Dad's death on day of baby's birth 'preventable', 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, 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.

Area coroner for Greater Manchester South, Christopher Morris, concluded that Mr Gibson died because of sudden cardiac death due to myocardial fibrosis.

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.

The inquest heard that in the morning she told him: "Wake up, it's baby day" but found him "stiff and cold" and attempted emergency first aid until an ambulance arrived at their home in Stretford, Greater Manchester, and he was declared dead.

Rebecca Moss gave birth to their daughter, Harper, the same day.

At the end of the two-day inquest, 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.

"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 that these measures would have avoided his death."    

Clinical director of cardiology for the hospital trust, Dr Mark Ainsley, 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".

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 which resulted in him attending the A&E at Wythenshawe Hospital on May 27, 2023.

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.

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.

A consultant at the hospital, Dr Matthew Thornber, said the two ECGs taken were not "textbook" examples of the appearance of a heart block and such diagnosis requires nuance and experience.

The coroner said he would write a Prevention of Future Deaths (PFD) 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."

Speaking outside the court, 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."