Thomas Gibson: Father-to-be who died on day of daughter's birth could have been saved with pacemaker

A father-to-be who tragically died on the day his daughter was born might have survived if a heart defect had been identified during a hospital scan, a coroner has ruled. Thomas Gibson, 40, would likely have been fitted with a pacemaker, which could have prevented his sudden death if the medical staff had correctly interpreted his electrocardiogram (ECG) at Wythenshawe Hospital in Greater Manchester, according to the findings from Stockport Coroner’s Court.

Just 11 days later, on the day Mr Gibson was to become a father, his heavily pregnant partner Rebecca Moss tried to wake him as she prepared for an elective Caesarean. “Wake up, it’s baby day,” she said, but found him unresponsive and cold.

Ms Moss performed emergency first aid until an ambulance arrived at their home in Stretford, Greater Manchester, where he was pronounced dead. She gave birth to their daughter, Harper, hours later that same day.

Concluding the two-day inquest, Coroner Christopher Morris stated: “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 that Mr Gibson died from sudden cardiac death due to myocardial fibrosis. 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.”

Dr Mark Ainsley, the hospital trust’s clinical director of cardiology, testified that if Mr Gibson’s heart problem had been identified on the ECG scan, he would have likely been monitored and treated immediately, including being fitted with a pacemaker, a procedure that takes “less than an hour.”

When asked by the coroner if this sequence of events would have likely prevented Mr Gibson's death, Dr. Ainsley responded, “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 revealed that Mr Gibson, who worked in a timber yard and was physically fit, had been suffering from a stomach bug for about three weeks before his death. This led to his visit to the A&E at Wythenshawe Hospital on May 27.

He was seen by Dr Oliver Handley, who noticed an abnormality on the ECG and sought a second opinion from Dr Thomas Bull, the medical registrar. Dr Bull identified the abnormality as an intraventricular block, which he deemed "not clinically significant" without other heart-related symptoms, and Mr Gibson was subsequently discharged. However, later analysis concluded that the ECG indicated a complete heart block, also known as a third-degree heart block, which is the most serious type.

Dr Matthew Thornber, a hospital consultant, explained that the ECGs taken were not typical examples of a heart block condition and diagnosing it requires nuance and experience. “This is not a barn door easy miss,” he said.

The coroner announced plans to write a prevention of future deaths report to the chief executive of Manchester University NHS Foundation Trust and the National Institute of Clinical Excellence regarding ECG interpretation practices.

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.”