discharge documentation
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.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to repeat observations 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.
Inner West London
Concerns raised1
Failure to use inpatient opportunities to address care and treatment needs before discharge
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.
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
Implement the piloted trauma-informed inpatient care approach across all sites.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 2019.
Action
Ensure community teams discuss all inpatients daily so they know patients’ progress and can contribute to admission goals.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 2019.
Action
Maximise available community support and interventions, including recovery, vocational, employment-support and peer-support services, within discharge planning.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 2019.
Suffolk
Concerns raised1
Failure to confirm addiction support at hospital 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Discharge processes lacking robustness
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.
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.4
Action
Complete a Rapid Review to identify lessons from the incident and support their embedding.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
Action
Share the discharge-learning response with relevant teams and staff to reinforce adherence to discharge procedures.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
Action
Include discharge-learning points in the safety huddle so ward staff are aware of them.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 2019.
Action
Re-circulate the discharge Standard Operating Procedure to staff, including staff on the discharge ward.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The discharge was considered safe because equipment was available, observations were stable, and nothing indicated continued hospitalisation was necessary.
Stated by Northern Care Alliance NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Nottinghamshire
Concerns raised6
Failure to fully and properly assess vulnerable patients before discharge
Failure to provide an adequate discharge summary
Failure to fully and properly investigate patients before discharge
Failure to provide prescribed antibiotics at discharge
Failure to assign clear responsibility for discharge decision making
Failure to accurately record the identity of the discharging clinician
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.
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
Replace the Symphony-Medisec link with a Medisec Viewer app that launches with Symphony and communicate its required use to all staff.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
Action
Audit 50 CDU discharges over three months to assess whether discharge summaries were documented.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
Action
Introduce a discharge checklist to improve discharge documentation and reduce recurrence of discharge omissions.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
Action
Continue developing an electronic CDU discharge summary and put it in place within three months.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
Action
Implement a CDU standard operating procedure defining responsibility across the patient pathway.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The patient received a thorough, appropriate emergency-department assessment for a condition usually managed in primary care.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
A CDU consultant made the discharge decision and identified the patient as medically fit for discharge, subject to specified conditions.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised5
Failure to assess and communicate night-time falls risk at discharge
Failure to take family views into account in discharge planning
Lack of a discharge care plan for care provision during the trial period
Failure to agree key care-plan aspects with community carers before discharge
Insufficient care support for a safe discharge home
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.7
Action
Use care-planning documentation to record identified risks, mitigation, equipment, training requirements and available community support.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Monitor discharge-checklist completion through Ward Manager oversight.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Reassess changed care needs through a senior professional and identify risks requiring further intervention.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Include reviewed carer guidelines in discharge information and provide accessible onward-referral and joint-planning contact details.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Reformat family care-planning documentation to record agreed expectations and actions, with multidisciplinary team involvement.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Upload care-planning documentation to electronic notes and provide copies to patients and families.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Require acceptance by an appropriate community team and clear risk mitigation before discharging patients requiring 24-hour supervision.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsive community care was unavailable at the time because stroke Early Supportive Discharge provision for Redbridge residents was limited.
Stated by Barts Health NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Brighton and Hove
Concerns raised1
Incomplete discharge documentation for handover to doctors
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
Appoint a discharge facilitator and refocus a band 7 nursing role on admissions, discharges and complete discharge-planning documentation.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.
Action
Revise the discharge-planner template to clarify recording of key information.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019.
Action
Use documentation audits to review discharge-documentation quality.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019.
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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.
