Recurring concern
Unreliable hospital discharge processes
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Request correctionFirst reported 30 Jan 2013•Latest report 10 Jun 2026
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
- Individual concerns
- 406
- Date range
- 2013–2026
- Stated actions
- 524
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Lack of protocol or guidance for Mental Health Nurses on referring acute-hospital discharge decisions to a doctor after self-harm
Responses linked to these concernsEach 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
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Action
Amend the Community Treatment Order Procedure to address the identified concerns.
Stated by North West Boroughs Healthcare NHS Foundation Trust -
Action
Communicate the amended Community Treatment Order Procedure to staff.
Stated by North West Boroughs Healthcare NHS Foundation Trust
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Concerns raised3
Failure to involve the patient’s Primary/Associate Nurse in discharge
Failure to review discharge decisions after material changes in patient presentation
Disjointed and uncoordinated discharge processes
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Implement a robust discharge process with pre-discharge assessment, discharge-day completion, crisis information, emergency contacts, seven-day follow-up and consent-based communication.
Stated by Pennine Care NHS Foundation Trust -
Action
Review, update and ratify the discharge protocol and guidance for similar situations through the Acute Care Forum and governance process.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Failure to allow sufficient time to assess tolerance of a newly started drug before 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 concernsEach 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
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Position
The Trust considers post-initiation hospital observation unnecessary because serious Septrin adverse events are more likely after prolonged treatment.
Stated by Stockport NHS Foundation Trust
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Concerns raised4
Failure to provide patients with discharge-summary copies and an understanding of their significance
Failure to send hospital discharge summaries electronically to GPs on the day of discharge
Failure to identify recent failed discharges during discharge planning
Failure to apply discharge policy and begin discharge documentation at the start of the care journey
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 concernsEach statement is shown once, even when linked to more than one 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 assess patients and ensure medical and social factors are in place before 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 concernsEach 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
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Position
The consultant-led written discharge plan was followed, providing sufficient arrangements for discharge despite the discharging doctor not personally seeing the patient.
Stated by Stockport NHS Foundation Trust
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Concerns raised3
Failure to communicate required discharge-assessment factors to the assessor
Failure of assessment notes to clearly and accurately record information for the discharge decision-maker
Lack of clarity about required coverage in discharge assessments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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
Lack of discharge follow-up mechanisms for patients transferring to a different area
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 concernsEach 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
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Action
Review Home Treatment Team processes for sharing information with new providers after service users relocate.
Stated by Surrey and Borders Partnership NHS Foundation Trust -
Action
Remind Home Treatment Team staff of local discharge and follow-up procedures for relocated service users.
Stated by Surrey and Borders Partnership NHS Foundation Trust -
Action
Obtain relocated service users’ residence and GP details, refer them to local mental health services, and notify the original GP where required.
Stated by Surrey and Borders Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Ensuring relocated patients receive appropriate mental health support is challenging when they have not registered with a GP because services are mainly GP-aligned.
Stated by Surrey and Borders Partnership NHS Foundation Trust
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Concerns raised1
Lack of joined-up care and discharge planning in the Acute Medical Unit
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 concernsEach 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
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Position
The records show suitable care and treatment were provided, with discharge arrangements planned and coordinated.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to document care plans for family members undertaking care obligations
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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 document discharge risk-factor assessments in clinical records
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026