Manchester dad who died on day of daughter's birth could have been saved, coroner rules

ITV Granada Reports correspondent Ann O'Connor was at the inquest into Thomas' death.

A dad-to-be who died on the day of his daughter's birth may have lived to meet her had a heart defect not been missed, a coroner has ruled.

Thomas Gibson was 40 when his partner Rebecca Moss tried to wake him at their home in Stretford on 7 June 2023, as she got ready to go to hospital for an elective caesarean.

She said to him: "Wake up, it's baby day."

When he didn't respond, she went to kiss him but found him stiff and cold.

Rebecca performed emergency first aid until an ambulance arrived, but he was declared by medics once they arrived.

Later that day, she gave birth to their daughter Harper.

An inquest has now concluded that Thomas' death could have been prevented, as an ECG scan 11 days beforehand had shown him "to be experiencing complete heart block".

However, medics at Wythenshawe hospital failed to "appreciate" this and did not provide any treatment.

Coroner Christopher Morris said: "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”, 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 Thomas 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.

On 27 May 2023, Thomas went to Wythenshawe Hospital's A&E department and received an ECG scan.

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.

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.

Miss 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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