A dad who died just hours before the birth of his daughter could have been saved, a coroner has ruled.
On the morning of 7 June last year, Rebecca Moss went to wake up her partner, Thomas Gibson, telling him “wake up, it’s baby day” as she was due to give birth by elective Caesarean that day.
Despite the best efforts of emergency services, he was declared dead in his home on the same day his daughter, Harper, was born.
An inquest at Stockport Coroner’s Court has heard Mr Gibson, 40, may have lived if a heart defect had not been missed during a hospital scan 11 days earlier.
If medics had correctly interpreted his electrocardiogram (ECG) scan at Wythenshawe Hospital in Greater Manchester he could have been given a life-saving device such as a pacemaker, Coroner Christopher Morris said.
Concluding the two-day inquest, he 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 result of sudden cardiac death due to myocardial fibrosis.
Image: Ms Moss said there were serious failings in care after Mr Gibson’s hospital admission. Pic: PA
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.”
Image: Mr Gibson may have lived if a heart defect had not been missed 11 days earlier. Pic: PA
Earlier, Dr Mark Ainsley, clinical director of cardiology for the hospital trust, said had Mr Gibson’s heart problem been spotted, he would possibly have been monitored and treated there and then fitted with a pacemaker in 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 said: “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.”
During the inquest, Mr Gibson, who worked at a timber yard, was described as physically fit, but had been suffering from a stomach bug, including cramps and diarrhoea, for around three weeks before his death.
It was this that led to him attending A&E at the hospital on 27 May 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.
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 were not “textbook” examples of a heart block condition. “This is not a barn door easy miss,” he said.
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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.”
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