Thomas Gibson

Inquest Index

~S1
|

~S3
|

~S4
|

SECTION A – Responses

Document

Date

Author

Pages

Regulation 28 Response - 
NICE

Regulation 28 Response - 
MFT

08/08/2024

A1 – A2

14/08/2024

A3 – A7

~E

~E

~E

 2nd Floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

08 August 2024  

Mr Chris Morris 
HM Area Coroner  
Coroner’s Court, 
1 Mount Tabor Street, 
Stockport 
SK1 3AG. 

Sent via email: 
Our reference: 

Dear Mr Morris 

Re: Regulation 28 Prevention of Future Deaths Report (Thomas Lee Gibson)  

I write in response to your regulation 28 report dated 19 June 2024 regarding the very 
sad  death  of  Thomas  Gibson.  I  would  like  to  express  my  sincere  condolences  to 
Thomas’s family.   

The patient safety leads at NICE have discussed the report and understand that your 
request is that we develop guidance on teaching clinicians to interpret ECG readings 
correctly. 

They have explained that teaching clinicians to take a history and interpret an ECG 
are  both  very  important,  however  we  do  not  feel  that  it  is  possible  to  produce  a 
guideline that would achieve this aim, and therefore we do not believe that NICE is the 
relevant  body  to  take  action  on  this  point.  We  would  suggest  that  the  request  is 
directed to the relevant Royal Colleges/Specialist Societies and to the General Medical 
Council  (GMC),  who  are  responsible  for  postgraduate  and  undergraduate  training 
respectively.  

You may also find of interest the MEdTEch briefing from NICE on a related topic; The 
technology  |  Remote  ECG  interpretation  consultancy  services  for  cardiovascular 
disease | Advice | NICE 

I  am  sorry  that  we  could  not  be  more  helpful  on  this  occasion,  but  hope  that  our 
suggestions above will help to ultimately achieve the necessary improvements in care.   

Yours sincerely, 

Chief Executive 

A1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                                                                                                  Page | 2 

A2 
 
 
 
 
  
        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Joint Group Chief Medical Officers’ Office 
Trust Headquarters 
Room 218, Cobbett House 
Oxford Road 
M13 9WL 

Tel:  

Email: 

14 August 2024 

HM Area Coroner Mr Christopher Morris  
Manchester South Area Coroner’s Court  
1 Mount Tabor Street 
Stockport 
SK1 3AG 

By Email 

Dear HMC Mr Morris, 

Re: Regulation 28 Report into the death of Thomas Gibson  

Thank  you  for  your  Regulation  28  Report  to  Prevent  Future  Deaths  dated  19th  June  2024 
addressed  to  Mr  Mark  Cubbon  in  his  capacity  as  Group  Chief  Executive  of  Manchester 
University NHS Foundation Trust (“MFT”, “the Trust”) following the inquest into the death of 
Mr Thomas Gibson which you heard on the 4th and 5th June 2024.  

I have now had the opportunity to acknowledge and consider the matters of concern that were 
raised within your report and which emerged during the inquest of Mr Gibson.  

On  behalf  of  the  Trust,  I  would  like  to  extend  my  sincere  condolences  to  the  family  of  Mr 
Gibson for their very great loss.  

During  the  inquest  you  heard  that  Mr  Gibson  attended  Wythenshawe  Hospital  Emergency 
Department  (ED)  following  a  period  of  gastric  illness  whereupon  an  ECG  was  performed. 
Following this, Mr Gibson was discharged. He sadly died eleven days later as a consequence 
of  sudden  cardiac  death  due  to  idiopathic  myocardial  fibrosis.    You  received  and  heard 
evidence on behalf of the Trust which accepts that the ECG was incorrectly interpreted and 
there was a failure to diagnose complete heart block. Had this been  recognised, Mr Gibson 
would  have  been  admitted  under  the  care  of  the  cardiologists  for  investigations  and 
interventions that would have followed, most likely avoiding his death. We are very sorry for 
the failure to correctly interpret Mr Gibson’s ECG.  

