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
Failure of coordinated discharge planning and joint working between trusts
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 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.9
Action
Establish an escalation pathway beyond the PTL meeting for delayed Mental Health Services discharges, bringing cases to GMMH senior leadership to support confirmation of hospital discharge dates.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 May 2025.
Action
Review Multi Agency Discharge Event governance, attendance, decision-making and data capture.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Action
Operate a senior system Multi Agency Discharge Event forum to improve clinically ready-for-discharge escalation.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Action
Develop a consistent end-to-end brokerage and funding pathway with responsibilities, stage time standards and a protocol for external-provider delays.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 20 May 2025.
Action
Provide additional voluntary, community and social-enterprise capacity in Manchester to prevent avoidable admissions and support timely discharge.
Stated by NHS Greater Manchester Integrated Care BoardStatus unclearThe respondent did not make the status of this action clear when they made their response on 20 May 2025.
Action
Roll out system-wide a four-level escalation policy for clinically ready-for-discharge mental-health patients by quarter three.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 May 2025.
Action
Conduct a joint internal review of the patient journey through a GMMH learning multidisciplinary meeting with partner agencies.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 May 2025.
Action
Establish a full-time Operational Manager for Community Flow to oversee early discharge planning, identify barriers, track actions, and coordinate senior communication with MFT.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The concern about lack of joint working is disputed because the case was repeatedly discussed at daily meetings involving the relevant organisations.
Stated by Manchester University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Issues specifically relating to the patient’s care will be addressed by Manchester University Hospitals and Greater Manchester Mental Health NHS Foundation Trusts.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Berkshire
Concerns raised1
Failure to take postoperative CRP results into account in discharge and scanning decisions
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.2
Action
Provide existing guidance on postoperative CRP monitoring and CT investigation triggers.
Stated by The Association of Coloproctology of Great Britain and IrelandStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
Action
Direct South East Clinical Quality colleagues to engage with the relevant ICB or Trust and seek assurance that learning from Lorraine’s case has been taken.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Existing guidance on CRP monitoring and CT investigation makes further ACPGBI guidance unnecessary at this time.
Stated by The Association of Coloproctology of Great Britain and IrelandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
ACPGBI is best placed to consider whether guidance is needed on recognising deterioration after bowel surgery.
Stated by Royal College of Surgeons of EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing NICE guidance, clinical judgement, local protocols and relevant professional guidance are relied upon instead of standalone CRP-based postoperative imaging guidance.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NHS Trusts are responsible for ensuring staff competence and should review their clinical protocols following the case.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of suitable non-acute or community provision for medically optimised patients
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.1
Action
Publish the revised Better Care Fund policy framework and commit approximately £9 billion for 2025–26 discharge-related activity.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 16 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Secretary of State may be better placed to address hospital bed demand and delayed discharges because the issue involves complex competing budgetary demands.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to account for cognitive, mental health and home-safety barriers when assessing engagement
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.4
Action
Conduct an independent structured judgement review and discuss its findings at ICAT governance and safeguarding meetings.
Stated by Whittington Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 March 2025.
Action
Add assessment-proforma requirements to consult patients’ families where appropriate and document mental-capacity decisions when patients do not consent.
Stated by Whittington Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 March 2025.
Action
Conduct mental-capacity assessments for patients who do not engage with services and involve families where appropriate.
Stated by Whittington Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 March 2025.
Action
Revisit training on identifying cognitive abilities, capacity, risk, and risk management under the Mental Capacity Act.
Stated by London Borough of IslingtonStated plannedThe respondent said that this action was planned when they made their response on 31 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The team had received and considered information about the patient’s unsafe home circumstances, neighbours and self-care difficulties.
Stated by Whittington Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
ICAT discharged the patient because other community services addressed all identified problems and provided a safety net for ongoing follow-up.
Stated by Whittington Health NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised2
Failure to ensure that discharge to a non-nursing care home is appropriate for a patient's condition and care needs
Failure of discharge letters to communicate clinically significant sedation and oxygen requirements
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Clear health and social care discharge guidance and discharge documentation concerns fall outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Further information about discharge guidance and documentation should be sought locally from Tameside and Glossop Integrated Care NHS Foundation Trust.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised2
Chaotic and unsupported discharge execution
Failure to actively reconsider discharge safety when arrangements change
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.6
Action
Recruit a Community and Inpatient Liaison Nurse to coordinate inpatient referrals and support safe discharge.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Action
Invite the appropriate Home Treatment Team to attend ward reviews on the day of discharge.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 March 2025.
