Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0479, written 24 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Sep 2025 |
|---|---|
| Reference | 2025-0479 |
| Deceased | Honoria Culshaw (1) |
| Coroner | Anna Morris |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Manchester University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Manchester University NHS Foundation Trust 1 CORONER I am Anna Morris KC, Assistant Coroner for the Coroner Area of Greater Manchester South. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner's and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST 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. 4 At the Inquest on the 11th September 2025 I made the following findings: I found that the 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 the deceased presented to her GP with signs of infection at the site of the surgical wound. In July 2024 the deceased presented to Wythenshawe Hospital with opening of her wound. This was likely evidence of a systemic infection arising from the pacemaker site and guidance indicates that consideration should have been given to extracting and replacing the pacemaker to remove the infection. She was advised to attend Royal Preston Hospital, her pacemaker care centre. 1 At the Royal Preston Hospital, a decision was made to manage the wound conservatively by re-siting the pacemaker box and prescribing anti-biotics. On the 15th August 2024 a swab came back positive for Morganella Morganii bacteria. It is not clear on the evidence who on the clinical team was aware of these results before the deceased underwent surgery on the 20th August to reposition her pacemaker. She was prescribed anti-biotics in any event that would have been appropriate to treat this particular bacteria. She was seen by a Consultant Cardiologist on the 3rd September 2024 who observed that the wound was healing and there were no clinical signs of infection. On the 9th September 2024, the Mrs. Culshaw presented again at Wythenshawe with further deterioration of her pacemaker wound and sepsis. She underwent an extraction procedure on the 16th September 2024 to remove the pacemaker and prescribed antibiotics. She completed the course of anti-biotics, but then developed a widespread acute rash, which was probably a reaction to the anti-biotics. She was also found to have suffered a pulmonary embolus, a known complication of pacemaker extraction surgery. Despite appropriate post-surgical interventions and treatment, the deceased’s condition began to deteriorate around the 10th October 2024. I find that the deceased’s exposure to repeated and persistent infections and sepsis, together with the physiological trauma of necessary surgery for pacemaker extraction and her inflammatory reaction to appropriate anti-biotic treatment is likely to have placed an unsustainable load on her cardio-respiratory system. The deceased’s physiological reserves were depleted by her chronic Idiopathic Thrombocytopenic Purpura and her underlying heart conditions. The deceased was placed on a palliative care pathway and discharged to her own home, where she died on the 25th October 2024. On the basis of the pathological evidence, I find that following her discharge, the deceased developed a pneumonia, in light of her co-morbidities and recent medical interventions, was fatal. 2 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Mrs. Culshaw attended Wythenshaw Hospital on the 10th July 2024 an 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 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. 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of 3 this report, 19th November 2025. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely – 1. Mrs Culshaw’s Family 2. Royal Preston Hospital – Lancashire Teaching Hospitals Foundation Trust I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner. Signed: Dated: 24th September 2025 4
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Joint Chief Medical Officers’ Office Trust Headquarters Room 216, Cobbett House Oxford Road M13 9WL 19 November 2025 Anna Morris KC Assistant Coroner Manchester South Coroner’s Office The Coroners Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Morris The late Mrs Honoria Culshaw – 11 June 1958 – 28 October 2024 Response to Prevention of Future Deaths Report I am grateful to you for providing us with the opportunity to respond to the concerns which arose during the Inquest into the death of the late Honoria Culshaw, namely “[a] lack for information sharing along a communication pathway between the cardiology department at Wythenshawe and the cardiology departments at local treating hospitals risks such referrals being delayed or not being made at all.” The team at Manchester University NHS Foundation Trust (‘the Trust’) would like to reiterate our condolences to the family of Mrs Culshaw on their loss. Actions taken by Manchester University NHS Foundation Trust The introduction in September 2022 of HIVE, the new electronic patient record at Manchester University NHS Foundation Trust, offered the chance for the Trust to develop new processes for communication across health providers, as can often be the case. Mrs Culshaw was discharged from the Emergency Department at Wythenshawe Hospital on 10 July 2024 following advice from the Cardiology registrar on call