Recurring concern
Unreliable return-from-hospital arrangements
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Request correctionFirst reported 12 Sep 2014•Latest report 15 Apr 2025
What this concern includes
Includes failures of the dedicated return-from-hospital process, including governing forms and protocols, communication with receiving care providers, confirmation of return, post-return evaluation or assessment, and related handover controls needed to resume safe care.
Not included
- Excludes general hospital discharge planning, discharge summaries, medication transfer or onward-care placement failures when they do not specifically concern the return-from-hospital process.
- Excludes failures limited to the quality of hospital treatment before return or ongoing care after a reliable return process has been completed.
- Excludes generic documentation, communication or assessment deficiencies unless they directly impair safe return from hospital.
- Excludes transport availability or transport safety failures where the concern is conveyance itself rather than safe receipt and follow-up after return.
- Reports
- 8
- Individual concerns
- 8
- Date range
- 2014–2025
- Stated actions
- 10
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
Failure to require notification of safe return to the hospital or care company
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 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
Some patient transport safety actions fall outside the Trust’s scope.
Stated by the Dudley Group NHS Foundation Trust
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Concerns raised1
Failure to conduct further risk assessments after a resident’s return from hospital
This report raised 10 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.1
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Action
Reassess tenants returning from hospital, including Care Manager risk assessment, ongoing observation and recording outcomes in tenant files and Birdie.
Stated by Hibiscus Housing Association Limited
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Concerns raised1
Inadequate protocols for return from hospital forms
This report raised 15 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.1
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Action
Train nurses and shift leaders on documentation, care plans, wound management, assessments, body maps, consent forms and hospital-return documentation.
Stated by Hill Care Group
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
Existing protocols for wound management and required care documentation are considered sufficient, with compliance monitored through regular audits.
Stated by Hill Care Group
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Concerns raised1
Failure to evaluate a patient’s situation and required action after return to the ward
This report raised 13 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 return interviews after unauthorised leave and use the information to guide care plans and future leave decisions.
Stated by Leeds and York Partnership NHS Foundation Trust -
Action
Audit compliance with the revised procedure’s return-interview requirements.
Stated by Leeds and York Partnership NHS Foundation Trust
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Concerns raised1
Failure to evaluate patients after return
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 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.6
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Action
Apply the falls prevention and post-fall protocol, including prompt assessment, incident recording, investigation and review of care plans and risk assessments.
Stated by Hc-One Limited -
Action
Increase Area Director and Quality Regulation Manager scrutiny of falls assessments and evaluations during visits and inspections.
Stated by Hc-One Limited -
Action
Discuss falls trends and share learning through quarterly Quality Governance Group meetings, with follow-up actions reviewed monthly.
Stated by Hc-One Limited
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Action
Share sample falls risk assessments with staff to clarify assessment and post-fall evaluation requirements.
Stated by Hc-One Limited -
Action
Implement a falls flow chart at Sunnyside Care Home to guide post-fall actions.
Stated by Hc-One Limited -
Action
Implement 24-hour post-incident observation records and senior clinical walk-rounds, with operational and internal inspection audits.
Stated by Hc-One Limited
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Concerns raised1
Lack of guidance for managing children returning to their local area after out-of-area psychiatric inpatient care
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 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
Inadequate communication and liaison between hospital and community care providers after discharge
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
Failure to reassess and update care plans and falls risks after hospital return
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