Home Safe and Sound: Effective Hospital Discharge highlighted 16 cases where Welsh hospitals fell short when discharging patients.
The report found examples of:
The Ombudsman said that, while he did not consider the cases to be typical of the services provided by the NHS in Wales, it was important that lessons were learnt from them.
He has suggested a number of areas for future consideration, including training for medical staff, senior doctor involvement in the discharge process where appropriate, better communication between and within primary and secondary care organisations, and appropriate assessment to put the patient at the centre of the discharge process.
Commenting on the report, Public Services Ombudsman for Wales, Nick Bennett, said:
“Leaving hospital can be a difficult and emotional process for a patient and it is imperative that discharge from hospital is conducted safely and that the right guidance is followed.
“The cases in my report, while not typical of everyday service in our hospitals, are alarming, and have resulted in unnecessary suffering.
“I would encourage all health boards to read this report and ensure lessons are learnt so other patients do not have to endure the same experience.”