Inquest into the Death of Kevin Ernest McCRACKEN
Deceased
Kevin Ernest McCRACKEN
Demographics
58y, male
Date of death
2020-07-11
Finding date
2022-05-20
Cause of death
Hypertensive and valvular heart disease
AI-generated summary
Kevin McCracken, 58, died of hypertensive and valvular heart disease following sudden cardiac collapse in a prison pre-release unit. He had complex pre-existing cardiac disease including previous valve replacement and aortic surgery with severe left ventricular hypertrophy. The coroner found his medical management in prison was appropriate and commensurate with community care standards, with regular cardiology review, comprehensive monitoring, and timely acute management. However, a Code Red medical emergency was not called initially despite prison procedures requiring it for life-threatening incidents—though this did not adversely affect outcomes given the rapid response by nearby staff. Five medication errors occurred over three years but were detected promptly with no adverse consequences. The death was not preventable given his underlying cardiac pathology and the extensive investigations and monitoring that had been undertaken.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Severe left ventricular hypertrophy
- Marked cardiomegaly
- Coronary artery atherosclerosis
- Multifocal scarring of heart muscle
- Cardiac arrhythmia
- Previous cardiac surgery with mechanical aortic valve prosthesis
Coroner's recommendations
- Educate prison staff on Code Red requirements for medical emergencies and ensure processes are initiated to guarantee adequate staff attendance and stopped radio traffic during a Code Red emergency
- Amend Standing Order 11.1 'Security & Control' to reflect requirements for calling Code Red medical emergencies
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