The Health Services Safety Investigations Body (HSSIB) has published an investigation into how communication failures at hospital discharge can lead to serious patient safety risks.

The report makes national recommendations but also includes local-level learning prompts to help NHS organisations identify and address risks in their own systems. These relate to the creation, sending, receipt, and actioning of discharge correspondence.

Key findings include:

• Harm caused by delayed or incomplete follow-up care after discharge.
• Discharge summaries not always reaching all care providers who need them.
• Poor interoperability between systems and lack of oversight across care pathways.
• Discharge planning that doesn’t reflect local system constraints or pressures.
• Lack of training for clinicians on writing safe, user-centred discharge correspondence.

You can read the full report and access the local learning prompts here: Workforce and patient safety: electronic communications on patient discharge from acute hospitals