Coroner's Finding: Esposito, Pasquale

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 22nd day of February and the 14th day of April 2022, by the Coroner’s Court of the said State, constituted of Ian Lansell White, Deputy State Coroner, into the death of Pasquale Esposito.

The said Court finds that Pasquale Esposito aged 76 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at the Lyell McEwin Health Service, Haydown Road, Elizabeth Vale, South Australia on the 10th day of February 2020 as a result of combined effects of acute myocardial infarction and urosepsis.

The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Pasquale Esposito was born on 23 January 1944 and died on 10 February 2020 at the Lyell McEwin Hospital. He was 76 years of age.

1.2. Mr Esposito's hospital casenotes were made available to Forensic Science South Australia.1 They were assessed by Dr Iain McIntyre and discussed with Dr Alexandra Yuill in a pathology review. The suggested cause of death from this pathology review at FSSA was the combined effects of acute myocardial infarction and urosepsis.2 I accept that suggestion and make a finding accordingly.

1.3. This is a mandatory inquest pursuant to Section 21 of the Coroners Act 2003, as amended, as Mr Esposito was in the custody of the Department for Correctional

1 FSSA 2 Exhibit C2a

Services3 at the time of his death. He had been in the custody of DCS since 3 November 1997 following his arrest for two charges of murder. He subsequently pleaded guilty to those charges and received a sentence from the Supreme Court of South Australia on 10 September 1998 of life imprisonment, with a non-parole period of 21 years. There are no concerns in relation to the lawfulness of his custody. He became eligible to apply for release on parole on 2 November 2018. A subsequent application for parole after that date was refused.

2. Background 2.1. Mr Esposito was born in Avellino in Italy and had one sister, Maria Votino. In 1956 he migrated with his family to South Australia. He returned to Italy in 1965 for a holiday and whilst there he was conscripted into the Italian Army where he served for a period of 18 months before returning again to South Australia.

2.2. In 1979 Mr Esposito met Mary Lopresti who he married. They had three children. In 1997 Mr Esposito's wife informed him that she wanted a divorce and on 2 November 1997 he shot her and her mother at close range, causing fatal injuries. He was arrested on two murder charges the following day and had been in the custody of the DCS ever since. These are the two murders that I referred to at the outset.

3. Mr Esposito’s medical history 3.1. Mr Esposito had a longstanding history of diabetes. He suffered from hypertension and significant coronary artery disease. He had been a smoker from the age of 16. He suffered a heart attack in prison in January 2010. He was at the Mobilong Prison at the time and underwent CPR for 15 minutes before being hospitalised.

3.2. During this hospital admission, he was discovered to have been suffering from a series of blocked cardiac arteries. A coronary artery bypass graft was performed to re-establish blood flow to his heart. Following the first heart attack Mr Esposito continued to have heart issues and poor health that impacted on the blood flow to his limbs. In 2018, he underwent a femoral endarterectomy which involved scraping

3 DCS

plaque from his left femoral artery, as well as the insertion of stents higher up his left leg.

3.3. Ultimately, he had to have part of his left toe amputated. It became gangrenous after an earlier toenail repair which did not heal properly due to the poor blood flow to his left foot. Subsequently, those same issues with poor blood flow meant that the wound for the amputated toe did not heal properly. It became necrotic and his left leg had to be amputated below the knee in March 2017. There was nothing further that could be done to restore blood flow to his lower leg.

3.4. During that hospital admission for the amputation of his lower left leg, Mr Esposito suffered from atrial fibrillation which was thought to be the result of stress from his already damaged heart and from the anaesthetic that he needed for his surgery.

4. Mr Esposito’s decline in health and death 4.1. On 31 August 2019, a code black medical emergency was called in the prison on account of Mr Esposito experiencing chest pain which radiated down his arm and low blood pressure. He was taken to the Royal Adelaide Hospital4 and was diagnosed to be having a heart attack. An angiogram showed that the grafts inserted after his first heart attack in 2010 were still present, but the peripheral vessels that led to the heart were becoming stenosed. On 9 September 2019 stents were put in place for those stenosed vessels. At that time, Mr Esposito was diagnosed with chronic obstructive pulmonary disease5, most likely caused by his long-term smoking.

4.2. I turn to the proximate circumstances of Mr Esposito's death. On 6 February 2020, Mr Esposito was reviewed in the prison health centre after reporting that he was experiencing ear pain. At that stage nothing of concern was noted. The following morning on 7 February 2020, he presented at the prison health centre with shortness of breath, chest pain, pain radiating down his left arm, elevated blood pressure and a temperature. Mr Esposito was conveyed to the Lyell McEwin Hospital by ambulance

4 RAH 5 COPD

where he continued to present with shortness of breath, and at that stage, chest pain.

He also had increased urinary frequency and jaw pain.

4.3. He was febrile and his white cell count was significantly elevated, which was consistent with him suffering from an infection. His C-reactive protein level was significantly elevated. A decision was made at that stage not to perform an angiogram, as Mr Esposito had undergone one a few months beforehand which did not show any blockages. He was assessed as having an infection that had precipitated further heart failure and a small heart attack.

4.4. The following day, whilst still in hospital, Mr Esposito’s breathing appeared to have improved. He was no longer complaining of chest pain and his heart rate and blood pressure had returned to normal. Blood tests returned a positive result for the presence of a bacteria and he remained stable until 10pm on 8 February 2020, when his heart rate increased significantly.

4.5. It was thought that Mr Esposito, on that occasion, had a small non-STEMI heart attack, precipitated by an infection. Mr Esposito was given non-invasive ventilation and antibiotics for the infection.

4.6. On 8 February 2020, Mr Esposito showed signs of improvement and was no longer suffering from chest pains.

4.7. Later that day at about 10pm his heart rate became elevated and he was in atrial fibrillation. On 9 February 2020, Mr Esposito was described as septic. He had heart failure, an acute pulmonary oedema and his troponin levels were over 1000. He had also suffered an acute kidney injury. At about 10pm on 9 February 2020, Mr Esposito experienced a pulseless electrical activity cardiac arrest. He underwent successful CPR, resulting in admission to the ICU where he was placed onto dialysis.

4.8. At about 6:06am on 10 February 2020, Mr Esposito experienced a further pulseless electrical activity cardiac arrest. CPR and adrenaline were administered. Mr Esposito went into ventricular fibrillation. After shocks had been administered he regressed to pulseless electrical activity. Subsequently, after 12 minutes of CPR being administered, his life was declared life extinct at 6:18am on 10 February 2020.

5. Conclusion and recommendation 5.1. Consistent with the conclusions in the report of the investigating officer, Detective Brevet Sergeant James Clegg, I find Mr Esposito was in lawful custody at the time of his death. The circumstances surrounding his death are not suspicious, and do not indicate the involvement of any third party or concerns relating to his care.

5.2. I have 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 14th day of April, 2022.

Deputy State Coroner Inquest Number 26/2021 (0287/2020)