Coronial
NTprison

Inquest into the death of Raymond McDonald

Deceased

Raymond McDonald

Demographics

49y, male

Date of death

2014-01-18

Finding date

2015-04-13

Cause of death

cardiac hypertrophy (longstanding heart disease) complicated by chronic renal failure (chronic glomerulonephritis) and ventricular arrhythmia

AI-generated summary

Raymond McDonald, 49 years old, died in custody at Darwin Correctional Centre from cardiac hypertrophy with underlying chronic renal failure and ventricular arrhythmia. He had presented 16 times with chest pain over 12 months and had multiple abnormal ECGs showing prolonged QTc intervals between 2011-2014. Although prison body count protocols were not fully complied with, this did not contribute to his death. The coroner found medical staff appropriately followed protocols and took his complaints seriously. However, the coroner recommended that prisoners with prolonged QTc on ECG and recurrent chest pain should receive further cardiac evaluation by a cardiologist and formal risk stratification. No foul play was identified. The underlying cardiac condition would have been difficult to detect and treat earlier, though further investigation may have enabled preventive therapy.

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Specialties

cardiologygeneral practicecorrectional healthpsychiatryforensic medicine

Error types

diagnosticdelay

Clinical conditions

cardiac hypertrophychronic glomerulonephritischronic renal failureventricular arrhythmiaprolonged QTc intervalhypertensionschizophreniachronic alcohol abuselatent tuberculosisHelicobacter pylori infection

Contributing factors

  • cardiac hypertrophy secondary to hypertension
  • chronic glomerulonephritis causing chronic renal failure
  • prolonged QTc interval on multiple ECGs
  • absence of further cardiac evaluation despite recurrent chest pain presentations
  • absence of beta-blocker therapy
  • patient refusal of further medical assessment

Coroner's recommendations

  1. That the Northern Territory Department of Health ensure that all prisoners with electrocardiograms (ECGs) developing prolonged QTc intervals should be referred for further cardiac evaluation by a cardiologist.
  2. That the Northern Territory Department of Health ensure that all prisoners with recurrent chest pains, even those considered atypical, be referred for further cardiac screening and risk stratification.
Full text

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