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
Concerns included inadequate discharge planning for Mr Slater, with no care plan, family involvement, or assessment for independent living. His flat was unsuitable, administrative processes were rushed, and there was a lack of structured support post-discharge.
Matched on
terms: care, discharge, planning
PFD report
85match
Gillian Crossley
The coroner noted inadequate documentation, insufficient observation and monitoring, and shortcomings in assessing and planning for Mrs. Crossley's discharge, compounded by poor communication among her care providers.
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
GIRFT recommendation
85match
Ophthalmology
Implement the actions of the High Impact Intervention (HII) on failsafe prioritisation for all ophthalmology patients, particularly those with glaucoma and medical retina conditions, and on undertaking a risk audit to identify and discharge those patients that are clinically ready to be discharged. Actions: a) Providers to audit their approach against the recommendations of the High Impact Intervention...
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
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
GIRFT recommendation
81match
Stroke
Ensure daily MDT patient goal setting (including social care support to facilitate discharge planning). Stroke survivors and those that support them must be involved in goal-setting and discharge planning discussions. a) Ensure all stroke services have structured daily MDT board rounds. b) Consider domiciliary care as part of early supported discharge (ESD) and integrated community stroke services. c)...
Matched on
terms: care, discharge, planning
CQC action
81match
Lister Hospital
The trust must ensure that information sharing and planning with social care providers is timely to ensure safe and timely discharge from the service.
Matched on
terms: care, discharge, planning
CQC action
81match
Clatterbridge Hospital
The service must ensure patients have timely access to care and treatment. It must ensure patient care is planned effectively to reduce length of stay and the number of patients moved between wards at night. It must ensure effective discharge planning take place for patients.
Matched on
terms: care, discharge, planning
GIRFT recommendation
80match
Mental Health Rehabilitation
3. All trusts, health commissioners and LAs should develop robust systems to bring patients treated out of area back to their local area. a A senior named placements co-ordinator, as part of the CRT, to review and plan the person's move back to local care, and in the community wherever possible. Need to have or be directly linked...
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
78match
#1 - 4th Report - Homecare medicines services: an opportunity lost
Homecare medicines services have significant potential to deliver high-quality care to patients in their homes and reduce pressure on hospitals. They should be a key part of future planning and resourcing for the NHS.
Matched on
terms: care, planning
GIRFT recommendation
76match
Acute and General Medicine
Ensure admission and readmission data is routinely and accurately recorded and monitored, and used to inform the provision of safe, effective, and efficient pathways. a Trusts to ensure accurate collection of discharge and transfer numbers to base medical wards each day to provide a basis for planning to facilitate adequate patient flow. b Trusts to ensure accurate collection...
Matched on
terms: care, discharge, planning
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
GIRFT recommendation
74match
Adult Critical Care
Ensure critical care discharges are discussed pre-emptively at hospital-wide daily bed management meetings and given the same level of priority as hospital admissions to ensure optimal patient flow and allow for new critical care admissions to be made in a timely manner. a GIRFT will support trusts to implement pathways that will facilitate optimal patient flow and timely...
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
Nicola Matthews
The coroner identified incomplete documentation of ward round decisions and a lack of clear, documented follow-up arrangements for patients discharged from inpatient care, particularly those at risk of self-harm. This meant staff lacked clarity on discharge plans and medication.
Matched on
terms: care, discharge
PFD report
73match
Kevin Paul Sutton
The coroner identified that the Trust failed to provide care plans for patients discharged from their wards to other establishments, raising a risk of future deaths.
Matched on
terms: care, discharge
PFD report
73match
Ricky Anderson
The coroner noted that Mr. Anderson's GP was not informed of his hospital admissions, leading to issues with medication supply. Furthermore, after an early discharge, there was over-reliance on family for information, and no care plan was established to assess his needs.
Matched on
terms: care, discharge
PFD report
73match
Jack William Partington
Concerns noted inadequate neonatal nursing handover, care planning, and isolated treatment decisions. Also, a lack of national policies for paralysing agents in neonates and insufficient ventilatory pressure monitoring post-intubation.
Matched on
terms: care, planning
PFD report
73match
Alan Stanfield Browning
Mr. Browning was discharged from Somewhere House without his family being informed of accommodation arrangements, and a Friday discharge limited time to secure proper housing. There was also a lack of clarity regarding routine family involvement in discharge planning.
Matched on
terms: discharge, planning
PFD report
73match
John Wilsher
The NNUH discharge letter contained inaccuracies, and there was a lack of awareness regarding prior concerns about the care home's suitability for the patient's deteriorating condition, leading to an inappropriate discharge. Delayed assessments also lacked essential nursing information.
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
GIRFT recommendation
73match
Children and Young People's Mental Health Services
There must be a clear strategy and plan on reducing the proportion of young people remaining on the inpatient unit for more than 60 days. The plan must include: • promotion and development of effective alternatives to an inpatient admission, including provision through social care and education; • rapid and appropriate access to therapeutic support on the inpatient...
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
Karen Sutton
The immunology team was not notified of the patient's hospital admissions, preventing their input into care and discharge. The patient was also discharged without prophylactic antibiotic medication due to a lack of a Trust-wide policy for inter-departmental admission sharing.
Matched on
terms: care, discharge
PFD report
69match
Norma Sheppard
The coroner noted considerable confusion regarding Mrs Sheppard’s discharge terms, with the written discharge letter indicating continued subcutaneous fluids while the understanding upon discharge was that she would not receive them. This discrepancy created difficulties in finding a suitable care home.
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
GIRFT recommendation
69match
Urology
Improve the secondary care pathway for patients with urinary tract stones. 9A: Providers to deliver effective conservative treatment and follow-up to reduce the need for emergency readmissions and surgical intervention, by: • providing specific stone clinics to offer conservative treatment; • providing timely follow-up to patients discharged with stones still in situ; • providing timely readmission for definitive...
Matched on
terms: care, discharge
GIRFT recommendation
69match
Respiratory Medicine
Optimise care for patients with chronic obstructive pulmonary disease (COPD) to reduce length of stay, readmission rates, and overall mortality by using discharge bundles. Where demand exists, consider implementing seven-day services. a) Ensure a named respiratory consultant is appointed as a clinical lead for COPD, with this leadership responsibility reflected in their job plan. b) Consider implementing seven-day...
Matched on
terms: care, discharge
GIRFT recommendation
69match
Cranial Neurosurgery
Address delayed inter-hospital transfers and discharge by increasing the rate of discharge to home for non-elective cranial neurosurgery procedures, ensuring a timely transfer to rehabilitation centres for major procedures, and timely repatriation to referring hospitals. 12A: Trusts to implement seven-day ward rounds and increase engagement with physiotherapy, to enable faster discharge, including weekend discharge. 12B: GIRFT Hubs to...
Matched on
terms: care, discharge