Recurring concern

Failure to reliably recognise and manage delirium

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First reported 16 Jul 2021•Latest report 7 Nov 2025

Definition

What this concern includes

Includes failures of controls specifically dedicated to delirium recognition and management, including assessment and diagnostic tools, clinical guidance, staff recognition, communication of symptoms and risks to carers or clinicians, discharge planning and safety-netting.

Not included

Excludes generic diagnostic, communication, training or discharge deficiencies that are not explicitly tied to delirium.
Excludes recognition or management failures concerning dementia, psychosis, excited delirium or other conditions unless the report explicitly identifies delirium as the shared concern.
Excludes general postoperative or acute-deterioration failures where delirium-specific recognition or management is not materially deficient.

Reports: 3
Individual concerns: 6
Date range: 2021–2025
Stated actions: 6

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

East Kent Hospitals University NHS Foundation Trust1

John Radcliffe Hospital1

Liverpool Heart and Chest Hospital1

MK Together Partnership1

National Institute for Health and Care Excellence1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

7 Nov2025
Kent and Medway
Concerns raised2
1. Failure to provide carers with guidance on recognising and responding to delirium symptoms
2. Failure to communicate relevant delirium risks and behavioural history to carers
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Review and make the Delirium leaflet accessible on the Trust intranet.
  Stated by East Kent Hospitals University NHS Foundation TrustStated completed
2. Action
  Share the Delirium leaflet with families and carers at discharge.
  Stated by East Kent Hospitals University NHS Foundation TrustStated planned
3. Action
  Request and develop IT record changes to distinguish carers from next of kin.
  Stated by East Kent Hospitals University NHS Foundation TrustStated in progress
1. Action
  Establish and operate a Carer Champion post supporting carer identification and involvement in discharge discussions.
  Stated by East Kent Hospitals University NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  The patient’s subsequent aggression was not predicted because there was no previous evidence of aggression.
  Stated by East Kent Hospitals University NHS Foundation TrustDisputes the concern
AI-generated summary

Ernest Roy Gray · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ernest Roy Gray was admitted to hospital after a myocardial infarction and developed hyperactive delirium and heart failure, with episodes of agitation and aggression. He was discharged home while still confused and later became unwell, was admitted to hospital, developed pneumonia, and died on 24 November 2023. Concerns included failure to involve his partner in discharge planning, inadequate holistic discharge planning and communication, and insufficient information about the possible fluctuating and aggressive manifestations of his delirium and what to do if symptoms occurred.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide carers with guidance on recognising and responding to delirium symptoms
Wider context from the report
“(3) Mr. Gray’s daughter was informed two days before the discharge that he had hyperactive delirium and that it would resolve itself but could take a few weeks. She was not made aware that Mr. Gray had at times been agitated and violent in hospital, nor was she told that although the hyperactive delirium was resolving it could fluctuate because it was likely triggered by a metabolic cause (renal function), heart failure or myocardial infarction. Neither she nor Mr. Gray’s partner were informed as to how symptoms may manifest or what to do if Mr. Gray was symptomatic. Had they known that Mr. Gray may become aggressive or violent to others particularly his carers, an early discharge would not have been encouraged ”
Source location
Ernest Roy Gray · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate relevant delirium risks and behavioural history to carers
Wider context from the report
“(3) Mr. Gray’s daughter was informed two days before the discharge that he had hyperactive delirium and that it would resolve itself but could take a few weeks. She was not made aware that Mr. Gray had at times been agitated and violent in hospital, nor was she told that although the hyperactive delirium was resolving it could fluctuate because it was likely triggered by a metabolic cause (renal function), heart failure or myocardial infarction. Neither she nor Mr. Gray’s partner were informed as to how symptoms may manifest or what to do if Mr. Gray was symptomatic. Had they known that Mr. Gray may become aggressive or violent to others particularly his carers, an early discharge would not have been encouraged ”
Source location
Ernest Roy Gray · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review and make the Delirium leaflet accessible on the Trust intranet.

Verbatim wording from the response
“1. Review of the existing Delirium leaflet will be shared as appropriate on patient discharge. This leaflet has been reviewed and is easily accessible on the Trust intranet. A hard copy will be handed out to families/carers for information.”

Source location
Response from East Kent Hospitals University NHS Foundation Trust
Page 3 · response
Published 14 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share the Delirium leaflet with families and carers at discharge.

Verbatim wording from the response
“1. Review of the existing Delirium leaflet will be shared as appropriate on patient discharge. This leaflet has been reviewed and is easily accessible on the Trust intranet. A hard copy will be handed out to families/carers for information.”

Source location
Response from East Kent Hospitals University NHS Foundation Trust
Page 3 · response
Published 14 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Request and develop IT record changes to distinguish carers from next of kin.

