HSSIB investigation report: Workforce and patient safety: electronic communications on patient discharge from acute hospitals (10 July 2025)

Summary

This Health Services Safety Investigations Body (HSSIB) investigation explored the patient safety risks associated with the communication of critical clinical information when patients are discharged from acute hospital inpatient settings, and the follow-up of ongoing actions for patients by primary and community care.

Discharge from hospital represents a transition of care from one provider (the hospital) to others (such as general practice, pharmacy and/or community care). To support patient safety, critical clinical information about the patient needs to flow between providers to ensure care after discharge is timely and appropriate. The main method for communicating information on discharge from hospitals is the electronic discharge summary. This provides an overview of why the patient was in hospital, what happened during the admission, and plans for their ongoing care.

This investigation considered communication processes between providers on discharge of patients from hospital, and how the use of electronic correspondence impacts on these processes. If critical clinical information is not communicated effectively at transitions of care, patients may come to harm by missing or receiving incorrect care. Patients and healthcare staff described multiple incidents of harm following discharge because of problems with the communication of information.

Content

Findings

• Patients are coming to harm where follow-up actions are needed after discharge from hospital and discharge planning has not accounted for constraints and challenges in the local health and care system (referred to here as ‘the local system’). This means actions are not always undertaken or completed within expected timeframes.
• A lack of integration – as evidenced by limited collaboration between primary, community and secondary care providers – contributes to discharge planning and communications that do not always ensure patients receive continuity in their care.
• Risks to patient safety associated with the quality and timeliness of discharge correspondence, most notably the discharge summary, have been “normalised”. There is unclear accountability for the safety of patients early after discharge.
• The current regulatory approach for inspection of care quality does not lend itself to effective scrutiny of cross-provider pathways, such as transitions of care between providers.
• Oversight mechanisms in providers and integrated care boards do not always exist or function to ensure that end-to-end discharge communication is achieved through the creation, sending, receipt and actioning of correspondence.
• A lack of interoperability between IT systems within and across providers means information does not pass seamlessly, increasing the risk of information being lost, delayed or missed.
• The design/configuration of the parts of electronic patient record for correspondence, including discharge summaries, can introduce the potential for errors and does not always support staff to create, send and process correspondence.
• Discharge correspondence may not be accurate in scenarios where patients continue to receive care in hospital after discharge correspondence has been sent.
• Discharge summaries are not actively sent to, or accessible to, all the providers of ongoing care who need to know the clinical information they contain.
• The content of discharge correspondence, including discharge summaries, does not always meet the information needs of recipients to ensure safety-critical actions for a patient’s ongoing care are handed over, understood and achieved.
• Medical staff writing discharge summaries recalled no specific education on the writing of user-centred and safe discharge correspondence during undergraduate and postgraduate education.
• The availability of discharge correspondence in different systems, for example shared care records, varies across the country with limited opportunities for primary and community care staff to access it via other routes if correspondence has not arrived.
• Patients do not always receive a copy of their discharge summary which removes this ‘backup’ option for providers to access information. It also means patients do not have information to support their own understanding of their care needs.

HSSIB makes the following safety recommendations

Safety recommendation R/2025/065:

• 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, and that can be contextualised to local system needs.

Safety recommendation R/2025/066:

HSSIB recommends that the Department of Health and Social Care, through its future strategic and policy programmes, sets specific expectations for NHS healthcare providers to ensure that:

• high-quality safety-critical information about patients is accessible after discharge, and
• processes exist to complete safety-critical actions for ongoing patient care within required timeframes.

This is to enable providers to deliver continuity in patient care after discharge from hospital.

HSSIB makes the following safety observation

Safety observation O/2025/074: 

Primary, community and secondary healthcare providers can improve patient safety by working collaboratively to recognise and mitigate local system challenges and constraints that prevent the:

• communication of high-quality safety-critical information about patients
• completion of actions for ongoing patient care within required timeframes.

HSSIB suggests safety learning for Integrated Care Boards

HSSIB suggests that integrated care boards support collaboration between primary, community and secondary care providers across their local systems to:

• jointly validate the quality of discharge correspondence
• plan for the constraints and challenges faced by different parts of their local systems
• assure themselves that risks to patient safety on discharge from hospital are mitigated as far as is practicable.

Local-level learning prompts

HSSIB investigations include local-level learning where this may help providers/organisations and staff to identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has identified learning to help consider and mitigate risks around creating, sending and processing discharge correspondence.

For providers creating and sending discharge correspondence

• How does your organisation ensure staff recognise discharge correspondence as safety-critical information for the clinical handover of care?
• Do your staff know who are the recipients of and users of your discharge correspondence, particularly discharge summaries?
• How does your organisation know that its correspondence meets the needs of those receiving and acting on the information?
• How does your organisation ensure important information about medication changes are reliably and accurately described in discharge correspondence?
• How does your organisation support staff to ensure the contents of discharge correspondence meets the needs of all likely recipients and is of high quality?
• How does your organisation know that all required discharge correspondence is reliably produced, sent and received by all necessary recipients, not just GPs?
• How does your organisation ensure patients and their families/carers (if appropriate) are given an accessible copy of any discharge correspondence?
• How does your organisation ensure discharge correspondence is updated if a patient has further clinical input after the correspondence was written?
• Do your staff recognise that capacity and resource issues in primary and community care mean time-critical actions after discharge may be delayed or unable to be actioned?
• How does your organisation support staff to communicate time-critical actions to providers of ongoing care so they are undertaken within the required time?
• Does your organisation have pathways for primary and community care to troubleshoot incomplete or ambiguous information in discharge correspondence?
• How does your organisation involve staff in the development and testing of EPR templates to ensure they are easy to use and do not contribute to incidents?
• Does your organisation include digital and clinical input in the training of staff to write discharge correspondence to help them understand what ‘good’ looks like?

For providers receiving and processing discharge correspondence

• Does your organisation have processes for identifying and prioritising safety and time-critical actions requested by secondary care?
• How does your organisation manage seemingly ‘duplicate’ correspondence to ensure it is not an updated version with further information or actions?
• Does your organisation have processes for effectively feeding back concerns and incidents to secondary care when discharge communications do not meet your needs?
• How does your organisation involve staff in the development and testing of software and processes to ensure they are easy to use and do not contribute to incidents?
• How does your organisation assure your internal processes for the administration of correspondence to ensure thoroughness of review while looking to be efficient?