Coroner's Finding: MITTIGA Saverio

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 10th day of October 2019 and the 15th day of January 2021, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Saverio Mittiga.

The said Court finds that Saverio Mittiga aged 89 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at Northfield, South Australia on the 6th day of June 2016 as a result of multi-organ failure on a background of advanced dementia and small cell lung cancer. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for inquest 1.1. Saverio Mittiga was born on 14 April 1927 and died at the Yatala Labour Prison Health Centre on 6 June 2016. He was 89 years old. This is a mandatory inquest pursuant to section 21(1)(a) of the Coroners Act 2003, as at the time of Mr Mittiga's death he was a prisoner serving a term of imprisonment of 15 years with a non-parole period of 11 years, which commenced on 8 July 2010, for three counts of indecent assault, two counts of unlawful sexual intercourse, two counts of aggravated indecent assault and one count of gross indecency. He was eligible for release on parole on 7 July 2021.

Mr Mittiga was therefore in lawful custody at the time of his death.

2. Cause of death 2.1. I find Mr Mittiga’s cause of death to be as suggested in a pathology review by Dr Iain McIntyre1 from Forensic Science South Australia, namely multiple organ failure with advanced dementia and small cell lung cancer.

3. Mr Mittiga’s medical care whilst in custody 3.1. Mr Mittiga entered prison as an 83-year-old man with complex health issues. His family doctor expected that Mr Mittiga would die whilst he was in prison. At the time of this death, Mr Mittiga was receiving end of life care for advanced dementia and small cell lung cancer. Other health issues included ischaemic heart disease, chronic obstructive airways disease, type 2 diabetes and peripheral neuralgia.

3.2. Mr Mittiga was first incarcerated at Mount Gambier Prison, where prison medical officer Dr Letitia Kavanagh was responsible for the medical care of prisoners, including Mr Mittiga. Dr Kavanagh states that Mr Mittiga was seen very regularly whilst incarcerated, due to his medical conditions. He was also treated at the Royal Adelaide Hospital on five occasions, which included a six-day admission from 12 January 2012 due to left-side chest pain.

3.3. On 16 August 2012, Mr Mittiga was seen by a renal specialist in relation to his kidney function. Dr Kavanagh noted that Mr Mittiga was becoming increasingly hard to mobilise and was becoming more frail. From 28 August 2013 Mr Mittiga was transferred to Yatala Labour Prison, where he remained until 26 February 2014, to address his mobility difficulties and for treatment of his diabetes. He was then returned to Mount Gambier Prison.

3.4. By 2015 it was evident to Dr Kavanagh that Mr Mittiga’s health was deteriorating significantly. In June 2015 she certified him as unfit for the work program in the prison.

On 3 August 2015 Dr Kavanagh conducted a mental state examination in which Mr Mittiga scored 15/30, suggesting he was suffering from dementia. He was treated with antibiotics on the basis of a differential diagnosis that an infection in his bladder was causing his confusion.

1 Exhibit C2

3.5. On 5 August 2015 and again on 12 August 2015 Dr Kavanagh wrote suggesting that Mr Mittiga should be moved to an infirmary. At the date of hearing the inquest it was not clear how those letters were dealt with. An affidavit of Angela Yvonne Gransden dated 12 May 2020 has been provided in response to a request I made for information in relation to that issue.2 Ms Gransden is the Director, Operational Support and Performance for the Department for Correctional Services and explains that it is not now clear from the records of G4S, the private operator of the Mount Gambier prison, or from the records of the Department for Correctional Services, exactly how these letters were dealt with. However, she states a Special Case Review of Mr Mittiga was conducted by the Mount Gambier Prison G4S Case Management Coordinator in September 2015. She postulates that it is likely that the letters from Dr Kavanagh triggered the Special Case Review which recommended on 24 September 2015 that Mr Mittiga be considered for transfer to the new Therapeutic Treatment Unit, which was expected to open at the Yatala Labour Prison by the end of 2015.

