Dad's death on day of baby's birth 'preventable'
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, a coroner has found.
Thomas Gibson, 40, died from a sudden cardiac arrest on 7 June 2023 after a hospital doctor "misinterpreted" a scan 11 days earlier, an inquest at Stockport Coroner's Court heard.
The inquest was told that had medics at Wythenshawe Hospital in Manchester given Mr Gibson a pacemaker he would still be alive.
Coroner Christopher Morris concluded Mr Gibson died as a consequence of sudden cardiac death due to myocardial fibrosis.
Emergency first aid
On 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 but found him "stiff and cold" and attempted emergency first aid until an ambulance arrived at their home in Stretford, Greater Manchester.
He was declared dead and she gave birth to their daughter, Harper, the same day.
At the end of the two-day inquest hearing, Mr Morris 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."
He added: "When the clinical team assessed him they did not appreciate 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."
Speaking outside the court, Mr Gibson's partner Rebecca Moss said: "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."
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 about 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 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.
'No other symptoms'
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 the ECG identified a complete heart block, also known as a third-degree heart block, the most serious kind.
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.
In a statement, 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 will be reviewing the coroner's conclusion carefully."
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