The Trust was able to provide some assurance of our learning and actions taken at the inquest. 
However, you felt there were matters of concern which remained and that your statutory duty 
under  Regulation  28  of  the  Coroners  (Inquest)  Rules  2013  was  engaged;  and  you 
subsequently wrote a Regulation 28 Report to Prevent Future Deaths to MFT to express your 
concerns.   

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • 
Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester •  
Wythenshawe Hospital • Withington Community Hospital • Community Services 

A3 
 
  
 
 
 
 
 
 
 
 You explained these were as follows: 

1.  Whilst some important learning has been derived from the Trust’s review of the 
care provided to Mr Gibson, I am concerned that a narrow focus on the error of 
three different doctors to interpret two ECGs correctly (rather than any broader 
consideration  of  the  context  in  which  such  misinterpretations  occurred) 
represents a missed opportunity to fully understand the factors that led to Mr 
Gibson’s discharge from hospital, thus creating a risk of future deaths.  

2.  Having carefully considered all of the evidence at inquest, I am concerned that 
there does not appear to be clear guidance available to those working within the 
Trust as to what is required when communicating (particularly as to test results 
and a patient’s presentation) as between different specialisms and as between 
different roles within the team.  

3.  Connected with the above, I am concerned that the court heard evidence to the 
effect  there  is  no  specific  guidance  as  to  expected  minimum  standards  as  to 
obtaining appropriate context / information for clinicians (whether from the HIVE 
system or otherwise) when asked to review a single test or investigation result 
in isolation.  

4.  I  am also concerned that there does not  currently appear to be any particular 
requirement  in  place  for  a  senior  review  of  the  patient  to  take  place  in 
circumstances  where  diagnostic  tests  undertaken  yield  results  which  appear 
incongruous / unexpected in the context of their presentation.  

5.  Given the Trust’s own findings on investigation, I am concerned that no wider 
audit  of  ECGs  interpreted  in  the  Emergency  Department  /  Acute  Medical  Unit 
prior to discharge of patients appears to have been undertaken; and  

6.  It is a matter of concern that no audit as to the sufficiency of detail contained in 
discharge summaries appears to have been undertaken to date in the light of the 
issues identified by the Trust’s High Impact Learning Assessment. 

MFT  is  committed  to  learning  from  any  incident,  and  we  thank  you  for  the  opportunity  to 
address  your  concerns  and  thereby  improve  the  care  we  provide.    A  multi-disciplinary 
approach has been taken to address your concerns as follows: 

1.  The Trust has given careful consideration to this concern and apologises for giving the 
impression of a narrow focus. The Trust is aware that  there is a longstanding issue 
with ECG interpretation both within the UK and  internationally. Multiple studies have 
confirmed  that  the  accuracy  of  ECG  interpretation  varies  from  42%  for  medical 
students and 75% for cardiologists (who are the experts at interpreting ECGs).1 These 
issues  with  ECG  interpretation  are  present  even  after  extensive  training  and  other 
interventions.  For  this  reason,  we  have  focused  on  the  Human  Factors  of  errors  in 
clinical medicine and have engaged with our Human Factors Academy (HFA). This will 
support us to understand better the other factors at play which contribute to incorrect 
ECG interpretation; and which can be mitigated in the future.  

1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522782/  

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • 
Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester •  
Wythenshawe Hospital • Withington Community Hospital • Community Services 

A4 
 
  
 
 
 
 
 
 
 
 
 
 Additionally,  we  have  confirmed  with  our  undergraduate  educator  colleagues  that 
training on ECG interpretation starts in the first year of medical school and is woven 
through a number of modules across the five years. 

