A man who became "delirious" after surgery took his own life in a bathroom at Liverpool Heart and Chest Hospital.
Brian Jackson, 64, died on July 23, 2020, seven days after undergoing a major heart operation at the specialist hospital in Broadgreen.
The surgery went well and Mr Jackson spent the next few days in the hospital's Post-Operative Critical Care Unit to recover.
READ MORE: Mum's 'tingling ankle' led to devastating diagnosis
But the warehouse team leader, of Rothesay Close, St Helens, began developing worrying psychological symptoms including confusion, agitation, severe paranoia and anxiety.
On the day of his death he was transferred to the hospital's Cedar Ward, and just a few hours later locked himself in a bathroom where he was found unresponsive.
An inquest on July 14 this year heard Mr Jackson's sudden psychological issues should have been recognised as Postoperative Delirium (POD), a problem which can occur particularly in older people after surgery.
Mr Jackson's death has now resulted in the issuing of a Regulation 28 notice, also known as a Report to Prevent Future Deaths, by David Lewis, assistant coroner for Liverpool and Wirral.
Mr Lewis issued the notice to the National Institute for Health and Care Excellence (NICE) after it refused to look at changing its guidance around a tool used to diagnose delirium, known as CAM-ICU.
He wrote that despite assessing Mr Jackson using that tool, staff at Liverpool Heart and Chest Hospital concluded he was not delirious.
Mr Lewis wrote in his report: "On a number of occasions the Deceased 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 cocktail of presentational symptoms to be taken into account."
Mr Lewis said he was told by senior hospital staff that their own investigations into the incident had revealed "shortcomings" in the CAM-ICU tool when assessing patients who appear paranoid but do not otherwise meet its criteria for delirium.
Doctors at the hospital recommended to NICE that changes be made to the CAM-ICU tool.
But Mr Lewis wrote that NICE refused to make any changes as the tool had "only recently been reviewed" in 2019 and "is not to be reviewed again for some time."
He said: "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."
A spokeswoman for Liverpool Heart and Chest Hospital said: "The Regulation 28 was issued for National Institute for Health and Care Excellence (NICE).
"Liverpool Heart and Chest Hospital NHS Foundation Trust continues to strive to improve the treatment of delirium for patients."
A NICE spokesperson said: “Our guideline on the prevention, diagnosis and management of delirium states that if indicators of delirium are identified, a clinical assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria or short Confusion Assessment Method (CAM) should be carried out to confirm the diagnosis.
"In critical care or in the recovery room after surgery, CAM-ICU should be used.
"The guideline says a healthcare professional who is trained and competent in the diagnosis of delirium should carry out the assessment.
"When contacted by the Liverpool Heart and Chest Hospital, NICE informed them we had published a surveillance review which said we are planning to update our guideline.
"This update will focus on the risk assessment and diagnosis of delirium, including in ICU settings."
Receive newsletters with the latest news, sport and what's on updates from the Liverpool ECHO by signing up here
