Recurring concern

Unreliable hospital discharge processes

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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

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.

  1. Manchester South

    AI-generated summary

    Joseph James GRANTHAM · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide timely and accurately directed discharge information identifying the responsible paediatrician

    Wider context from the report

    “1. After his birth Joseph was transferred to the neonatal unit at St Mary's due to the complexities of his health. Following his discharge, it took 6 weeks for the trust to send the discharge paperwork to the GP and the District General Hospital (DGH) to whom they were transferring his paediatric care. As a result, there was no clear understanding amongst health professionals as to the paediatrician with responsibility for his care. Letters were therefore copied into a mixture of paediatricians. The discharge letter to the DGH was addressed to a consultant who was in fact a registrar at the trust. ”

    Source location

    Joseph James GRANTHAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. West Yorkshire (Western)

    AI-generated summary

    Michael Christopher Hopkins · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michael Christopher Hopkins sustained a right patella fracture requiring surgery and was discharged from hospital. He later collapsed at home and died from a pulmonary thromboembolism, and the report raised a concern about information given at discharge to patients at risk of thromboembolism after surgery for trauma.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure discharge information addresses thromboembolism risk after trauma-related surgery

    Wider context from the report

    “To review current practice guidelines with respect to the information provided to patients on discharge from hospital that may be at risk of the formation of thromboembolisms given they have had recent surgery after sustaining a trauma. ”

    Source location

    Michael Christopher Hopkins · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review patient information provided after blood-clot risk assessment.

    Verbatim wording from the response

    “The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant key performance indicators. Since the Regulation Report was received, we have reviewed the information provided to all patients (not just those who have experienced a trauma), following that assessment of risk, and as a result, the Trust has developed a revised leaflet that all patients will receive. I have attached an example of the leaflet to this letter, and confirm this leaflet will be introduced from the 1st December 2018.”

    Source location

    2018-0331-Response-by-Bradford-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 1 March 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a revised leaflet for patients following blood-clot risk assessment.

    Verbatim wording from the response

    “The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant key performance indicators. Since the Regulation Report was received, we have reviewed the information provided to all patients (not just those who have experienced a trauma), following that assessment of risk, and as a result, the Trust has developed a revised leaflet that all patients will receive. I have attached an example of the leaflet to this letter, and confirm this leaflet will be introduced from the 1st December 2018.”

    Source location

    2018-0331-Response-by-Bradford-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 1 March 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce the revised leaflet for all patients from 1 December 2018.

    Verbatim wording from the response

    “The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant key performance indicators. Since the Regulation Report was received, we have reviewed the information provided to all patients (not just those who have experienced a trauma), following that assessment of risk, and as a result, the Trust has developed a revised leaflet that all patients will receive. I have attached an example of the leaflet to this letter, and confirm this leaflet will be introduced from the 1st December 2018.”

    Source location

    2018-0331-Response-by-Bradford-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 1 March 2019

    Open published response

  3. West Yorkshire (Western)

    AI-generated summary

    Stanford Shirley Bell · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stanford Shirley Bell, who had dementia, fell at Riverview Nursing Home on 22 February 2018 and later died on 2 March 2018 after suffering seizures and an acute on chronic subdural haematoma. Concerns included the absence of hospital discharge papers and written neurological-observation recommendations, and delayed referral from the care home after seizures following head trauma.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Absence of discharge papers for patients neurologically assessed with head injuries

    Wider context from the report

    “For Airedale Hospital to review procedures at hospital discharge with respect to patients neurologically assessed with head injuries given the absence of discharge papers ”

    Source location

    Stanford Shirley Bell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Coventry

    AI-generated summary

    Ruth Marian Perkin · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ruth Marian Perkin was admitted to a care home on 9 February 2018, suffered two falls shortly afterwards, and was found to have a right neck of femur fracture after the second fall. She underwent hip repair, later contracted pneumonia, and died on 29 March 2018. The principal concern was that discharge to the care home while her needs were still being assessed, together with staffing and care arrangements, may have increased her risk of falls and death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure care needs are assessed before discharge to the care home

    Wider context from the report

    “(4) I was informed by the Care Home Manager that if Mrs Perkin not suffered a fracture and had been returned to the care of the Care Home after her second fall, she would have suggested to the hospital that, in view of Mrs Perkin’s tendency to act in disregard of care instructions, she was in fact most likely in need of 1:1 care. (5) I was informed that for the 20 residents at the Care Home there are 5 staff on duty during the day, reducing to 3 staff at night, and my concern is that Mrs Perkin’s discharge to the Care Home under the D2A scheme, when her needs were still being assessed, actually placed her at an increased risk of falls and death as a result. ”

    Source location

    Ruth Marian Perkin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. London (East)

    AI-generated summary

    William George BARTRAM · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    William Bartram was born with a chordee and hydrocele and was reported to have an inadequate urine stream from shortly after birth. Raised creatinine results and concerns about his urine output were not acted upon, and he died from septic shock on 12 March 2017 after deteriorating in hospital. The principal concerns were unclear processes for repeat blood samples, failure to highlight or act on abnormal results, and inadequate advice to his parents about what constituted a healthy urine stream.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clear discharge advice to parents about a healthy urine stream in babies

    Wider context from the report

    “(3) Mr and ████████ did not receive clear advice as to what to look out for, in terms of a healthy urine stream. Advice to parents on the discharge of babies from hospital, would be helpful. Mr and ████████ accepted reassurance from staff, as they were unclear as to what was “normal”. ”

    Source location

    William George BARTRAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Somerset

