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.
Inner South London
Concerns raised3
Failure to complete accurate discharge passports containing patients’ clinical, therapy, equipment and home-environment needs
Failure to provide social work and/or occupational therapy assessment within 24 hours of discharge
Failure to conduct an overarching coordinated investigation of the integrated multidisciplinary discharge process
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.5
Action
Strengthen multidisciplinary discharge-passport completion, checking, approval, electronic-record updating and daily validation before discharge.
Stated by Lewisham and Greenwich NHS Trust and London Borough of LewishamStated completedThe respondent said that this action was complete when they made their response on 29 January 2025.
Action
Develop standards, role definitions, guidance and staff teaching for prescribing pressure-care equipment and hospital beds.
Stated by Lewisham and Greenwich NHS Trust and London Borough of LewishamStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2025.
Action
Progress the Occupational Therapy Policy through Trust governance approval.
Stated by Lewisham and Greenwich NHS Trust and London Borough of LewishamStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2025.
Action
Perform additional electronic-record checks for last-minute changes in condition or discharge support needs under an embedded discharge protocol.
Stated by Lewisham and Greenwich NHS Trust and London Borough of LewishamStated completedThe respondent said that this action was complete when they made their response on 29 January 2025.
Action
Conduct further multi-agency discharge events to improve communication and joint working.
Stated by Lewisham and Greenwich NHS Trust and London Borough of LewishamStated plannedThe respondent said that this action was planned when they made their response on 29 January 2025.
South Wales Central
Concerns raised1
Delays in discharging medically fit patients for non-medical reasons
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.5
Action
Roll out the Optimise patient-flow programme to the Princess of Wales site using real-time tracking, eWhiteboards, Red2Green and SAFER board rounds.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2025.
Action
Continue the STAMP acute-medicine transformation programme to improve hospital flow and support discharge planning across the organisation.
Stated by Cwm Taf Morgannwg University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 20 January 2025.
Action
Implement the Discharge to Recover then Assess model to move patients no longer requiring acute care into appropriate settings promptly.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 20 January 2025.
Action
Develop and operate a centralised Discharge Hub for patient flow and community bed allocation.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 20 January 2025.
Action
Continue collaboration with local-authority partners to improve social-care availability and reduce delayed discharges.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2025.
Essex
Concerns raised1
Failure to provide discharge summaries to care homes
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
Remind Emergency Medicine clinicians to complete discharge summaries for every patient, including those discharged somewhere other than home.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2024.
Action
Remind nursing staff to verify discharge-summary completion before patients leave the department.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2024.
Action
Publish learning from the case in the January 2025 all-staff patient safety bulletin, emphasising complete and accurate discharge summaries at discharge.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2024.
Action
Monitor discharge-summary issuance through the 2025 trust-wide corporate audit programme and use findings to determine further action.
Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2024.
Inner West London
Concerns raised1
Lack of suitable community social care delaying discharge of patients ready to leave hospital
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 South
Concerns raised1
Delays in identifying suitable care home placements
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
Continue reviewing discharge processes, alternatives to hospital admission, and patient-flow pathways across Greater Manchester hospitals.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 24 September 2024.
Action
Conduct a further Single Assessment Framework assessment reviewing previously identified shortfalls and whether the provider has sufficiently improved.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 24 September 2024.
Action
Update statutory hospital-discharge guidance to support safe, coordinated transfers and continuity of care.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 24 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Care home placement shortages and hospital discharge delays fall outside the regulator’s remit.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Secretary of State and Greater Manchester Integrated Care are considered better placed to address care placement shortages and discharge delays.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire Eastern
Concerns raised1
Premature discharge after prolonged labour and induced delivery
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
Immediate postnatal care and discharge were considered compliant with national guidance, so earlier discharge arrangements were not changed.
Stated by Leeds Teaching Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cheshire
Concerns raised1
Failure to alert a doctor to significant deterioration before discharge home
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing policy-based escalation was considered sufficient because observations did not warrant medical review before discharge.
Stated by Stockport NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Trust disputes that significant deterioration was identified on discharge, citing a NEWS of zero throughout the admission.
Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester North
Concerns raised2
Failure to commence and complete a safety plan during admission and before discharge
Failure to complete the discharge clinical entry and risk assessment
This report raised 12 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
Remind staff to complete required My Safety Plans and monitor compliance through daily dashboard reviews and audits.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
Action
Remind staff to complete discharge clinical entries, risk assessments, checklists and crisis-information provision in accordance with policy.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The NHS sending provider is responsible for overseeing individual care, including engagement in communication, discharge and care planning for out-of-area patients.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East London
Concerns raised2
Lack of safety planning before discharge
Lack of adequate risk formulation before 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.12
Action
Implement discharge steps and multidisciplinary discharge planning meetings with managerial and matron oversight.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Review named-nurse processes and guidelines to clarify risk-assessment and discharge responsibilities across inpatient wards.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Action
Improve discharge and care-planning documentation with discharge prompts, carer involvement, and service-user review of correspondence.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Provide Trust-wide community mental-health-team training on enhanced transition care planning.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Roll out STORM risk-management training to frontline staff, targeting 60% of registered urgent-care practitioners by the end of 2024.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Action
Re-share the clinical risk policy and provide ward posters on safe discharge steps.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Implement the Safety Action Plan to document agreed discharge actions, relapse signatures, and multidisciplinary outcomes in patient records.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Action
Provide clinical risk-assessment training and apply the clinical risk policy.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Operate a clinical dashboard identifying missing risk formulations and crisis summaries for managerial follow-up.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Review inpatient and community care plans and risk assessments during staff one-to-one supervision.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Conduct record, matron, and person-centred audits of risk formulation, crisis summaries, and care documentation, with feedback to staff.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Review care-coordinator roles and responsibilities and continue risk-assessment improvement through the Disengagement Safety Improvement Programme.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Central and South East Kent
Concerns raised2
Lack of a clearly documented and recorded process for patient self-discharge
Failure to maintain a signed record of patient self-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.
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
Update and disseminate policies clarifying staff duties for missing patients and patients attempting self-discharge, including patient risk assessment.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
Action
Issue updated discharge guidance requiring capacity, safeguarding, consultation, medication, notification, documentation and self-discharge form checks.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
Action
Require post-discharge welfare telephone calls for ward patients who self-discharge.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
No actions by NICE are considered necessary to address the issues raised in the report.
Stated by National Institute for Health and Care ExcellenceNo action considered necessaryThe respondent said that no further action was needed.
Position
The concerns are local Trust issues outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
East Kent Hospitals University NHS Foundation Trust should respond to and address the concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
