A DAD-to-be who died on the day his daughter was born 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), Stockport Coroner’s Court heard.
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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.
Concluding the two-day inquest hearing, coroner Christopher 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 ruled that Mr Gibson died as a consequence of sudden cardiac death due to myocardial fibrosis – scarring of the heart muscles.
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”.
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 expertise which could have saved Tom’s life was just one phone call away
Rebecca Moss
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.”
SUDDEN 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, 2023.
Urgent signs of cardiac arrest
A cardiac arrest is when your heart suddenly stops pumping blood around your body.
Although it’s sometimes mistaken for a heart attack, it is different.
If someone is in cardiac arrest, they will collapse suddenly and will be:
- Unconscious
- Unresponsive
- Not breathing or not breathing normally
Without immediate treatment, the person will die.
If you see someone having a cardiac arrest, phone 999 immediately and start CPR.
Source: British Heart Foundation
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.”
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How to do CPR
Learning CPR could save someone’s life if their heart stops in public, as survival chances plummet in the minutes it takes for an ambulance to arrive.
The British Heart Foundation has free online CPR training.
Here are six key steps to performing CPR on an adult:
- Shake and shout: Check the area for any immediate risks and then shake and shout at the unconscious person to try to wake them.
- Check breathing: Check whether the patient is breathing by watching their chest for movement, listening and placing your cheek by their nose and mouth to feel for air. If they are breathing, put them in the recovery position.
- Call 999: Call an ambulance if they have collapsed, whether they are breathing or not. If there is another bystander, ask them to phone while you start CPR.
- Chest compressions: Kneel beside the person, place the heel of your hand on the bone in the centre of their chest and place your other hand beside it and interlock your fingers. Push your bodyweight through your hands to pump their chest hard, trying to compress it by 5cm to 6cm each time. Do it twice every second, 30 times in a row.
- Rescue breaths: After 30 chest compressions, pinch the person’s nose, put your mouth over theirs and blow air into their lungs. Do this twice.
- Repeat: Do another 30 chest compressions followed by another two breaths. Keep repeating until paramedics arrive.
Source: NHS