concerning her implanted medical device. This advice for further action of referring Mrs Culshaw to Preston Cardiology was documented on the discharge letter and sent to Mrs Culshaw’s general practitioner to action in line with Trust policies in place at that time. In the UK, discharge letters are traditionally only sent to a patient’s general practitioner. It is possible in the Trust’s electronic patient record system’s (HIVE) functionality to send copies of the discharge summary to additional recipients as well as the general practitioner. This functionality is available in all workflows including those used by the Emergency Department and Cardiology. A10 Onward communication and referral to external providers have been a key area of focus and improvement for the Trust. Following this case, further work is being done with discharge communications from Emergency Departments to provide structured discharge information and also built in reminders to staff that if a referral is required, the correct process is following at the point of discharge. This includes working with digital colleagues to review the practicalities of amending the current Emergency Department notes that are generated by the Trust. As part of the rolling programme of improvements of the use of HIVE, the Trust is committed to improve the discharge process in our Emergency Departments to ensure that the workflow is seamless and our clinical teams are aware of the functionality to send copies of Emergency Department discharge letters to a full range of healthcare providers. This would include cardiology departments at providers such as the Royal Preston Hospital. In keeping with a system approach to patient safety, the Trust is looking to make the process as simple as possible for clinical teams by making workflows seamless and intuitive, and supporting staff training and induction in relation to the discharge processes. The Trust will also develop additional HIVE tip sheets and video guides to increase knowledge and awareness of the Emergency Department’s discharge navigator within HIVE. The tip sheets and video guides will be availably by 15 December 2025 and shared with all relevant staff members by this date by the Emergency Department’s Clinical Head of Division. ‘correspondence’ the tab in Once the tip sheets and video guides are available, Emergency Department discharge processes will be incorporated into the normal weekly Resident training sessions and as part of Residents’ Trust Induction. This training will include a topic on communicating with healthcare professionals other than the patient’s general practitioner when it is relevant to do so. The target date for this reaching all current Emergency Department Resident staff at the Trust is 31 January 2026. This training will be incorporated into Emergency Department Residents’ Induction training in time for the next cohort starting in February 2026. The Emergency Department Trust Specialty Training Lead (TSTL) will amend and update the Induction training package accordingly. The intention is that the ‘correspondence’ workflow will appear in the ‘Dispo’ section (the discharge navigator for the Emergency Department). This will require a fundamental HIVE build and therefore will not be completed until June 2026. We have reinforced with the Cardiology Department that communication with other secondary and tertiary care providers is of paramount importance to ensure continuity of care is maximised for patients. From 15 December 2025 onwards when the tip sheets and video guides are available, Cardiology Residents’ training will include focused education regarding the processes available to copy inpatient discharge letters that are sent to general practitioners to other relevant healthcare providers. This uses the same process within the electronic patient record as medical staff use to send letters following outpatient clinic appointments. This training will be A11 incorporated into Cardiology Residents’ Induction training in time for the next cohort starting in February 2026. The Cardiology Trust Specialty Training Lead (TSTL) will amend and update the Induction training package accordingly. The tip sheets and video guides will be shared with all relevant staff members by 15 December 2025 by the Cardiology Clinical Head of Division. Furthermore, these tip sheets and video guides will ensure that the on-call Cardiology teams are aware of the Permanent Pacemaker Extraction services that are available at Wythenshawe and the indications for referral and how to generate a referral. This will also be covered in the Induction training. The Associate Medical Director for Quality and Patient Safety will also share the tip sheets and video guides with all the Medical and Nursing Directors across the Trust for more widespread distribution. This will be completed by 15 December 2025. I trust that this reply has assured you that Manchester University NHS Foundation Trust has taken your concerns seriously and have learned from the events which contributed to Mrs Culshaw’s death. On behalf of the Trust, I would like once again to offer Mrs Culshaw’s family condolences on their loss. Yours sincerely Joint Chief Medical Officer / Caldicott Guardian www.mft.nhs.uk Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services A12
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