A report of investigations into unsafe discharge from hospital


After a stay in hospital, it should be a relief to get back to the comfort of your own home. But cases we have seen show that this couldn't be further from the truth for some people. These people have been sent home alone unable to cope. They often end up back in hospital, or stuck in hospital because of delays by other services in arranging support or appropriate residential placements.

As the independent organisation responsible for making final decisions on complaints that have not been resolved by the NHS in England, we see the harrowing impact of poorly managed hospital discharges on individuals and their families.

This report focuses on nine experiences drawn from recent complaints we have investigated, which best illustrate the problems we are seeing. The people that have come to us have been badly let down by the system. How else do we describe the actions of a hospital sending a vulnerable 85 year old woman with dementia home without telling her family, despite being unable to feed herself or go to the bathroom? How else do we describe the tragic story of a woman in her late 90s who was discharged without a proper examination, to then die in her granddaughter’s arms moments after the ambulance dropped her home?

People told us how their loved one’s traumatic experience of leaving hospital, including repeated emergency readmissions, added to their pain and grief. One woman captured the sentiment of many, saying she would be ‘haunted for the rest of her life’ by her mother’s avoidable suffering before her death.

In our 2011 report on NHS care of older people1, we found that discharge arrangements could be ‘shambolic and ill prepared with older people being moved without their families’ knowledge and consent’. It is disheartening that we continue to see these and other failings regularly in the complaints we receive.

People told us how their loved one’s traumatic experience of leaving hospital, including repeated emergency re-admissions, added to their pain and grief.'

We are aware that structural and systemic barriers to effective discharge planning are long standing and cannot be fixed overnight. Above all, these include the need for better integration and joint working of health and social care services, which have historically operated in silos.

Moreover, the need to reduce the mounting financial and logistical costs to the NHS of delayed transfers of care from hospital mean it is a top priority for policy makers and managers.

However, we are publishing these cases to highlight the human costs of poorly planned discharge in terms of patient outcomes and experience, and the untold anguish it can cause their families and carers. These make clear that early discharge without the right support can be just as problematic for people as unnecessary delays.

The people whose stories we tell in our report experienced suffering and distress as a result of poor or absent care. Tragically, some have died and their families want to know what has been learned and what will change as a result of their complaints.

By sharing their stories we want to shine a light on the failings that we have seen and contribute to the national debate about how to improve people’s experience of leaving hospital. In response to important contributions by Healthwatch England and others, the Department of Health has recently established a national programme board to develop a vision for improving discharge that all health and social care services can share. We ask the Department of Health and the NHS as part of their work in this area to establish the scale of the problems we highlight in this report, and to understand why they are happening so that others do not have to experience such avoidable and unnecessary suffering.

Dame Julie Mellor DBE
Chair and Ombudsman, Parliamentary and Health Service Ombudsman

May 2016

1  PHSO (2011) Care and compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people