Background Hospital teams must plan a safe and effective transfer of care for patients returning home in the last days of life. To support this Leeds Teaching Hospitals NHS Trust (LTHT) launched a revised Rapid Discharge Plan (RDP) in January 2014.

Aim To assess the quality of transfer of care (ToC) for patients returning home from LTHT who died within a week of discharge (June 2014 – May 2015).

Methods A convenience sample of 45 patients was selected from a database of 228. Clinical notes were reviewed for recognition of dying (prognosis days) pre-discharge, RDP use, and evidence of eight key interventions necessary for a successful ToC.

Results Median survival from discharge was 4 (1–7) days. Thirty-one (69%) had a progressive life-limiting illness and 12 (27%) had multi-morbidity/frailty.

Twenty-five patients (56%) were recognised to be dying. Key interventions took place for the majority, including: advance care planning (ACP) (96%), Fast Track discharge (92%), anticipatory prescribing (88%) and do not attempt cardiopulmonary resuscitation form (DNACPR) (84%).

The RDP was used in 11 (44%) of those recognised to be dying. The RDP patients had a median of six (5–8) key interventions compared to four (1–5) for those without an RDP.

Eight (18%) were perceived to be in the last weeks to months of life and twelve (27%) were not recognised to be approaching the EoL at all. Ten (83%) of those not recognised to be near the EoL had multi-morbidity/frailty, whereas 29 (87%) of patients in the other two groups had a life-limiting illness. The majority (73%) of those not recognised had two or more markers of deteriorating health.

Conclusion Appropriate planning occurred for the majority of patients recognised to be dying. This was enhanced by use of the RDP. Recognition is a barrier to planning; particularly in those with multi-morbidity and frailty.