News

07/06/2024

Emily Slocombe, instructed by CL Medilaw, acts for family in the inquest into the preventable death of Thomas Gibson.

News

Tom was a 40-year-old man who tragically died from an undiagnosed cardiac condition on the day that his daughter was born.

Following a two-day inquest at South Manchester Coroners Court, HM Coroner Christopher Morris found failings in Tom’s care. The coroner concluded that Tom, eleven days prior to his death, had been seen at Wythenshawe Hospital where the clinical teams assessing him did not appreciate that his ECGs showed him to be experiencing complete heart block. Had the correct diagnosis been made, Tom would have been admitted and probably have had an implantable device fitted. The coroner said that it is likely that those measures would have prevented Tom’s death, a fact that it is admitted by the Trust.

Tom’s partner reflected that “the expertise which could have saved Tom’s life was just one phone call away”, and “communication could have made all the difference”.

Tom was typically a fit and well man, with a manual job. On 18 May 2023, Tom began to experience significant gastrointestinal symptoms. It was as a result of those symptoms that Tom attended Wythenshawe Hospital on 27^th May 2023, where the incorrectly interpreted ECGs were performed. Tom was discharged home, with no mention of the abnormal ECGs in the discharge summary. Tom consulted his GP twice between the A&E visit and his death, but the surgery was not aware that ECGs were done in A&E, or their results.

On the morning of 7 June 2023, Tom’s partner Rebecca awoke early to get ready for her caesarean section appointment, and when she went downstairs, she devastatingly found Tom dead on the sofa.

The coroner expressed that whilst he heard evidence on the learning and changes that have taken place since Tom’s tragic death, he continued to have concerns and will be writing two Prevention of Future Deaths reports. The coroner remarked that he particularly felt the need to write the Prevention of Future Deaths report to the Trust as this inquest was not the first time in recent years that he had heard an inquest involving a young patient who tragically died following sudden cardiac arrest from this hospital where similar issues had arisen. These will be sent to:

• Manchester University NHS Foundation Trust regarding:
  • The absence of clear guidance on communication between specialisms and doctors of different grades;
  • The requirement to consider the wider clinical picture when asked to look at something in isolation;
  • The need for senior review of patients when tests produce unexpected results;
  • The apparent absence of audits on ECG interpretation;
  • The apparent absence of audits on the adequacy or otherwise of discharge summaries.
• The National Institute for Health and Care Excellence (NICE) regarding the apparent absence of guidance to all levels of health care professionals as to the interpretation and referral criteria arising from abnormal ECGs.

Emily Slocombe was instructed by Charlotte Moore, Partner, and Ashley Landes, Solicitor, of CL Medilaw.