Man who died on day of daughter’s birth could have been saved, coroner rules

A father-to-be who died on the day of his daughter’s birth may have lived if a heart defect had not been missed on a hospital scan, a coroner has ruled.

Thomas Gibson, 40, would probably have been given a pacemaker which would have likely prevented his sudden death, had medics correctly interpreted his electrocardiogram (ECG) scan at Wythenshawe Hospital, in Greater Manchester, Stockport Coroner’s Court heard.

Eleven days later, the day Mr Gibson was due to become a father, his partner Rebecca Moss tried to rouse him as she prepared to go to hospital for an elective Caesarean.

“Wake up, it’s baby day,” she told him and went to kiss him but found him stiff and cold.

Ms Moss attempted emergency first aid until an ambulance arrived at their home in Stretford, Greater Manchester, and he was declared dead.

She gave birth to their daughter, Harper, the same day.

Coroner Christopher Morris, concluding the two-day inquest hearing, said: “I can’t even begin to fathom what that must have been like for her, particularly in the context of what should have been the happiest day for both of them.”

The coroner ruled Mr Gibson died as a consequence of sudden cardiac death due to myocardial fibrosis.

He added: “Eleven days previously Mr Gibson had been seen at his local hospital which provides specialist cardiac services.

“When the clinical team assessed him they did not appreciate that the ECG showed him to be experiencing complete heart block.

“Had this been appreciated Mr Gibson would have been admitted under the care of cardiologists, a series of investigations undertaken, which would probably have culminated in an implantable device, such as a pacemaker being fitted.

“It is likely these measures would have avoided his death.”

Earlier Dr Mark Ainsley, clinical director of cardiology for the hospital trust, said if Mr Gibson’s heart problem had been spotted on the ECG scan he would possibly have been monitored and treated there and then and fitted with a pacemaker, a procedure that takes “less than an hour”, he said.

The coroner asked: “Do you think that sequence of events would likely have avoided his death?”

Dr Ainsley replied: “I think the short duration between the ECG and his heart giving way, I think it’s more than likely he would have avoided his death.”

The inquest heard that Mr Gibson worked in a timber yard and was physically fit but had been suffering from a stomach bug, including cramps and diarrhoea, for around three weeks before his death.

It culminated in him attending the A&E at Wythenshawe Hospital on May 27 last year.

He was seen by Dr Oliver Handley, who recognised that his ECG trace showed signs of an abnormality and referred it to a more senior medic, Dr Thomas Bull, the medical registrar, for a second opinion.

Dr Bull said the ECG scan was likely to represent an abnormality he described as an intraventricular block, which is “not an uncommon finding” and not clinically “significant” without other heart-related symptoms.

As there were no other heart-related symptoms he was discharged.

But later analysis concluded that the ECG identified a complete heart block, also known as a third-degree heart block, the most serious kind.

Mr Gibson died from sudden cardiac death on June 7 last year.

Dr Matthew Thornber, a consultant at the hospital, said the two ECGs taken were not “textbook” examples of looking like a heart block condition and such diagnosis requires nuance and experience.

“This is not a barn door easy miss,” he said.

The coroner said he would be writing a prevention of future deaths report, addressed to the chief executive of the Manchester University NHS Foundation Trust and the National Institute of Clinical Excellence concerning clinical practice around the interpretation of ECG scans.

Toli Onon, joint group chief medical officer at Manchester University NHS Foundation Trust, said: “We wish again to extend our condolences and sincere sympathies to Mr Gibson’s family at this very difficult time.

“The Trust has undertaken a thorough investigation to examine the circumstances following Mr Gibson’s very sad death, and we apologise for where our care has fallen short of the high standards to which we aspire.

“We are committed to providing the best care possible for our patients and we will be reviewing the Coroner’s conclusion carefully, to ensure further learning for the Trust is addressed and applied to our constant work to improve our patients’ safety, quality of care, and experience.”

Outside court Ms Moss, supported by lawyers from CL Medilaw, representing the family at the hearing, said: “There were serious failings in care following Tom’s admission into hospital back in 2023.

“The ECG that identified a complete heart block was missed by doctors and he was discharged without knowing the dangers of sudden cardiac death.

“Medics admitted over the last two days of the inquest that he should have received treatment and a pacemaker.

“The expertise which could have saved Tom’s life was just one phone call away.

“I sincerely hope that there will be learnings from Tom’s avoidable death.

“I am told that inquests aren’t about blame but I have every right to be angry and to seek answers for Tom, Harper and our family.”