Care and discharge planning
Failure to develop detailed and comprehensive client assessments, recovery plans, and discharge plans.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
90match
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
When transferring or discharging a Service User [patient] from an inpatient or day case or accident and emergency Service, the Provider must within 24 hours following that transfer or discharge issue a Discharge Summary to the Service User’s GP and/or Referrer and to any relevant third party provider of health or social care …’ 1.2.2 The ‘discharge summary’...
Matched on
terms: care, discharge
PHSO recommendation
90match
Discharge from mental health care: making it safe and patient-centred
NHS England should make sure that patients and their support network are active and valued partners in planning transitions of care and are empowered to give feedback, including through complaints.
Matched on
terms: care, discharge, planning
PFD report
89match
Gareth Slater
Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living assessment, and an unsuitable unfurnished flat.
Matched on
terms: care, discharge, planning
PFD report
85match
Alan Stanfield Browning
A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on a Friday, highlighting a lack of robust discharge planning.
Matched on
terms: care, discharge, planning
PFD report
85match
Gillian Crossley
Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers were identified.
Matched on
terms: care, discharge, planning
PPO recommendation
85match
The Governor and Head of Healthcare
The Governor and Head of Healthcare should implement a process to ensure that healthcare staff are notified when prisoners return from hospital and that all discharge information is shared promptly to inform care planning.
Matched on
terms: care, discharge, planning
PPO recommendation
85match
The Head of Healthcare
The Head of Healthcare should ensure that processes and systems are in place regarding release and discharge planning for all prisoners known to healthcare and who require ongoing healthcare input.
Matched on
terms: care, discharge, planning
Committee recommendation
83match
#17 - Inadequate adult social care system imposing significant costs on the NHS, particularly from delayed discharges
Social care is a vital public service in and of itself and should not be valued only for how it supports the NHS. However, the current state of adult social care is imposing significant costs on the NHS. The best estimate we found was that delayed discharges alone are costing almost £1.9 billion. This does not account for...
Matched on
terms: care, discharge
CQC action
82match
Trent Lodge Residential Care Home
The registered person must ensure that each service user is protected against the risks of receiving care and treatment that is inappropriate or unsafe by means of the carrying out of an assessment of the needs of the service user and the planning and delivery of care in such a way as to meet service user’s individual needs...
Matched on
terms: care, planning
HSSIB recommendation
81match
Unplanned delayed removal of ureteric stents
It is recommended that the British Association of Urological Surgeons provides guidance for staff working within the stone care pathway to promote consistent advice to patients as part of discharge planning.
Matched on
terms: care, discharge, planning
Committee recommendation
78match
#4 - Set out actions to address delayed discharges caused by hospital, community, and social care constraints.
Not enough is being done to tackle delayed discharges, which cause inefficiencies both within hospitals and more widely across the care system. Delays with discharging patients when they are medically fit for discharge reduces available bed capacity, which in turn slows admissions from A&E departments, which in turn slows the rate at which ambulances can hand over new...
Matched on
terms: care, discharge
Committee recommendation
74match
#9 - Fourteenth Report: Readying the NHS and social care for the COVID-19 peak
On 17 March the NHS told trusts to discharge urgently all medically fit hospital patients with COVID-19 to maximise inpatient and critical care capacity. On 2 April, the Department told care homes that they needed to make their full capacity available and could admit patients with COVID-19 by isolating suspected or confirmed cases. Some Local Authorities were pressurising...
Matched on
terms: care, discharge
Committee recommendation
74match
#18 - Publish annual official estimates of delayed discharge costs to the NHS, broken down by reason
We recommend that the Department provides an official estimate of how much delayed discharges are costing the NHS, broken down by the reason for the delay and including costs associated with the beds themselves, staff time and wider activity that cannot happen as a result of a delayed discharge. This should be published and updated annually. (Recommendation, Paragraph...
Matched on
terms: care, discharge
HSSIB recommendation
74match
Medication not given: discharge from an acute hospital to the community
How does your organisation work with other services to help provide co-ordinated care for patients discharged home who need insulin support?
