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Investigation and inquest
On 15/03/2019 I commenced an investigation into the death of Geoffrey Duke. The investigation concluded at the end of the inquest 14th May 2019. The conclusion of the inquest was: The deceased had a history of asthma and diabetes. He was allergic to penicillin. Following complete heart block a pacemaker was fitted in 2007. He underwent routine box change at Good Hope Hospital, Birmingham on the 15th June 2016 requiring an additional lead. He became unwell and was treated at Good Hope in February 2017 with a diagnosis of bronchopneumonia. He was unwell again and treated at Burton Queens Hospital in August 2017 with a diagnosis of sepsis of unknown source. No consideration was given on either occasion to the possibility of the pacemaker as the source of infection. He was readmitted to Burton Queens Hospital on the 16th October 2017. An echocardiogram on the 18th October 2017 found significant vegetation on the pacemaker wires. It is likely that the infection had occurred at the time of the pacemaker box change and that he had been suffering with undiagnosed endocarditis for some months. He was transferred to the Royal Stoke University Hospital, Stoke-on-Trent on the 1st December 2017. Whilst awaiting pacemaker wire extraction he was treated with antibiotics which caused a skin reaction. Tests showed the vegetation had increased in size. He became very unwell and surgery was carried out on the 5th December 2017. During surgery a small amount of pacemaker insulation stripped off and remained adherent to the left subclavian vein. Five days post operatively he deteriorated with signs of a severe drug reaction likely due to the vancomycin treatment. His drugs were changed. He continued to deteriorate and died at the hospital at 9.36 pm on the 20th December 2017.
Circumstances of the death
See above.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
Mr. Duke underwent pacemaker box change on 15th June 2016. He was subsequently unwell on a number of occasions. He visited Good Hope Hospital on 6th February 2017, his GP on a number of occasions and Burton Queens Hospital in August 2017. No consideration appears to have been given that the pacemaker box change may have been the source of his undiagnosed infections. No referral was made to a Cardiologist. His problem was diagnosed on his first admission on 27th October 2017. At inquest there was no evidence of a referral process for patients having undergone pacemaker surgery who subsequently become unwell.
