It should have been the happiest day. Instead they have to live without dad

June 7, 2023 should have been the happiest day of Tom Gibson and Rebecca Moss' lives. The couple had shared the special news they were expecting their first child with their loved ones around Christmas time. They had spent months preparing.

Tom was 'so excited to finally be a dad himself for the first time' and 'spent nearly every weekend putting up Ikea furniture and getting everything ready in anticipation of the new arrival'. They were 'both looking forward to being able to enter this new chapter in our lives together', Rebecca would later recall.

Baby Harper arrived safely, but that day will, each year, bring unimaginable pain. Hours before the child was due to be delivered, 40-year-old Tom was found unresponsive on the sofa - the victim of sudden cardiac death.

READ MORE: 'My partner died the day our child was born and a phone call could have saved his life – I have every right to be angry'

Rebecca went to the same hospital for a planned caesarean section where, less than two weeks prior, Tom had been at A&E. The carpenter was said to have been an 'extremely fit' and healthy man. He had been to Wythenshawe Hospital with a stomach bug and while there, underwent a routine heart exam.

The results of the electrocardiogram (ECG) revealed abnormalities, but three doctors who analysed the findings determined there were no critical concerns. Tom was discharged.

Had the medics interpreted the results correctly, Tom would have received treatment. He would likely have had a pacemaker fitted and his death 'would have been avoided', a coroner ruled at the conclusion of an inquest into his death – days before the first anniversary of the tragedy.

What the results actually showed was a 'complete heart block' – the most serious kind, which can lead to sudden cardiac death. Rebecca has spent the last year fighting for answers as to why the major problem was missed when – as one Wythenshawe Hospital consultant said in court – 'the information was there'.

Here, Helena Vesty looks back at the inquest into Tom's death and speaks to his devastated partner...

'Our daughter will celebrate her first birthday... her dad won't be there'

Rebecca has been raising a baby she expected to bring up with her life partner, while spending hours working through documents and liaising with lawyers. Giving evidence at the inquest, she told the court: "When we found out Harper was breech and that I'd need to have a C-section unless the baby turned round, we decided to try everything we could to get her to move.

"[Tom] even came with me to an acupuncture clinic, where they stuck needles in my toes to try and encourage the baby to turn around on their own. This was on the morning of his 40th birthday, which proves just how much he cared and how much wanted everything to go to plan for us.

"Tom was always great with kids, which probably comes from being a big kid himself. He spent lots of time with his nieces and nephews when they were younger and he would joke that he ran 'Tom's Daycare' when he lived at his dad's house.

"Harper will celebrate her first birthday on Friday, June 7 2024 – and her dad won't be there. 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. When I was pregnant, these are the things he told me he was looking forward to the most. We had so many plans for the future together."

The missed diagnosis that could have saved his life

During the inquest into Tom's death, the court heard how he had been suffering from a stomach bug from May 18, 2023. On May 27, Tom had woken up feeling 'extremely unwell', heard the court, and went to A&E.

Tom, from Stretford, Trafford, was sent home after 12 hours at Wythenshawe Hospital. He was told by doctors he had a campylobacter infection, the cause of his gastroenteritis illness, which would likely resolve itself given he was an otherwise fit and healthy young man.

The court heard how A&E doctors carried out an electrocardiagram (ECG) on the morning of May 27. The results came back as abnormal and Tom was moved to the resus area of A&E, reserved for the most unwell patients, and a course of magnesium was started intravenously.

Another ECG was carried out later that afternoon. Medic Dr Oliver Handley noticed the result was unusual again and asked for it to be reviewed by a more senior colleague. Medical registrar Dr Thomas Bull looked at the second test result and determined the ECG trace was likely to represent an abnormality that was 'not an uncommon finding' and not clinically 'significant' without other heart symptoms.

Dr Bull advised that if there were no more symptoms suggesting a problem with Tom's heart, he should be discharged. The ECGs were not escalated to a cardiology specialist until after Tom's death and, later analysis revealed signs of a 'complete heart block’, particularly in the first ECG.

Electrical cardiology consultant Dr Mark Ainslie, the clinical director of cardiology at Wythenshawe Hospital, reviewed the ECG results after Tom's death without being told he had died. Dr Ainslie said that although the second ECG test results were harder to discern, the first ECG showed 'complete heart block' to him.

Taken together, the two tests indicated the complete heart block and could have kickstarted treatment – which, he said, might have been quicker than at other hospitals, as Wythenshawe is a cardiology centre for the north west, with 24-hour access to cardiology consultants.

The procedure to fit a pacemaker takes 'less than an hour', he said, and had it been fitted 'it's more than likely that he would have avoided his death'. Another Wythenshawe Hospital consultant said the ECG results — particularly on the second ECG — were 'not classical heart block' results, explaining that they were 'easily misinterpreted as normal' even by 'fairly senior doctors'.

"It's quite shocking that an ECG has been misinterpreted by three people," Dr Matthew Thornber told the court. Despite the difficulty of assessing the ECG results, the consultant admitted it was a 'triple missed opportunity', adding: "I think we've failed… because he shouldn't have been discharged. It wasn't easy, but the information was still there."

