Liverpool Heart and Chest Hospital

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First report 12 May 2021•Latest report 16 Jul 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Liverpool Heart and Chest Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Liverpool and the Wirral

    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. The report was sent to Liverpool Heart and Chest Hospital; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liverpool Heart and Chest Hospital; that does not assign responsibility.

    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. ”
    Open source report

  2. Manchester South

    AI-generated summary

    MARY ANNE MELLOR · 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

    Mary Anne Mellor died at Stepping Hill Hospital from a ruptured thoracic aortic aneurysm caused by a leak from an aortic stent. The leak was not identified on CT scans in 2019 and 2020 because 3D reconstruction was not used. Concern remained that other patients with aortic stents could be at risk of leaks not being identified, potentially depriving them of elective surgical management before life-threatening complications 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. The report was sent to Liverpool Heart and Chest Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure use of 3D reconstruction when reporting aortic stent surveillance CT scans

    Wider context from the report

    “(1) Following a thorough investigation, I HCH recognised that the leak was not identified on the CT scans in 2019 and 2020 because 3D reconstruction was not used when they were reported. LHCH have amended their reporting protocol for aortic stent surveillance accordingly and requested that Medica, who continue to report such scans for LHCH, do the same. However, as of the date of the inquest, LHCH had received no response from Medica and could not assure me that Medica are using 3D reconstruction to report this type of scan and/or intend to do so in future. (2) I am therefore concerned that other patients at LHCH with aortic stents remain at risk of leaks not being identified, potentially depriving them of elective surgical management before life threatening complications occur. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026