2.  Clarification  of  roles  and  responsibilities  is  a  key  aspect  of  our  training  and  the 
mechanism  for  securing  a  senior  /  speciality  review  is  clearly  defined.  There  is  an 
opportunity at least twice daily to discuss medical cases both on the ward and in ED. 
It is part of standard medical training around how and when to escalate patients with 
tools  such  as  the  SBAR  (Situation,  Background,  Assessment,  Recommendation) 
taught and reinforced in undergraduate and postgraduate training across the UK.   The 
SBAR tool is recommended by NHS England for use by all clinical staff; it is described 
as ‘a structured way of communicating information that requires a response from the 
receiver. As such, SBAR can be used very effectively to escalate a clinical problem 
that requires immediate attention, or to facilitate efficient handover of patients between 
clinicians or clinical teams’. Consultants from a range of specialties make themselves 
available  as  much  as  possible,  with  named  consultants  present  in  ED  and  on  the 
admitting wards 7 days a week.  A consultant attends medical handover twice a day 
and each department at Wythenshawe, Trafford, Withington and Altrincham (“WTWA”) 
(and indeed across MFT) discusses SBAR and escalation processes for senior review 
at induction with the junior doctors. It is also written in the induction booklets handed 
out at the start of each placement for the medical teams. 

ECG  training  is  delivered  regularly  as  part  the  Wythenshawe  medical  teaching 
programme.  The  training  also  encourages  junior  members  of  the  team  and  other 
Health Care Professionals (HCPs) to have a low threshold to seek a second opinion 
either  from  a  Consultant/Specialist  Trainee  (who  are  signed  off  as  competent  to 
interpret ECGs independently) or cardiologist. 

3.  The  reality  of  practice  in  a  busy  Emergency  Department  does  mean  that  at  times, 
clinicians  will  be  presented  with  a  test  result  in  relative  isolation  without  a  fully 
comprehensive clinical picture, and asked to comment on this result in the context of 
other  potentially  competing  priorities.  In  any  situations  of  competing  priorities, 
clinicians need to be able to weigh the relative risks and benefits of dealing with one 
matter  ahead  of  another.  We  recognise  the  challenge  this  real-world  scenario 
presents,  and  the  need  to  support  staff  to  recognise  and  mitigate  the  risk  of  those 
“human factors” and situational challenges that can impact a correct diagnosis being 
reached.  The  concept  of  “human  factors”  in  healthcare  is  described  as  “enhancing 
clinical  performance  through  an  understanding  of  the  effects  of  teamwork,  tasks, 
equipment, workspace, culture and organisation on human behaviour and abilities and 
application  of  that  knowledge  in  clinical  settings”.2  We  are  therefore  expanding  our 
simulation  and  Human  Factors  training.  This  HF  training  will  form  part  of  regular 
teaching  programmes  for  medical  and  surgical  junior  doctors  and  the  content  and 
syllabus  will  be  discussed  with  the  HFA.  The  aim  is  to  have  a  rolling  12-month 
programme  established  by  31  December  2024.  This  program  will  look  at  how  to 
provide  training  across  MFT  sites.  It  is  anticipated  that  Human  Factors  training  will 
focus on increased vigilance in the interpretation of screening investigations such as a 
chest radiograph or ECG when patients do not have typical presenting features, as in 
the case of Mr Gibson. The Human Factors training will also reinforce the importance 
of  clinicians  having  a  robust  systematic  process  for  interpreting  ECGs.  There  are 

2 Catchpole (2010), cited in department of Health Human Factors Reference Gorup Interim Report 
March 2012, National quality Board, March 2012.  
www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • 
Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester •  
Wythenshawe Hospital • Withington Community Hospital • Community Services 

A5 
 
  
 
 
 
 
 
 
 ongoing discussions with Cardiology and the Human Factors Academy to ensure this 
training achieves these objectives. 

4.  Whilst  no  Consultant  reviewed  the  ECG  prior  to  Mr  Gibson  being  discharged,  the 
Registrars did review this. A Registrar is an appropriately senior clinician to discharge 
a  patient;  it  is  not  anticipated  or  reasonable  for  a  Consultant  to  oversee  all  ECG 
interpretation 24 hours a day, as the opportunity cost of this would adversely impact 
other activity that necessitates Consultant input.  

Acute Medicine and ED have weekly junior doctor teaching sessions.  Once a month 
these are based on ‘missed opportunities’ or ‘lessons learnt’ from the previous month.  
This  includes  clinical  cases  or  themes  relating  to  errors  to  ensure  learning  is 
disseminated  across  the  teams.    Relevant  cases  are  also  added  to  the  monthly 
governance meetings and mortality meetings which have a broader reach to include 
Consultants and senior nursing staff. 

