Honoria Culshaw · Prevention of Future Deaths report

On the 19th December 2024, I commenced an investigation into the death of Honoria Culshaw. On the 11th September 2025 I heard the inquest touching on her death. On that date I returned a narrative conclusion as follows:

The deceased died from pneumonia which she developed following treatment for sepsis which originated from an infected pacemaker site. Her underlying cardiac and immunological conditions contributed to her deterioration following necessary surgery on the 16th September 2024 to extract her pacemaker and made it more likely that she would contract a fatal pneumonia.

Mrs. Culshaw attended Wythenshawe Hospital on the 10th July 2024 and presented with an opening of her pacemaker scar. I heard evidence at the inquest from ████████, a Consultant Cardiologist at Wythenshawe 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 10th July 2024 to the Emergency Department medical team. I heard evidence that Wythenshawe is one of 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 Hospital is not a specialist surgical centre for pacemaker extraction. I heard that the decision of the Consultant Cardiologist at Royal Preston was to re-position, rather that extract the pacemaker.

I heard evidence that on the 15th August 2024, a swab from the pacemaker wound tested positive for the Morganella Morganii bacteria, which was also found post-mortem. It is not clear from the evidence who on the surgical team was made aware of this result, and whether it was properly taken into consideration as part of the pre-operative risk assessment. Mrs. Culshaw had her pacemaker re-sited on the 20th August 2024.

I found that Mrs. Culshaw’s experience 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 of test results, which in this case may have resulted in an extraction process not taking place at the earliest opportunity.