Electronic communication failures lead to patient harm, finds report
- 21 July 2025
- An HSSIB investigation found that electronic communication following a hospital discharge is leading to patient harm
- The report cites lack of integration and collaboration between primary, community and secondary care providers
- HSSIB recommends that DHSC sets expectations for NHS healthcare providers to ensure continuity of patient care after hospital discharge
A report from the Health Services Safety Investigations Bureau (HSSIB) has found that patients are coming to harm due to failures in the electronic communication of critical clinical information following hospital discharge.
The investigation, published on 10 July 2025, says that essential details about diagnoses, medications and necessary follow-up care are often delayed, incomplete or missed, leading to instances of harm for patients, including fatalities.
Nick Woodier, senior safety investigator at HSSIB, said: “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.”
He added that the NHS 10 year health plan emphasises the importance of ensuring that 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,” Woodier said.
The investigation found that electronic systems used for discharge summaries are often poorly configured, increasing the potential for errors. In some cases, summaries are sent before care has concluded, meaning that they contain outdated or incorrect information.
HSSIB recommends that the Department of Health and Social Care (DHSC) should focus on “establishing standards for access to high-quality, safety-critical information that can be contextualised to match local systems’ needs” and that expectations are set for NHS healthcare providers to ensure continuity of patient care after hospital discharge.
It also suggests actions for integrated care boards to bolster collaboration and recommends learning prompts to help local staff address patient safety concerns.
A spokesperson for DHSC told Digital Health News: “It is unacceptable that patients suffer harm while attempting to be discharged from hospital and our thoughts are with those who have been affected.
“Our 10 year health plan will transform the NHS and bring it into the 21st century. We are simplifying the systems intended to improve care and safety – merging organisations, clarifying remits and strengthening powers.
“This will lift the bureaucratic burden to boost the quality of care and put patient experience at the heart of the NHS.
“Crucially, we will also harness the power of technology as part of a fundamental shift from analogue to digital and make the NHS App the digital front door to the NHS.
“This will be underpinned by a single patient record ensuring seamless care for everyone – whether in a health setting or at home – which all healthcare staff will have access to no matter where they are.”
A previous HSSIB report, published in July 2024, found that patient safety incidents relating to the use of GP online consultation tools had been underreported.
