A father who died just hours before his daughter was born could have been saved, a coroner has ruled.
On the morning of June 7 last year, Rebecca Moss went to wake her partner, Thomas Gibson, telling him “wake up, it’s baby day” as she was due to give birth by elective caesarean section that day.
An inquiry heard She went to kiss him but found him stiff and coldthen called an ambulance.
Despite the efforts of emergency services, he was pronounced dead at his home on the same day his daughter, Harper, was born.
An inquest at Stockport Crown Court heard that Mr Gibson, 40, could have survived if a heart defect had not been detected during a hospital scan 11 days earlier.
If doctors had correctly interpreted his electrocardiogram (ECG) at Wythenshawe Hospital in Greater Manchester, he could have received 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 imagine what it must have been like for her, especially in the context of what must have been the happiest day for them both.”
The coroner determined that Mr. Gibson died as a result of sudden cardiac death due to myocardial fibrosis.
He added: “Eleven days earlier, Mr Gibson had been seen at his local hospital, which offers specialist cardiac services.
“When the clinical team assessed him, they did not realize that the ECG showed that he had complete heart block.
“If this had been appreciated, Mr Gibson would have been admitted under the care of cardiologists, a series of investigations carried out, which would probably have culminated in the installation of an implantable device such as a pacemaker.
“It is likely that these measures would have prevented his death.”
Gibson might have survived if a heart defect had not gone unnoticed 11 days earlier. Photo: PA
Previously, Mark Ainsley, clinical director of cardiology at the Hospital Trust, said that if Gibson’s heart problem had been detected, 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 this sequence of events would likely have prevented his death?”
Dr Ainsley said: “I think the short period between the ECG and his heart giving out, I think it is more than likely that he would have prevented his death.”
During the inquest, Mr Gibson, who worked in a timber mill, was described as physically fit but had been suffering from a stomach illness, including cramps and diarrhea, for around three weeks before his death.
That’s what led him to go to the hospital’s emergency room on May 27 last year.
He was seen by Dr Oliver Handley, who recognized that his ECG tracing showed signs of abnormality and referred him to a more experienced doctor, Dr Thomas Bull, the medical registrar, for a second opinion.
Dr Bull said the ECG likely represents an abnormality which he described as an intraventricular block, which is “not an uncommon finding” and is not clinically “significant” without other heart-related symptoms.
As there were no other heart-related symptoms, he was discharged.
But further analysis concluded that the ECG identified a complete heart block, also known as third-degree heart block, the most serious type.
Dr Matthew Thornber, a consultant at the hospital, said the two ECGs were not “textbook” examples of a heart block condition. “This is not an easy barn door,” he said.
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Toli Onon, joint group medical director at the University of Manchester NHS Foundation Trust, said: “We wish to again extend our condolences and sincere sympathies to Mr Gibson’s family at this very difficult time.
“The Trust carried out a thorough investigation to examine the circumstances following Mr Gibson’s sad death, and we apologize that our care fell short of the high standards to which we aspire.
“We are committed to providing the best possible care to our patients and will carefully review the coroner’s conclusion to ensure that additional learning for the trust is addressed and applied to our ongoing work to improve the safety of our patients, the quality of care and experience.”
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Outside court, Ms Moss, supported by lawyers from CL Medilaw, representing the family at the hearing, said: “There were serious failures in care following Tom’s admission to hospital in 2023.
“The ECG that identified complete heart block was not noticed by doctors and he was discharged without knowing the dangers of sudden cardiac death.
“Doctors admitted in the last two days of the inquest that he should have received treatment and a pacemaker.
“The experience that could have saved Tom’s life was just a phone call away.
“I sincerely hope there are lessons learned from Tom’s preventable death.
“I’ve been told the inquests are not about guilt, but I have every right to be angry and to seek answers for Tom, Harper and our family.”
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