Our latest report sets out an investigation focused on the risks associated with the electronic discharge summary – the primary tool for transferring clinical information about patients from hospitals to primary and community care. We found vital information about diagnoses, medications, and necessary follow-up care is often delayed, incomplete, or missed altogether, leading to incidents of patient harm after hospital discharge.
Examples in the report include:
- A patient had a bile duct procedure, and the discharge summary did not include information about the procedure after they left hospital. The patient went to the GP because of ongoing pain but the GP was unaware of the details of the procedure. The patient died of pancreatitis which is a complication of bile duct procedures.
- A patient who had recently been discharged from hospital was administered insulin by a community nurse. The nurse did not realise that the patient’s insulin regimen had changed during their hospital stay. The patient became unresponsive and needed to be readmitted to hospital.
Patient and family experience
Patients and families met with HSSIB to share stories and experiences of care not being followed up and the impact this had on them.
Family members described the “devastating” impact, “suffering” and “ongoing trauma” associated with these experiences – the level of which was hard to capture in the report fully. Some families had said they had to “battle” to access that care which prevented them from spending quality time with their loved ones in their last weeks.
Where people had come to harm, several patients and families described feeling that their experiences were unheard by organisations and actions had not been taken to improve care; they therefore felt their “suffering means nothing”.
The report highlights how gaps in the coordination between hospitals, GPs, pharmacies, and community care providers are contributing to unsafe transitions. Discharge processes often fail to take into account the complexity and constraints of the local health and care system, resulting in follow-up actions not being carried out or completed within expected timeframes.
Key findings
Key findings include:
- Documented cases of patient harm where critical follow-up actions were not undertaken due to poor discharge communication.
- Lack of interoperability between IT systems, leading to missed, delayed, or lost clinical information.
- Discharge summaries not reaching all providers responsible for ongoing care, and sometimes not reaching patients themselves.
- No clear accountability for the safety of patients in the early post-discharge period.
- Normalisation of poor-quality discharge communication, with limited regulatory oversight of cross-provider pathways.
- Insufficient education and training for clinical staff on how to write effective, user-centred discharge correspondence.
The investigation also found that electronic systems used to generate and send discharge summaries are often poorly designed or configured, increasing the potential for errors. In some cases, discharge summaries are generated and sent before care has concluded, meaning they contain outdated or inaccurate information.
Safety recommendations
The report concludes with recommendations to the Department of Health and Social Care (DHSC). One is focused on providing standards to support access to high quality safety critical information that takes account of the complexity of local systems. The other is aimed at setting expectations for NHS healthcare providers to enable them to deliver continuity in patient care after discharge from hospital.
We have also suggested actions for integrated care boards (ICBs) and included comprehensive learning prompts in the report to help staff at a local level respond to patient safety concerns.
Investigator’s view
Nick Woodier, Senior Safety Investigator, said: “We heard throughout the investigation about the distressing impact on patients and families when care is not followed up. One thing we have heard from several families is that when there are gaps in information, they are left to take on responsibility of ensuring the right information is communicated to the right place for their loved ones. They felt they didn’t have support from healthcare organisations. This is a heavy burden to carry, especially if someone has complex health needs.
“The main issues stem from discharge planning not considering the organisation of the local health and care system, alongside a lack of integration – as evidenced by the limited collaboration between primary, community and secondary care – and IT systems not passing information seamlessly along. These factors make continuity of care challenging. Staff we spoke to within the NHS have expressed that it is difficult and stressful to make decisions based on incomplete information, which hinders their ability to deliver the highest standard of care.
“The recent publication of the 10 Year Plan emphasises how important it is to ensure digital systems and electronic communications are invested in and fit for future delivery. Our report is specifically calling for stronger oversight and accountability to ensure critical information is reliably communicated, supporting a safe discharge process for patients needing vital follow up care.”
Related articles
Failing to communicate: challenges with electronic communication systems
Read article
Electronic patient record systems: recurring themes arising from safety investigations
Read article