    AI-generated summary

    Robin Damien Richards · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Robin Damien Richards, who had a history of mental health problems and diagnoses including Asperger's Syndrome, ADHD and a learning disability, was found suspended by his belt at supported accommodation on 29 June 2015 and died in hospital on 3 July 2015. Concerns included a shortage of suitable supported accommodation, the suitability and inspection of his placement, and shortcomings in communication, handover, discharge planning, care planning and risk assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clarity in discharge plans and placement expectations

    Wider context from the report

    “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests. (2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected. (3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified; a) Poor communication with family and between Trust staff. b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement. c) An inadequate handover. d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him. e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards ”

    Source location

    Robin Damien Richards · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Northamptonshire

    AI-generated summary

    Gladys Kathleen Rich · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input

    Wider context from the report

    “3. There does not seem to be any mechanism for ensuring that Falls Prevention Service input is in fact delivered when it is required and that a patient is only ever discharged or that it is clear that the underlying symptoms causing the falls are resolved or that measures have been put in place to mitigate the falls risk. ”

    Source location

    Gladys Kathleen Rich · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.

    Verbatim wording from the response

    “Although we believe we followed normal and reasonable procedures in this case, in future to further mitigate against shortcomings of the Falls Team, we will contact them after sending them referrals and action plans. This will be done to ensure that the Falls Team have received them and to find out what action they intend to take. All contact will be recorded in our residents’ Care plans under the visiting professionals’ information section.”

    Source location

    2018-0149_Redacted-Response-by-Avenue-House-Care-Home
    Page 1 · response
    Published 8 July 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    After submitting referrals and action plans, the care home must wait for the Falls Team’s input and decisions.

    Verbatim wording from the response

    “C) The management of the home completed the falls risk assessment and action plan and sent this by post, and not by the fax facility. There was a copy of this in the resident’s file for reference. There was no information in the resident’s file to say that the falls team hadn’t received this information. Mrs Rich had also been referred to the Falls Team prior to admission to Avenue House and again this was not followed up by the Falls Team. Once falls risk action plans are received by the falls team, they do not typically give the home even a rough estimate of how long it will be before it is followed up and the resident is seen. Therefore the care home simply has to wait for the Falls’ Team’s input.”

    Source location

    2018-0149_Redacted-Response-by-Avenue-House-Care-Home
    Page 1 · response
    Published 8 July 2018

    Open published response

  8. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Kenneth William Horne · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kenneth William Horne suffered two falls at Royal Stoke University Hospital, including one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter, there was no nurse-to-nurse discharge call, and the Transfer of Care form was not up to date. He fell approximately six hours after admission to Leek Moorlands Hospital, sustaining a serious chest wall injury, and later died from sepsis, bronchopneumonia and chest wall injury.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to include falls in hospital discharge information

    Wider context from the report

    “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter. (2) There was no nurse to nurse discharge call between the hospitals. (3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital. As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December. ”

    Source location

    Kenneth William Horne · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require significant inpatient falls to be recorded in discharge summaries.

    Verbatim wording from the response

    “1. All Clinical Leads to instruct Junior Doctors and Nurse Practitioners that when summarising discharge letters, any significant event such as patient falls while in hospital is reflected on their discharge summary.”

    Source location

    2018-0131-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
    Page 2 · response
    Published 1 July 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Coordinate an audit of discharge summaries with external auditors.

    Verbatim wording from the response

    “In addition to this, the Corporate Governance Team are in the process of co-ordinating an audit of discharge summaries with our external auditors. It is hoped that this will take place within the 2018/19 financial year and any findings will be addressed by the Corporate Governance Team.”

    Source location

    2018-0131-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
    Page 2 · response
    Published 1 July 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Address findings from the discharge-summary audit.

    Verbatim wording from the response

    “In addition to this, the Corporate Governance Team are in the process of co-ordinating an audit of discharge summaries with our external auditors. It is hoped that this will take place within the 2018/19 financial year and any findings will be addressed by the Corporate Governance Team.”

    Source location

    2018-0131-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
    Page 2 · response
    Published 1 July 2018

    Open published response

  9. Cornwall and Isles of Scilly

    AI-generated summary

    Miriam Roach · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Miriam Roach, who had a history of depression, anxiety, alcohol dependency and self-harm, was discharged from hospital on 30 June 2017 after assessment following an overdose. She died by suicide on 1 July 2017 by hanging. The substantive concerns related to aftercare and the absence of arrangements to contact patients discharged home with moderate to high risks of self-harm or suicide.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Deficiencies in aftercare or transition arrangements for patients discharged home at moderate to high risk of self-harm or suicide

    Wider context from the report

    “(1) Regarding the aftercare or transition arrangements for those discharged from hospital to home with a moderate to high risk of self-harm and/or suicide following incidents of self-harm or suicide. (2) Specifically the obligations for putting in place contact arrangements for such patients. ”

    Source location

    Miriam Roach · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Somerset

    AI-generated summary

    Edward Arthur Lundy · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Edward Arthur Lundy, who had a history of depression, was found hanging in a barn on 23 August 2016 and could not be revived. The concerns identified included a lack of continuity in his care, no psychiatric assessment despite a referral indicating this was needed, and insufficient documentation and discussion of care options and risks with his family. The report also states that evidence had not been produced showing that the proposed actions had been implemented or shared nationally.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to document discharge consultation and explicitly discuss risks with families

    Wider context from the report

    “1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced. 2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings. 3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission. There has been no evidence produced as to compliance with the recommended actions. There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts. That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure. ”

    Source location

    Edward Arthur Lundy · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026