Matched on
terms: care, discharge
HSSIB recommendation
74match
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
Health and care organisations can improve patient safety by allocating a point of contact for patients and/or their carers when people are discharged from services out of normal working hours. This will ensure patients and their carers are able to escalate any concerns relating to their ongoing care and drive improvements in care co-ordination.
Matched on
terms: care, discharge
Committee recommendation
74match
#21 - Facilitate integrated working between health and social care services to reduce delayed discharges.
We have previously noted that the fragility of the adult social care provider market was exacerbating the difficulties in discharging older patients from hospital.55 NHS England agreed that there is a clear challenge in social care. Different solutions are needed in different parts of the country, but health and social care services must work together to tackle problems...
Matched on
terms: care, discharge
Committee recommendation
74match
#20 - Delayed hospital discharges attributable to four categories, including hospital processes and social care.
NHS England told us that the reasons why patients might experience delays in leaving hospital could be divided into four categories. For one group of patients, accounting for around 20%, the delays are related directly to activity in the discharging hospital.51 NHS England told us it was largely the responsibility of the leadership within these hospitals to improve...
Matched on
terms: care, discharge
PFD report
73match
John Walker
Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.
Matched on
terms: care, planning
PFD report
73match
Kevin Paul Sutton
The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking inadequate ongoing care.
Matched on
terms: care, discharge
PFD report
73match
Ricky Anderson
Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient early without a care plan.
Matched on
terms: care, discharge
PFD report
73match
William Beckwith
A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.
Matched on
terms: care, discharge
PFD report
73match
Sybil Roberts
A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, leading to repeated falls due to unupdated care plans.
Matched on
terms: care, discharge
Inquiry recommendation
73match
LAMI-71 - Require documented future care plan for discharging children with protection concerns.
Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. Hospital chief executives must introduce systems to monitor compliance with this recommendation.
Matched on
terms: care, discharge
Inquiry recommendation
73match
F239 - Continuing responsibility for care
The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be acceptable for patients to be discharged in the middle of the night, still less so at any time without absolute assurance that a patient in need of care will receive it on arrival at the planned...
Matched on
terms: care, discharge
Committee recommendation
73match
#4 - Seventh Report - Supporting people with dementia and their carers
However, the evidence we have taken has made it clear that improving diagnosis alone is not sufficient: people living with dementia and their carers need appropriate post- diagnostic support throughout the rest of their life. We are clear that there should be no gap between receiving a diagnosis and providing both immediate support and planning longer-term care for...
Matched on
terms: care, planning
HSSIB recommendation
73match
Electronic prescribing and medicines administration systems and safe discharge
The processes for medicines reconciliation in the community would benefit from being reviewed, taking into account the intent for practice-based pharmacists outlined in NHS England’s Long Term Plan (NHS England, 2019). Summary Care Records
Matched on
terms: care, discharge
PHSO casework decision
73match
P-003316 - Herefordshire and Worcestershire Health and Care NHS Trust
Mr and Mrs D complained H&W Trust failed to provide appropriate home care after Mr F's hospital discharges, and WAH Trust discharged him without an adequate care plan. They alleged this led to neglect, sepsis, and his death.
Matched on
terms: care, discharge
LGO / SPSO decision
73match
21-013-691 - Buckinghamshire Council
Summary: Ms X complains about the Council’s failure to enforce a condition of a planning permission granted by the Planning Inspectorate. There was fault by the Council because of unreasonable delay in dealing with the matter. The Council agreed to act to remedy the injustice.
Matched on
terms: care, planning
LGO / SPSO decision
73match
24-020-114 - Isle of Wight Council
Summary: We cannot by law investigate this complaint about an alledged failure by the Council to provide information to the Planning Inspectorate for the purposes of an appeal. This is because we have no legal jurisdiction to investigate a complaint when an appeal has been made to the Planning Inspectorate, acting on behalf of the relevant Government minister.
Matched on
terms: care, planning
PFD report
69match
Nicola Matthews
Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for future harm.
Matched on
terms: care, discharge
PFD report
69match
Rosemary Brownyn Ferguson
Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to a friend regarding patient care, combined with scanty hospital notes, created significant misunderstandings and risks.
Matched on
terms: care, discharge
PFD report
69match
John Malone
A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate ongoing care.