Verbatim wording from the response
“1. We have requested IT record changes to correctly identify the carer(s) involved so they can be involved in appropriate discussions and decisions. Our current IT systems do not allow us to differentiate ‘carer’ from ‘next of kin’ (they can be different as was the case with Mr Gray). We recognise that this will be key in clearly identifying the carer for future discharge conversations so we have raised this urgently with the Sunrise team to investigate. The request has been made and is being prioritised.”

Source location
Response from East Kent Hospitals University NHS Foundation Trust
Page 2 · response
Published 14 November 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish and operate a Carer Champion post supporting carer identification and involvement in discharge discussions.

Verbatim wording from the response
“3. We have allocated an experienced discharge advisor to a new Carer’s Champion post. This individual has been identified, and they commenced their role in early January. They will support the ward multi-disciplinary teams to identify the patient’s carer and ensure that the carer themselves is involved in the discharge discussions from early in the admission.”

Source location
Response from East Kent Hospitals University NHS Foundation Trust
Page 2 · response
Published 14 November 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The patient’s subsequent aggression was not predicted because there was no previous evidence of aggression.

Verbatim wording from the response
“While a therapy assessment appointment had been arranged to attend Mr Gray’s home following discharge, this unfortunately did not take place in time to prevent the tragic death of his partner. It is a common occurrence that patients are discharged with ongoing confusion, and it is recognised that this will often be eased, by being in familiar surroundings. There had been no previous evidence of any aggression in Mr Gray, and the tragic events that followed were absolutely not predicted.”

Source location
Response from East Kent Hospitals University NHS Foundation Trust
Page 3 · response
Published 14 November 2025
Open published response
7 Jun2023
Milton Keynes
Concerns raised2
1. Failure to highlight delirium symptoms to the GP
2. Failure to educate relatives about the possibility of delirium
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David WOOD · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

David Wood had recently undergone open heart surgery and was suffering from depression and difficulty sleeping after discharge from hospital. On 22 June 2022, he was found suspended by the neck at his home. A review identified concerns about communication of possible delirium to his GP and wife, discharge planning, and the protocols for discharge following heart surgery.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to highlight delirium symptoms to the GP
Wider context from the report
“Following the death of Mr. Wood a review was conducted by the trust and the review recognised that it would have been helpful if the symptoms of delirium had been highlighted to the GP and that it would have been useful if there had been a discussion with Mrs Wood to educate her as to the possibility of delirium, and to help plan his discharge from hospital and inform her when she should seek further medical assistance. The protocols for discharge following heart surgery should be reviewed in order to prevent similar deaths. ”
Source location
David WOOD · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to educate relatives about the possibility of delirium
Wider context from the report
“Following the death of Mr. Wood a review was conducted by the trust and the review recognised that it would have been helpful if the symptoms of delirium had been highlighted to the GP and that it would have been useful if there had been a discussion with Mrs Wood to educate her as to the possibility of delirium, and to help plan his discharge from hospital and inform her when she should seek further medical assistance. The protocols for discharge following heart surgery should be reviewed in order to prevent similar deaths. ”
Source location
David WOOD · Prevention of Future Deaths report
Page 1 · concerns
Open source report
16 Jul2021
Liverpool and the Wirral
Concerns raised2
1. Use of an inadequately effective CAM-ICU tool for delirium assessment
2. Inconsistent recognition and diagnosis of delirium by hospital staff
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Complete the review of guideline CG103 on delirium prevention, diagnosis and management.
  Stated by National Institute for Health and Care ExcellenceStated completed
2. Action
  Update guideline CG103, focusing on delirium risk assessment and diagnosis, including in intensive care settings.
  Stated by National Institute for Health and Care ExcellenceStated planned
AI-generated summary

