“To the Group Chief Executive Officer, Manchester University NHS Foundation Trust 1”

The coroner’s concerns

– To the Group Chief Executive Officer, Manchester University NHS Foundation Trust 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. To the Chief Executive, National Institute for Health and Care Excellence 1. The court heard evidence that ECGs are used by different professional groups in a wide range of clinical settings. A consultant cardiologist in this case gave evidence that complete heart block was sometimes a wholly incidental finding on ECG, with the patient not previously exhibiting any obvious signs or symptoms. In the present case, the court heard evidence that the computer-generated interpretations of two EGCs were both incorrect, and that three different (relatively experienced) doctors misinterpreted the ECGs. In those circumstances, I am concerned there are currently no authoritative national guidelines (such as those which exist for CTGs) in place as to the use and interpretation of ECGs in various clinical settings.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0327

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0