5.  As  stated  above,  it  is  well  documented  that  ECG  interpretation  accuracy  varies 
between 42% and 75% (expert cardiologists) and so it has been agreed by the Clinical 
Head of Division and the WTWA  Associate  Medical Director for Quality and Patient 
Safety that performing a random audit of selected ECGs would not provide assurance 
of the quality of interpretation. The only way to seek assurance would be to audit all 
ECGs and this would be extremely onerous on the ED department and  distract from 
delivery of patient care. An audit presented in August 2024 has shown that we perform 
100-190  ECGs  every  day  in  ED  which  amounts  to  41%  of  all  attendees.    Of  these 
ECGs, 35-56% of them have an abnormality detected.  

However, it was agreed that there would be benefit in performing an audit to ensure 
that  the  correct  processes  are  being  followed  in  ED  with  regard  to  the  Standard 
Operating Procedure (SOP). i.e. ECG reviewed by the appropriately qualified member 
of  staff  with  interpretation  and  action  plan  documented.  This  audit  used  data  from 
timepoints in December 2023 with 64% of ECGs having an interpretation documented 
within the medical records.  Of those not interpreted within the ED, some patients had 
opted to leave the department, and some had been under the care of specialties so 
not the direct responsibility of ED teams.  Since that audit we have revised the SOP 
around  documentation  standards  and  delivered  education  on  which  patients  should 
receive an  ECG.    The  second  phase  of  the  audit  will  now take  place  to  assess  the 
impact of that intervention.  Our expected standard is that 100% of ECGs will have an 
interpretation  documented.    Although  this  cannot  guarantee  accurate  interpretation 
each  time,  the  standard  will  enforce  that  a  period  of  time  be  given  to  the  ECG 
interpretation, ensuring due attention and thus removing some of the human factors 
issues which can limit focus and assessment skills in the moment.  

6.  A Task and Finish Group involving colleagues in Primary Care and MFT clinicians was 
set up in April 2024 to ensure that discharge summaries confirm to a basic standard 
set by the Professional Records Standards Body. A new template has been produced 
which includes all relevant descriptors.  It is important that discharge summaries are 
kept succinct to enable all relevant information to be easily accessed by the receiving 
clinician. However it is also important that the relevant information is included to ensure 
that  the  care  provided  and  ongoing  plan  can  be  understood  by  Primary  Care 
colleagues. As part of the changes made, this new version will automatically provide 
any  medication  updates  and  concerns  and  each  section  must  be  completed:  see 
example below. This template has been signed off by Primary Care; and colleagues in  

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • 
Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester •  
Wythenshawe Hospital • Withington Community Hospital • Community Services 

A6 
 
  
 
 
 
 
 
 
 
 Primary  Care  have  been  encouraged  to  feed  back  any  suboptimal  discharge 
summaries.  

Recommended Actions for GP or Receiving Dept: 
Please document any recommended actions for the GP or Receiving Dept if needed. 
*** 

Problem List at Discharge: 
Please ensure problem list is updated if it differs from below {(click here to update):1} 
There are no hospital problems to display for this patient. 

Clinical Summary: 
Please document a clinical summary of this admission, including procedure or investigation 
results information. 
*** 

Hospital Plan: 
Please note that results of any outpatient investigations will be sent to the Attending 
Consultant at discharge. {(click here to update):1} 
*** 

Rationale for Medication Changes: 
Document rationale for medication changes. Please note medication information is already 
included within the Discharge Summary Letter and does not need to be repeated. 
*** 

We hope that this response provides you and Mr Gibson’s family with assurance in respect of 
the  matters  of  concern  you  have  raised,  and  we  thank  you  for  your  Report.  The  Trust  is 
committed  to  ensuring  patient  safety  is  our  priority  at  all  times.  If  you  require  any  further 
information, please do not hesitate to contact us.  

Yours sincerely 

Joint Group Chief Medical Officer / Responsible Officer 

On behalf of  

Chief Executive Manchester University NHS Foundation Trust 

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • 
Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester •  
Wythenshawe Hospital • Withington Community Hospital • Community Services 

A7