Matched on
terms: care, discharge
PFD report
69match
Michael Irlam
A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in care, risking patient abandonment.
Matched on
terms: care, discharge
PFD report
69match
Norma Sheppard
The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically regarding the provision of sub-cutaneous fluids, which presented difficulties in finding a suitable placement.
Matched on
terms: care, discharge
PFD report
69match
Graham Watts
The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.
Matched on
terms: care, discharge
PFD report
69match
Andrey Wakefield
Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.
Matched on
terms: care, discharge
PFD report
69match
Farres Ikken
Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap in post-hospital care.
Matched on
terms: care, discharge
PFD report
69match
John Wilsher
An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led to an inappropriate patient placement.
Matched on
terms: care, discharge
Inquiry recommendation
69match
LAMI-72 - Ensure identified GP for children with deliberate harm concerns discharged from hospital.
No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been admitted.
Matched on
terms: care, discharge
PHSO casework decision
69match
P-001660 - Northern Care Alliance NHS Foundation
The Trust improperly discharged a very unwell COVID-19 patient, had a COVID-positive relative collect her, provided insufficient basic care, restricted visitors, and gave unclear updates.
Matched on
terms: care, discharge
PHSO casework decision
69match
P-003297 - Royal Devon University Healthcare NHS Foundation Trust
Mrs E complained Royal Devon University Healthcare NHS Foundation Trust staff failed to communicate with her and her son, inappropriately discharged him without monitoring, and stopped his omeprazole prescription.
Matched on
terms: care, discharge
PHSO casework decision
69match
P-003598 - Gloucestershire Health and Care NHS Foundation Trust
Mrs N complained the Hospital Trust caused discharge delays and both Trusts failed to assess and provide adequate home care for her terminally ill husband, especially in his narrowboat home.
Matched on
terms: care, discharge
LGO / SPSO decision
69match
NIPSO-17984 - Belfast Health and Social Care Trust
The Belfast Health and Social Care Trust has apologized to a patient who was forced to arrange her own care package after being discharged from the Royal Victoria Hospital, Belfast.
Matched on
terms: care, discharge
LGO / SPSO decision
69match
NIPSO-20700 - Belfast Health and Social Care Trust
We found that the Belfast Health and Social Care Trust did not provide a patient with a multi-disciplinary review prior to her discharge from the Royal Victoria Hospital.
Matched on
terms: care, discharge
LGO / SPSO decision
69match
21-013-816b - Bromley Healthcare CIC Ltd (21 013 816b)
Summary: Mrs D complained about the way the Council, the Trust and Bromley Healthcare dealt with her late brother Mr S’s discharge from hospital, wheelchair provision and social care. We have not upheld the complaints about the Council and Bromley Healthcare. Most complaints about the Trust are also not upheld. However, we found the Trust was at fault...
Matched on
terms: care, discharge
HSSIB recommendation
69match
Workforce and patient safety
HSSIB recommends that the NHS England/Department of Health and Social Care, in collaboration with relevant national bodies including the Professional Record Standards Body, adopts user-centred design principles to develop and validate new discharge correspondence templates for primary and community care settings. This is to provide standards for discharge correspondence that support recipients’ access to high-quality safety-critical clinical information,...
Matched on
terms: care, discharge
CQC action
69match
Royal Victoria Infirmary
The service must ensure that timely care planning takes place where responsibility for care and treatment is shared with, or transferred to others services.
Matched on
terms: care, planning
PHSO casework decision
69match
P-003080 - Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr A complained his wife was prematurely discharged from hospital without a care package or explanation, causing stress that accelerated her deterioration and contributed to her subsequent death.
Matched on
terms: care, discharge
LGO / SPSO decision
69match
21-017-636 - London Borough of Hillingdon
Summary: We will not investigate Mr X’s complaint about the Council’s handling of a planning matter. This is because the complaint is late and the injustice Mr X claims is not the result of any fault by the Council.
Matched on
terms: care, planning
LGO / SPSO decision
69match
21-018-433 - Kirklees Metropolitan Borough Council
Summary: We will not investigate this complaint about how the Council dealt with the complainant’s planning application. This is because the complainant had the right to appeal to the Planning Inspector.
Matched on
terms: care, planning