Coroner's Finding: CATINO Giovanni

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 5th day of March 2019 and the 8th day of May 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Giovanni Catino.

The said Court finds that Giovanni Catino aged 91 years, late of 23 Bice Street, Marleston, South Australia died at the Repatriation General Hospital, 216 Daws Road, Daw Park, South Australia on the 12th day of January 2016 as a result of ischaemic and hypertensive heart disease. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Mr Giovanni Catino was 91 years of age when he died on 12 January 2016 at the Repatriation General Hospital (RGH). At the time of Mr Catino's death he was subject to a Level 2 Inpatient Treatment Order (ITO) that had been made pursuant to the Mental Health Act 2009. Accordingly, Mr Catino's was a death in custody within the meaning of that expression in the Coroners Act 2003 and this inquest was held as required by section 21(1)(a) of that Act.

2. Cause of death 2.1. Mr Catino’s cause of death was determined by a post-mortem examination conducted by Dr Stephen Wills of Forensic Science South Australia. In his report1 Dr Wills gave the cause of death as ischaemic and hypertensive heart disease, and I so find.

1 Exhibit C2a

3. Background and medical history 3.1. Mr Catino was born in Molfetta, Italy on 2 March 1924. He was a fisherman and then later a cook in the navy. He served in World War 2. Mr Catino married in 1945 and had five children. The family migrated to Australia in 1962 and Mr Catino worked as a bus driver upon arrival in Australia. His previous medical history included treatment for ischaemic heart disease, chronic renal impairment, anaemia and type 2 diabetes.

3.2. Mr Catino was diagnosed with Alzheimer's dementia in 2008. Following this there was a steady decline in his functioning as the behavioural and psychological symptoms of dementia progressed. He was originally treated in the community with the assistance of the RDNS and Domiciliary Care, but due to increased resistance to care, it became necessary for Mr Catino to transfer to a nursing home.

4. Mr Catino’s detention under the Mental Health Act 2009 4.1. Mr Catino was first admitted to the RGH on 1 October 2015 following transfer from the Flinders Medical Centre on a Level 1 ITO. The order had been instituted following a code black event. The ITO was reviewed and a Level 2 ITO was made on 6 October 2015 as Mr Catino had attempted to abscond from the RGH. This order was allowed to expire because Mr Catino's behaviour settled.

4.2. On 17 November 2015 Mr Catino was again placed under a Level 1 ITO which was confirmed on 19 November 2015 by psychiatrist and psychogeriatrician, Dr Richard Weeks. Dr John Veale placed Mr Catino on a Level 2 ITO on 25 November 2015. This ITO was confirmed with an expiry of 2pm on 13 January 2016.

4.3. According to Dr Veale, the ITO in this circumstance was put in place for Mr Catino to have continued treatment and to prevent him leaving the hospital due to his history of attempting to abscond. It would also allow nursing staff to deliver proper nursing care.

With multiple records of aggression and other behaviours to compromise his treatment, Mr Catino's treating doctors regarded the orders as appropriate and necessary.

4.4. In addition to the ITO, Mr Catino was subject to an order under section 32 of the Guardianship and Administration Act 1993 with guardianship granted to Mr Catino's daughter, Ippolita Lellmann.

5. Mr Catino’s death 5.1. On the evening of 12 January 2016 Mr Catino had been displaying the symptoms of his illness including restlessness, yelling and intrusive behaviours that involved him wandering into other patients’ rooms. At 9pm a 500mcg dose of clonazepam was administered to Mr Catino. Clonazepam is a sedating anti-psychotic medication prescribed to Mr Catino on his PRN2 medication chart.

5.2. He was redirected to his room and left for 30 minutes whilst the medication took effect.

At this time his other regular medications were prepared for the evening. Nurse Bhalla attended to administer Mr Catino's medications at approximately 9:30pm. Mr Catino was lying in his bed unresponsive. A code blue was called and the intensive care critical care unit attended. Cardiopulmonary resuscitation was performed for approximately 30 minutes as per advanced life support protocol. There was no return of spontaneous circulation.

6. Investigation and conclusions 6.1. Mr Catino's death in custody was investigated by Detective Brevet Sergeant Barber of SAPOL. Detective Barber’s report3 sets out a timeline of events concerning Mr Catino, including his diagnosis and the occasion of his death. Detective Barber concluded that the care and treatment afforded to Mr Catino whilst detained at the RGH was appropriate. Detective Barber did not identify any deficiency in Mr Catino's care or management whilst he was a patient.

6.2. I note that a concern was raised in the statement4 of Mr Catino's daughter, Ippolita Lellmann, indicating that she was worried about the effect of the sedating drug Mr Catino received before his death. I hope that Ms Lellmann will be reassured by the post-mortem toxicological analysis of preserved peripheral blood which does not suggest that clonazepam could have contributed to his death. Furthermore, the pathologist, Dr Wills, has excluded it as a factor in the cause of death found at autopsy.

2 PRN is defined as ‘as required’ 3 Exhibit C12a 4 Exhibit C6

6.3. I conclude that the treatment Mr Catino received during his period of detention was appropriate and thorough. Mr Catino's detention did not contribute to his death in any way.

6.4. I have no recommendations to make in this matter.

Key Words: Death in Custody; Inpatient Treatment Order; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 8th day of May, 2019.

State Coroner Inquest Number 1/2019 (0087/2016)