Father,would have survived if doctors realised serious heart condition (2024)

A man who died hours before his baby daughter was born would probably have survived had doctors spotted just days earlier that he was suffering from a serious heart condition, a coroner said today.

Carpenter Tom Gibson, 40, was 'cold and unresponsive' when his 39 weeks pregnant partner Rebecca Moss tried to rouse him before going into hospital for an elective Caesarean section, saying: 'Wake up, it's baby day!'

He had undergone an ECG scan 11 days earlier after attending Wythenshawe Hospital in Manchester over a sickness bug.

But doctors failed to appreciate that the result showed a potentially deadly complete heart block and discharged him without specialist treatment.

The coroner's devastating finding came as the first pictures were released showing 37-year-old Ms Moss with their daughter Harper, who turns one on Friday.

Chris Morris concluded after a two-day inquest at Stockport Coroner's Court that it was 'likely' Mr Gibson would have survived if he had been admitted to the cardiac unit and fitted with a pacemaker.

He criticised the hospital, saying he would be writing to bosses under the Rule 28 measure for the prevention of further deaths

Afterwards Ms Moss said there had been 'serious failings' in Mr Gibson's treatment.

'The ECG which identified a complete heart block was missed by doctors and he was discharged without knowing the dangers of sudden death,' she said.

'Staff failed to identify that Tom was in need of serious medical attention and no escalation was made that could have saved his life.

'Medics have admitted over the last two days that he should have received treatment and a pacemaker.

'The expertise which could have saved Tom's life was just one phone call away.

'Learning this here was devastating and it is my view that there is a culture of failing to recognise when specialist guidance is needed at Wythenshawe Hospital.'

Coroner Mr Morris said in his conclusion: 'Mr Gibson died from a sudden cardiac arrest.

'He had been seen 11 days earlier at his local hospital which provided specialist cardiac service.

'The clinical team assessing him did not appreciate that an electro cardiogram showed him to be experiencing a complete heart block.

'Had this been appreciated, Mr Gibson would have been admitted to the care of a cardiologist and a series of investigations undertaken which would probably have culminated in an implantable device such as a pacemaker being fitted.

'It is likely such measure would have avoided his death.'

Mr Morris said the case raised concerns about further deaths, especially because this was the second recent case of a young patient dying from a heart attack after being discharged from the same hospital.

The coroner said an investigation carried out by the hospital had been 'unduly narrow' and there was 'an absence of clear communication' between doctors on different grades.

He plans to write to the chief executive of the Manchester University NHS Foundation Trust – which runs the hospital - and the National Institute for Health and Clinical Excellence about concerns about guidelines on interpreting ECG results and referring patients.

Earlier Ms Moss told the inquest how she found Mr Gibson 'cold and unresponsive' when she tried to wake him on the couch at their home in Stretford, Greater Manchester on June 7 last year.

He was rushed to Wythenshawe Hospital but efforts to revive him failed.

Ms Moss was taken separately to the same hospital where she later gave birth.

'Harper will celebrate her first birthday on Friday and her dad won't be there,' Ms Moss told the hearing.

'He won't be there for any of her birthdays.

'He won't ever be there on Christmas morning, and he won't be there on Father's Day.

'Harper will instead visit her dad's grave when she's old enough to understand. Tom will never get to push her on a swing or teach her how to ride a bike.

'Tom will live on through his daughter but that doesn't change the fact that he should still be here with us today.'

The inquest had been told that Mr Gibson had been taken to hospital with a severe stomach bug the previous month and an ECG had detected a heart blockage.

He was taken into a resuscitation unit and treated with magnesium.

A second ECG revealed the heart abnormality and a junior doctor referred the test result to a middle-ranking registrar.

He in turn said the finding was 'not uncommon' in a 40-year-old fit man and discharged Mr Gibson with advice to go to his GP if his condition did not improve.

The registrar, Dr Thomas Bull, has admitted he should have sought the advice of 'more experienced eyes'.

Dr Mark Ainslie, clinical director of cardiology at the Manchester University NHS Foundation Trust, said it was 'more likely' that Mr Gibson would have survived if he had been fitted with a pacemaker.

He said there had been a ' lot of soul searching ' since Mr Gibson's death with mandatory referrals now required when an alert is raised by an ECG scan.

Afterwards Toli Onon, joint group chief medical officer at Manchester University NHS Foundation Trust, expressed its 'condolences and sincere sympathies'.

She added: 'The trust has undertaken a thorough investigation to examine the circ*mstances 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.'