Poor Hospital Discharge Summaries Putting Patients in Danger

Vital information about diagnoses, medications, and follow-up care is often delayed, incomplete, or missed altogether when patients are discharged from hospital, an investigation has found.

The Health Services Safety Investigations Body (HSSIB) said that electronic communication systems in the NHS are failing to support safe hospital discharge.

The electronic discharge summary is the primary tool in the NHS for transferring clinical information from hospitals to primary and community care. 

Under the NHS eDischarge Summary Standard, hospitals should provide standardised clinical details that can be extracted directly into GP IT systems. 

However, the HSSIB found gaps in coordination between hospitals, GPs, pharmacies, and community care providers that were 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,” the report said.

Cases of Patient Harm

Key findings from the investigation included:

• Documented cases of patient harm where critical follow-up actions were not undertaken due to poor discharge communication.
• Poor interoperability between IT systems, causing delays or loss of information.
• Discharge summaries not reaching all care providers, or even patients.
• No clear accountability for the safety of patients in the early post-discharge period.
• A “normalised” risk culture around poor discharge communication.
• Inadequate training for medical staff on writing effective discharge documents.

In one case, a discharge summary left out details of a bile duct procedure. The patient later died of pancreatitis after the GP, unaware of the surgery, failed to act when the patient presented with ongoing pain.

In another case, a community nurse administered insulin based on outdated instructions. The patient became unresponsive and was readmitted to hospital.

Patients and Families Carry the Burden

Patients and families described their experiences to the HSSIB as distressing and, in some cases, traumatic.

Some families described losing precious time with loved ones due to delays in care. Others were upset that that no one took responsibility or acknowledged the harm caused.

Nick Woodier, HSSIB senior safety investigator, said families often had to act as the main communicators between services.

“This is a heavy burden to carry, especially if someone has complex health needs,” he said.

Poor IT Design and Rushed Processes

The investigation also found that the IT systems used to generate discharge summaries were often poorly designed or configured, increasing the potential for errors. In some cases, summaries were sent before care had concluded, resulting in outdated or inaccurate information being passed on.

Woodier said that poor planning and a lack of understanding of local health and care systems were key factors.

NHS staff told the HSSIB that it was “difficult and stressful to make decisions based on incomplete information”, and that this hindered their ability to deliver the highest standard of care.

The HSSIB called for better oversight and clearer accountability to ensure essential clinical information is shared accurately and on time.

Woodier said that digital systems need further investment to ensure they are reliable and fit for the future.

Dr Sheena Meredith is an established medical writer, editor, and consultant in healthcare communications, with extensive experience writing for medical professionals and the general public. She is qualified in medicine and in law and medical ethics.