Finding into death of Ralph James McCracken

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: 1208/11

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008 Inquest into the Death of RALPH JAMES MCCRACKEN Delivered On: 29 November, 2011 Delivered At: Coroner’s Court of Victoria Level 11, 222 Exhibition Street Melbourne Victoria 3000 Hearing Dates: 29 November, 2011 Findings of: CORONER KIM M W PARKINSON

Police Coronial Support Unit: Leading Senior Constable King Taylor

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I, KIM PARKINSON, Coroner having investigated the death of RALPH MCCRACKEN

AND having held an inquest in relation to this death on 29 November, 2011 at Melbourne

find that the identity of the deceased was RALPH JAMES MCCRACKEN born on 3rd September, 1945

and the death occurred on 3rd April, 2011

at St Vincent’s Hospital, Victoria Parade, Fitzroy, Victoria 3065

from:

la, COMPLICATIONS OF END STAGE CHRONIC OBSTRUCTIVI

PULMONARY DISEASE

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in the following circumstances:

1, Mr McCracken was born on 3 September 1945 and was 65 years old at the time of his death. Mr McCracken had a past medical history of cholecystectomy in 1992, oesophageal dysphasia, atrial fibrillation, epilepsy and depression,

2. Mr McCracken was a person in custody as defined by s3(e) of the Coroners Act 2008 ("the Act") and accordingly his death was reportable pursuant to s5(c) of that Act. An inquest into his death is mandatory pursuant to s52(2)(b) of the Act.

3. On 24 January 2011, Mr McCracken was admitted to St Vincent's Hospital, St Augustine’s Ward, with an ischaemic left leg. He underwent an urgent femoral embolectomy. After the operation the blood flow to his leg improved, however he developed compartment syndrome, necessitating further surgical intervention.

4. Post surgery he developed abdominal pain, After investigations, including CT, he was found to have developed pancolitis and underwent further surgery. Colorectal surgeon, Dr Jamie Keck reports that he was found to have extensive pancolitis with a perforation of the sigmoid colon, He underwent subtotal colectomy with formation of an ileostomy, He made a slow recovery from the surgery and developed respiratory infections, He was admitted to the Intensive Care Unit for one week after surgery.

Due to poor oral intake, a PEG tube was placed.

5. Dr Keck states that Mr McCracken was diagnosed with a pseudomonas chest infection and he developed some pseudomonas infection around his PEG tube. He also had abnormal liver function, which the surgeon attributes to the drugs he was taking during his admission, including antibiotics. He was seen regularly by the gastroenterology clinicians during his admission, together with the colorectal unit and general medical registrar. He was also seen by the psychiatry unit for persistent depression. Mr McCracken signed a not for resuscitation order on 31 March 2011. He was assessed by psychiatrist Professor Ed Harari as competent to make decisions about his ongoing management, including a ‘not for resuscitation order.

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6. Mr McCracken’s condition continued to decline, including ongoing problems with nutrition, poor mobility and recurrent chest infections. A CT scan showed a lung abscess and worsening pneumonia. Mr McCracken died on 3 April 2011.

7, An examination and report was undertaken by Dr Matthew Lynch, Senior Forensic Pathologist of the Victorian Institute of Forensic Medicine. Dr Lynch commented that his findings upon examination were consistent with the medical history and that a post mortem CT scan revealed emphysema with pulmonary consolidation and right upper lobe consolidation. He reported that a reasonable medical cause of death may be stated as complications of end stage chronic obstructive pulmonary disease.

8. Having considered the available evidence, I am satisfied that Mr McCracken died from natural causes. I am satisfied that his care and management was reasonable and appropriate. I find that Mr Ralph McCracken died on 3 April 2011 and that the cause of his death was complications of end stage chronic obstructive pulmonary disease.

Signature:

KIM M W PARKINSON CORONER

29th November, 2011

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