Brian Jackson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Following major heart surgery, Brian Jackson developed symptoms associated with post-operative delirium and, after transfer to a hospital ward, used a ligature to hang himself in a locked bathroom on 23 July 2020. He died at the scene despite prompt medical attention. Concerns included inconsistent recognition of delirium and reliance on the CAM-ICU assessment tool, which may fail to identify some patients at risk, including those presenting with paranoia or hypoactive symptoms.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Use of an inadequately effective CAM-ICU tool for delirium assessment
Wider context from the report
“Following major heart surgery the Deceased spent a week on the Post-Operative Critical Care Unit, during which he presented intermittently with a range of symptoms which I was told in evidence constituted delirium, but were not consistently recognised or diagnosed as such by hospital staff. These symptoms were variously described as including confusion, agitation, severe paranoia and anxiety. On a number of occasions the Deceased’s was assessed using the tool known as CAM-ICU, which I heard is a nationally recognised diagnostic tool, in widespread use across the country. On each occasion the result was negative for the purpose of delirium diagnosis, contradicting the view expressed in court to the effect that a diagnosis of delirium was appropriate. The hospital had its own policy concerning the management of patients at risk of delirium, the use of which depended in large measure upon a diagnosis being made. My impression was that the CAM-ICU results relied too heavily upon whether the patient was orientated in time and place, without allowing for a more complex cocktails of presentational symptoms to be taken into account. I was told by senior hospital staff that their investigation has revealed shortcomings in the efficacy of the CAM-ICU tool, notably in assessing the risk faced by patients with ‘hypo symptoms’ of delirium, or patients who produce a negative CAM-ICU result but present with evidence of paranoia. I heard details of extensive changes made by the hospital in its local arrangements and also that the hospital had approached NICE to ask if the CAM-ICU tool itself could be modified to take account of the lessons it had learnt in this case. I was told that the response from NICE was that use of the tool (and NICE guidance around this subject) had only recently been reviewed, in 2019, and is not to be reviewed again for some time. I am concerned that across the country an assessment tool remains in widespread use despite the problems identified and is likely to remain so for the indefinite future, meaning that patients at risk of delirium are not diagnosed or treated optimally. The outcome of this cases illustrates the gravity of the harm that can result. ”
Source location
Brian Jackson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inconsistent recognition and diagnosis of delirium by hospital staff
Wider context from the report
“Following major heart surgery the Deceased spent a week on the Post-Operative Critical Care Unit, during which he presented intermittently with a range of symptoms which I was told in evidence constituted delirium, but were not consistently recognised or diagnosed as such by hospital staff. These symptoms were variously described as including confusion, agitation, severe paranoia and anxiety. On a number of occasions the Deceased’s was assessed using the tool known as CAM-ICU, which I heard is a nationally recognised diagnostic tool, in widespread use across the country. On each occasion the result was negative for the purpose of delirium diagnosis, contradicting the view expressed in court to the effect that a diagnosis of delirium was appropriate. The hospital had its own policy concerning the management of patients at risk of delirium, the use of which depended in large measure upon a diagnosis being made. My impression was that the CAM-ICU results relied too heavily upon whether the patient was orientated in time and place, without allowing for a more complex cocktails of presentational symptoms to be taken into account. I was told by senior hospital staff that their investigation has revealed shortcomings in the efficacy of the CAM-ICU tool, notably in assessing the risk faced by patients with ‘hypo symptoms’ of delirium, or patients who produce a negative CAM-ICU result but present with evidence of paranoia. I heard details of extensive changes made by the hospital in its local arrangements and also that the hospital had approached NICE to ask if the CAM-ICU tool itself could be modified to take account of the lessons it had learnt in this case. I was told that the response from NICE was that use of the tool (and NICE guidance around this subject) had only recently been reviewed, in 2019, and is not to be reviewed again for some time. I am concerned that across the country an assessment tool remains in widespread use despite the problems identified and is likely to remain so for the indefinite future, meaning that patients at risk of delirium are not diagnosed or treated optimally. The outcome of this cases illustrates the gravity of the harm that can result. ”
Source location
Brian Jackson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Complete the review of guideline CG103 on delirium prevention, diagnosis and management.

Verbatim wording from the response
“Liverpool Heart and Chest Hospital informed us that they were undertaking a root cause analysis which was considering the ‘CAM/ISITIU – RASS delirium risk assessment’. We advised them that we had recently completed a review of CG103 and that we were going to update the guideline, focusing on the risk assessment and diagnosis of delirium, including in ICU settings. We also advised how they could engage with the development process and send evidence to us for consideration during the update.”

Source location
2021-0246-Response-from-NICE_Published
Page 1 · response
Published 22 July 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update guideline CG103, focusing on delirium risk assessment and diagnosis, including in intensive care settings.

Verbatim wording from the response
“Liverpool Heart and Chest Hospital informed us that they were undertaking a root cause analysis which was considering the ‘CAM/ISITIU – RASS delirium risk assessment’. We advised them that we had recently completed a review of CG103 and that we were going to update the guideline, focusing on the risk assessment and diagnosis of delirium, including in ICU settings. We also advised how they could engage with the development process and send evidence to us for consideration during the update.”

Source location
2021-0246-Response-from-NICE_Published
Page 1 · response
Published 22 July 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to provide carers with guidance on recognising and responding to delirium symptoms

Failure to communicate relevant delirium risks and behavioural history to carers

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to highlight delirium symptoms to the GP

Failure to educate relatives about the possibility of delirium

Concerns raised2

Use of an inadequately effective CAM-ICU tool for delirium assessment

Inconsistent recognition and diagnosis of delirium by hospital staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Actions described in response 4

Respondent positions 1

Actions described in response 2