In the days after Tom's A&E visit, he remained unwell with the stomach bug. The night before the C-section appointment, 'Tom still didn't feel well, so we decided that he wouldn't come with me to the caesarean section, which we were both disappointed about', Rebecca said.

"Tom was feeling so poorly that he decided that he was going to miss the birth of his first child," she added. He decided to sleep downstairs, to avoid passing any infection on to Rebecca, whose mum was going to take her to Wythenshawe Hospital – the same hospital that had sent him home.

In the morning, she found Tom dead.

'Wake up, it's baby day'

Rebecca recounted in court the horror of what she experienced that morning. "I was saying 'wake up, it's baby day'. Tom didn't respond, so I went over to the couch to give him a kiss. He was lying in his usual sleeping position. When I touched him, he was cold and stiff. He wouldn't wake up."

Rebecca told the court how she called 999, pulled Tom to the floor and started trying to resuscitate him. It was too late.

"The shock, trauma and not to mention the physical exertion of having to pull Tom off the couch and perform chest compressions at 39 weeks pregnant was overwhelming," she said. Hours later, Rebecca had to go to the hospital where Tom had been in A&E and make sure Harper was born safely, traumatised by the sudden loss of the love of her life that very morning.

"I just felt numb and not really 'in the room', but I was adamant I wanted Harper here safely, despite what had happened to Tom. She was my priority at that moment in time," she said. "Once she was born, I was so relieved. It turned the most awful day in my life into the best day of my life."

'I have every right to be angry'

Area coroner for Greater Manchester central Chris Morris recorded a narrative conclusion, stating Tom died from sudden cardiac death due to myocardial fibrosis. The coroner said: "Eleven days previously, Mr Gibson had been at his local hospital which provides specialist cardiac services, where the clinical team assessing him did not appreciate that ECGs showed him to be experiencing complete heart block.

"Had this been appreciated, Mr Gibson would have been admitted under the care of cardiologists and a series of investigations undertaken which would have culminated in an implantable device such as a pacemaker being fitted. It's likely these measures would have avoided his death."

Rebecca said that 'while nothing can bring Tom back', she was satisfied with the coroner's findings and said there had been 'serious failings' in Tom's care. "Staff failed to identify that Tom was in serious need of medical attention and no escalation was made that could have saved his life," she added.

"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.

"Learning this here was devastating. Communication could have made all the difference to Tom's life and we wouldn't be in the situation we are today.

"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."

The coroner will be writing to the chief executive of Manchester University NHS Foundation Trust (MFT), which operates Wythenshawe Hospital, with a report to prevent future deaths. The report will cover clinical practice around the interpretation of ECG tests.

'Not the first time'

The coroner said Tom's tragic death was 'not the first time [he] had to hear in recent years an inquest involving the death of a young patient following sudden cardiac death, following discharge from this particular hospital where these broader issues have arisen to a greater or lesser extent'.

Toli Onon, the joint group chief medical officer at Manchester University NHS Foundation Trust, responded to the coroner's findings saying: "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."

'I'm sorry I can't be there'

For Rebecca, these were hard-won findings; conclusions she wished she never needed. But she has 'done it all for Harper' in the hope that, one day, her little girl will be able to get the answers she needs from her mum and, crucially, know that lessons have been learned.

Rebecca added: "I feel relieved that it's over, obviously. But I also feel like I have some answers, a bit of peace, and a bit of closure. It's very important for me to know that learnings have been learned from Tom's passing. I'm very satisfied with how the coroner looked at everything and came back with his narrative."

Standing outside Stockport Coroners' Court, Rebecca told the Manchester Evening News what she thought Tom would say if he was with her. She fought tears as she said: "I think he would have said, because I know exactly what he would have said, 'keep going, you're doing the right thing, I fully back you in what you're doing… I'm sorry I can't be there'."

'He would have loved Harper as much as everybody does'

Rebecca is now looking to her future with Harper, speaking of days with 'nana', time spent at nursery and planning her daughter's first birthday celebrations which took place this weekend. It's going to be difficult to navigate that life without Tom.

"Harper and I are getting used to life as just the two of us," said Rebecca in court. "I never thought I'd have to live my life without Tom, I was looking forward to all the memories we were going to make together with Harper.

"She looks so much like him in her eyes and her smile. I hope she will inherit his kindness too. While Tom isn't here physically, his legacy lives on through Harper and we will make sure she knows who he was and what a wonderful man her dad was.

"It's important to me that Tom's story is shared, because he deserved to be treated better than he was. He was let down by the very people who were supposed to care for him. He deserved better and I want everyone to know it."

Rebecca contemplated the moment she will have to tell Harper what happened to her daddy, adding: "It'll be a very difficult conversation, but I'm used to having difficult conversations as you can imagine in this process.

"I'll have to handle it very sensitively with her and make sure she's old enough to understand. I hope she knows that I did everything I could for her and it wasn't her dad's fault, and it wasn't my fault, it wasn't the family's, it wasn't anybody's fault. It was just something that happened, it was just an awful thing that happened.

"I just want her to know that everybody loves her and he would have loved her as much as everybody does."