3.6. On 29 November 2015, Mr Mittiga was sent to Mount Gambier Hospital Emergency Department due to chest pain. It was considered that the pain was due to gastritis and a fluid restriction was imposed to control his oedema.

3.7. A further Special Case Review was completed by the Case Management Coordinator on 18 December 2015, and appears to have addressed the apparent further decline in Mr Mittiga's overall health. It recommended that Mr Mittiga be transferred to Yatala Labour Prison on 21 December 2015 and that he remain there pending the opening of the new High Dependency Unit which, by then, was expected to open in January 2016.3

3.8. On 21 December 2015, Mr Mittiga was transferred to Yatala Labour Prison, where he was initially housed in E Division, which at that time was co-located with the Health Centre. Then on 27 December 2015 he was moved to the Health Centre, where he remained until 20 March 2016, except during hospital admissions from 17 to 26 January 2016, 27 January to 8 February 2016 and 26 February to 4 March 2016.

3.9. Dr Farrall, a medical officer at Yatala Labour Prison, states that on 18 January 2016 a CT scan showed multiple mediastinal lymph nodes, and that Mr Mittiga's cancer was 2 Exhibit C18 3 The same Therapeutic Treatment Unit referred to in the Special Case Review on 24 September 2015

at a stage for palliative care.4 On 26 February 2016, with his condition rapidly deteriorating, Dr Farrall drew up a seven-step pathway, an end of life plan.

3.10. On 21 March 2016, Mr Mittiga was moved to the High Dependency Unit, the newly opened aged care unit at Yatala Labour Prison. On 27 May 2016 he was moved back to the Yatala Labour Prison Health Centre for more intensive care. During this time he was prescribed morphine for pain and clonazepam for agitation. Nursing staff continued to administer these medications and treat his pain.

4. Mr Mittiga’s death 4.1. On 6 June 2016 Sarah Legg was on duty with another nurse, Sophia Jackowicz, providing care to Mr Mittiga.5 At 9am he was given a bed bath and provided with 2mg of morphine before being locked in his Health Centre cell. Periodic checks were conducted throughout the morning through the window of his cell. At 11am a further 2mg of morphine was administered for pain and he was provided with pressure area care and mouth toilet. Throughout the morning Mr Mittiga was unconscious and did not respond to verbal cues. His breathing was rapid but regular and he appeared comfortable. At 12:30pm, Ms Legg conducted a visual check on Mr Mittiga in his cell and he appeared no longer to be breathing. The cell door was opened and life was declared extinct at 12:34pm by Dr Farrall. Helen Stead, an enrolled nurse at the prison, identified the body of Mr Mittiga.6

5. Conclusion 5.1. The SAPOL investigation revealed no suspicious circumstances surrounding the death of Mr Mittiga, nor were there any concerns relating to his care, nor involvement of any third party.

5.2. Detective Brevet Sergeant Leverington, who conducted the investigation, suggested that consideration should be given to the establishment of an infirmary and aged care facility at the Mount Gambier Prison. Ms Gransden advised in her statement that the High Dependency Unit at the Yatala Labour Prison was officially opened on 2 February 2016 and provides accommodation for prisoners with high care needs due to mental 4 Exhibit C4 5 Exhibit C3, Statement 6 Exhibit C1a

health requirements, age or infirmity due to other cause.7 It is intended as a state-wide facility to which prisoners who meet the criteria for such accommodation may be transferred, if their needs cannot be met elsewhere in the prison system. I assume for the purposes of this inquest that this facility satisfactorily provides for those needs. I have heard no evidence to the contrary.

5.3. Mr Mittiga was 83 years of age when he entered the prison system as a sentenced prisoner and I find that during his incarceration he was provided with appropriate care, both non-medical and medical, until his death due to natural causes on 6 June 2016 at the age of 89 years.

6. Recommendations 6.1. I make no recommendations Key Words: Death in Custody; Prison; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 15th day of January, 2021.

State Coroner Inquest Number 29/2019 (1023/2016) 7 Exhibit C18