Coroner's Court of Western Australia

Inquest into the Death of Kevin Ernest McCRACKEN

Inquest into the Death of Kevin Ernest McCRACKEN

Delivered on :20 May 2022

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Kevin Ernest McCracken (Mr McCracken) died on 11 July 2020 at Bunbury Regional Hospital from hypertensive and valvular heart disease. He was 58 years old. At the time of his death, Mr McCracken was a sentenced prisoner, and so accordingly, he was a ‘person held in care’ with respect to the Coroner’s Act 1996 (WA) in which a coronial inquest is mandatory.

Mr McCracken had a number of significant medical conditions when he was admitted on remand to Hakea Prison on 7 March 2015. He already had a complex cardiac disease, which included a heart valve replacement surgery in 1990, aortic arch surgery in 1997 and a severe ventricular hypertrophy.  In addition, he had been diagnosed with hypertension, pulmonary embolism, gastro-oesophageal reflux, osteoarthritis in the lumbar spine and osteoporosis. Mr McCracken also had complex regional pain syndrome in his right leg, following an injury in a 2013 workplace accident which resulted in chronic pain and issues with mobility. At the time of his admission into prison, Mr McCracken took daily blood pressure medications, analgesia and warfarin. He was later sentenced to terms of imprisonment and his earliest date for parole eligibility was 5 March 2025.

On 11 July 2020, Mr McCracken was housed in the pre-release unit at Bunbury Regional Prison. At about 3.10 pm, Mr McCracken walked into the kitchen area, paused for a moment, and then fell face-forward onto the floor. Another prisoner grabbed his arm as he fell, in an attempt to break his fall, and placed Mr McCracken in the recovery position. This prisoner believed that Mr McCracken was having a fit. Assistance for prison staff was called for and three prison officers quickly attended the kitchen with resuscitation equipment, including a defibrillator.  A short time after that, a prison nurse also attended. The nurse instructed staff to call a Priority 1 ambulance and commenced CPR.  St John Ambulance received the call and arrived at the prison at 3.32 pm.  Ambulance officers observed that Mr McCracken was in ventricular fibrillation, despite multiple shocks and doses of adrenaline being administered. His condition deteriorated to asystole prior to being placed in the ambulance.  Resuscitation efforts were maintained in transit to the Bunbury Regional Hospital. Despite extensive resuscitation attempts, Mr McCracken was pronounced dead at the Bunbury Regional Hospital at  4.24 pm on 11 July 2020.

The Coroner found Mr McCracken died from hypertensive and valvular heart disease and that his death occurred by way of natural causes.

The coroner was satisfied that Mr McCracken’s supervision, treatment and care he received whilst in custody was appropriate.

Catch Words : Death in Custody : Supervision, Treatment and Care : Natural Causes

Last updated: 18-Jul-2022

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