Two hospital trusts warned over communication after woman dies because of infected pacemaker site
Two hospital trusts have been warned over communicating properly, following the death of a woman who used a pacemaker.
Honoria Culshaw, who lived in Stockport, but was originally from Preston, died aged 79 from pneumonia which she developed following treatment for sepsis, which originated from an infected pacemaker site.
Delays in removing the pacemaker - inline with international clinical guidance - were caused by a referral not being communicated by Wythenshawe Hospital to either Royal Preston or to Mrs Culshaw’s GP. Now a Prevention of Future Deaths Report has been compiled by Anna Morris KC, Assistant Coroner for Greater Manchester South, who is concerned there is a risk that future deaths will occur unless action is taken.
The background
Mrs Culshaw had a pacemaker fitted in 2013 to support her heart function. In November 2023 the pacemaker’s batteries were replaced in a surgical procedure. In March 2024, Mrs Culshaw presented to her GP with signs of infection at the site of the surgical wound, then in July 2024, she presented to Wythenshawe Hospital with an opening of her wound. A Consultant Cardiologist at Wythenshawe said that international clinical guidance indicates that any opening of an implantation scar should be interpreted as a sign of systemic infection of the wound and that extraction and replacement of the pacemaker should follow in order to remove the infection.
This was the advice of the on-call Cardiologist at Wythenshawe on the July 10, 2024, to the Emergency Department medical team. Although Wythenshawe is one a limited number of specialist surgical centres for the extraction of pacemakers, Mrs Culshaw was not admitted to Wythenshawe Hospital, but discharged to the care of Royal Preston Hospital, where her pacemaker had been fitted. Royal Preston Hosptial is not a specialist surgical centre for pacemaker extraction.
Referral not communicated
Coroner Morris said: “The expectation of Wythenshawe Hosptial at the time of her discharge appears to be that Royal Preston would refer her back to Wythenshawe for extraction. However, the need for extraction and therefore a referral was not communicated by Wythenshawe to either Royal Preston or to Mrs Culshaw’s GP. It is not clear that it was adequately explained to Mrs Culshaw’s family.
“Mrs Culshaw re-presented at Wythenshawe on the 9th September, again with signs of infection and underwent an extraction procedure as an inpatient on the 16th September 2024. However, I found that her experienced of persistent and prolonged infection depleted her physiological reserve and contributed to her succumbing to a fatal pneumonia on the 25th October 2024.”
“I am concerned that this lack of information sharing along a communication pathway between the Cardiology department and specialist surgical extraction team at Wythenshawe and the Cardiology departments at local treating hospitals risks such referrals being delayed or not being made at all, as happened in the present case.”
What happens now?
The report has been sent to both Manchester University NHS Foundation Trust and Lancashire Teaching Hospitals, who have a duty to respond by November 19. Their response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise they must explain why no action is proposed.
Lancashire Teaching Hospitals
A Lancashire Teaching Hospitals spokesperson said: “The Trust would like to offer its sincere condolences to the family and friends of Honoria Culshaw. We welcome the independent scrutiny of the Coroner and are committed to providing assurance around our processes and to adopt any learning from the inquest and our own investigations.”
Manchester University NHS Foundation Trust
A spokesperson for Manchester University NHS Foundation Trust said: “We wish again to offer our sincere condolences to Mrs Culshaw’s family and friends for their loss. We are committed to providing the highest standards of care and will be reviewing the Coroner’s concerns carefully. Any learning identified will be addressed and applied as part of our ongoing work to improve patient safety, quality of care, and experience.”