Action
Assign a registered nurse to coordinate each patient’s safe-discharge preparation, travel, support, follow-up and crisis-contingency plans.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 March 2025.
Action
Complete a thematic review of inpatient deaths to inform discharge safety improvements.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Action
Mobilise the new inpatient operating model and its implementation plan for proactive, safe and effective discharge across adult and older-adult wards.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Action
Assign Family Ambassadors to support family engagement, information sharing and recording family information for multidisciplinary consideration.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Swansea and Neath Port Talbot
Concerns raised1
Failure to involve community care co-ordinators and professionals in multidisciplinary discharge decisions
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.6
Action
Hold weekly multidisciplinary ward meetings with community mental health services and other agencies to support collaborative discharge decisions.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 March 2025.
Action
Hold weekly discharge planning meetings attended by inpatient and community team representatives to discuss and prioritise discharge plans.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 March 2025.
Action
Use a revised pre-discharge checklist requiring communication and collaboration with care coordinators, families, carers and relevant agencies, with weekly clinical-record audits.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 March 2025.
Action
Undertake a clinical audit of adult inpatient discharges against national transition guidance and present its findings.
Stated by Swansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2025.
Action
Issue formal correspondence reaffirming compliance with discharge-planning policy, the pre-discharge checklist and patient information requirements.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 March 2025.
Action
Cascade the discharge-planning correspondence through ward, team-manager and consultant forums.
Stated by Swansea Bay University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 10 March 2025.
South Wales Central
Concerns raised1
Failure to implement a “Failed Discharge” policy
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
Implement operational general surgery guidelines for patients returning to emergency departments after discharge, and embed them in governance, staff induction and accessible policy resources.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 7 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing guidelines, policies and awareness measures are considered sufficient to prevent further similar patient presentations.
Stated by Cwm Taf Morgannwg University Local Health BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Dorset
Concerns raised1
Lack of responsible clinician involvement in 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.
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
Add discharge-planning requirements to the Liaison Psychiatry standard operating procedure for consultant consideration of 48-hour follow-up and documentation of the rationale when follow-up is not required.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 January 2025.
Action
Strengthen collaboration with Devon Partnership Trust to establish effective, comprehensive discharge pathways between the organisations.
Stated by Dorset Healthcare University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 January 2025.
Action
Provide discharge-planning feedback, including the Coroner’s concerns and the family’s experience, at relevant multidisciplinary team meetings.
Stated by Dorset Healthcare University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 January 2025.
Action
Introduce Learning and Review Groups within the Trust’s patient safety framework to share and disseminate learning across directorates.
Stated by Dorset Healthcare University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 January 2025.
Action
Share specific learning about discharges to and from services outside Dorset through the Learning and Review Groups at the scheduled April 2025 meeting.
Stated by Dorset Healthcare University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Dorset HealthCare disputes involvement in the discharge planning concerned, stating it was only contacted to arrange a psychiatric outpatient appointment.
Stated by Dorset Healthcare University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Discharge arrangements are led by the team seeking to transfer care, assigning responsibility to the transferring NHS provider.
Stated by Dorset Healthcare University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Liverpool and the Wirral
Concerns raised1
Backlog of patients fit for discharge awaiting social care packages
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.6
Action
Develop NHS and social care local partnerships to reduce delayed discharges and ensure hospital departments are no longer blocked by patients awaiting discharge.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 31 January 2025.
Action
Reform the Better Care Fund so pooled NHS and local-authority funding supports reductions in emergency admissions, delayed discharges and care-home admissions.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 31 January 2025.
Action
Implement plans to improve ambulance handovers, response times and urgent and emergency care flow.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 January 2025.
Action
Strengthen use of Discharge Ready Date data in operational decision-making to identify delays and support timely discharge.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 January 2025.
Action
Publish the 2025/26 Better Care Fund policy framework and planning requirements to support coordinated health and social care discharge plans.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 31 January 2025.
Action
Work with local areas and health, social care and local government partners to improve timely hospital discharge and maximise discharge-funding impact.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 January 2025.
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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.
