Finding into death of John Salemme

IN THE CORONERS COURT COR 2022 002890 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Paresa Antoniadis Spanos Deceased: John Salemme Date of birth: 18 March 1974 Date of death: 29 May 2022 Cause of death: 1(a) Cardiac hypertrophy, combined with effects of gamma hydroxybutyrate and amphetamines Place of death: 5/318 Haughton Road, Clayton, Victoria, 3168 Key words Accurate information to emergency services; Disclosure of substance use; GHB; Amphetamines

INTRODUCTION

1. On 29 May 2022, John Salemme was 48 years old when he was found deceased at his friend’s house in Clayton, Victoria. At the time, Mr Salemme lived in Noble Park, Victoria.

2. Mr Salemme was born in Caulfield to parents Liliana and Franco Salemme. He had two sisters and was the middle child. The family was of Italian heritage and when Mr Salemme was about 12 years old, he moved to Italy for several years with his Nonna. When he was about 15 years old, he returned to Australia and commenced work as a butcher. After an injury suffered when struck by a car, Mr Salemme changed career and became a painter.

3. By the early 2000s, all of Mr Salemme’s family had returned to live in Italy. From this point onwards he only had sporadic contact with his family.

4. Mr Salemme attended multiple General Practitioners (GPs) of the Hanover Street Medical Centre (the clinic). Medical records obtained from the clinic suggest Mr Salemme did not have any known medical history and was not treated for any significant underlying natural disease.

5. On 23 May 2022, he presented to Dr Karoly Albert of the clinic and complained of intermittent numbness in his hands due to his occupation as a painter. Dr Albert diagnosed him with carpal tunnel syndrome and the following day administered a depo-medrol injection to treat the condition. The evidence suggests this was Mr Salemme’s last consultation with a medical professional. No other issues were raised during the consultation.

THE CORONIAL INVESTIGATION

6. Mr Salemme’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.

7. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

8. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of

comments or recommendations in appropriate cases about any matter connected to the death under investigation.

9. Victoria Police assigned Detective Senior Constable Amelia Kelly to be the Coroner’s Investigator for the investigation of Mr Salemme’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

10. This finding draws on the totality of the coronial investigation into the death of John Salemme including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased

11. On 29 May 2022, John Salemme, born 18 March 1974, was visually identified by his friend, who signed a formal Statement of Identification to this effect.

12. Identity is not in dispute and requires no further investigation.

Medical cause of death

13. Forensic Pathologist Dr Hans De Boer, from the Victorian Institute of Forensic Medicine (VIFM), conducted an autopsy on Mr Salemme’s body in the mortuary on 6 June 2022 and provided a written report of his findings dated 7 October 2022.

14. The autopsy showed evidence of cardiac hypertrophy (enlarged heart) with heart weight recorded in the >95th percentile for height, weight and sex. There was evidence of mild fibrosis2 and mild coronary artery atherosclerosis (blockage). Dr De Boer advised that ‘cardiac hypertrophy may eventually result in dysfunction of the heart muscle, causing cell damage 1 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

2 Thickening or scarring of the tissue.

and fibrosis and that fibrosis in turn alters the electroconductive of the heart, which can cause (fatal) cardiac arrhythmias’.

15. Fatty liver and mild lymphocytic thyroiditis were identified, however, these were considered incidental findings not related to the cause of death.

16. Minor injuries were observed to the head, abdominal wall and both hands. Injuries to the ribs and heart were consistent with the application of cardiopulmonary resuscitation (CPR). There was no evidence of any injuries that could have caused or contributed to death.

17. Routine toxicological analysis of post-mortem samples detected Gamma Hydroxybutyrate (GHB),3 and methylamphetamine4 and amphetamine.5 No alcohol or other commonly encountered drugs or poisons were detected.

18. Dr De Boer advised that amphetamines (including methylamphetamine) increase the risk of cardiac arrhythmias, especially where there is underlying natural disease.

19. Dr De Boer provided an opinion that the medical cause of death was 1(a) cardiac hypertrophy, combined with effects of gamma hydroxybutyrate and amphetamines.

20. I accept Dr De Boer’s opinion.

Circumstances in which the death occurred

21. On the evening of 28 May 2022, Mr Salemme was at his home in Noble Park with his friend, Mr SD, and his two other housemates. The group all smoked what MR SD described was a small amount of the drug ‘ice,’ before Mr Salemme and MR SD left to go to their friend, Ms KH’s house in Clayton at about 1.30am.

22. They arrived at Ms KH’s house where Mr Salemme had a couple of glasses of milk. Shortly after the pair arrived, Ms KH left the house leaving Mr Salemme and MR SD in the property.

At some point while at Ms KH’s house, Mr Salemme used GHB. MR SD stated he did not see him take the substance but did notice a change in his demeanour consistent with his observations of Mr Salemme when he had used GHB in the past.

3 GHB is a colourless, odourless and slightly salty tasting liquid freely soluble in water. It has no legitimate therapeutic use in Australia.

4 Methylamphetamine (“speed” or “ice”) is a strong stimulant drug used recreationally.

5 Amphetamines is a collective word to describe central nervous system (CNS) stimulants structurally related to dexamphetamine.

23. At around 3.00am, Ms KH returned to her property. Mr Salemme was heavily intoxicated and, according to MR SD, “wasn’t in total in control of his actions.”6 MR SD tried to get Mr Salemme to their car to take him home, but he forcefully resisted. Mr Salemme was overheating and appeared as if he was panicked.

24. With the assistance of MR SD, Mr Salemme reached the front courtyard where he continued to deteriorate and to resist MR SD’s efforts to get him into the car. After a brief struggle, Mr Salemme collapsed in the front garden.

25. MR SD contacted emergency services at 5.39am and requested assistance. A transcript from the call shows that MR SD advised that Mr Salemme was intoxicated from alcohol, was conscious and breathing, and had not taken any other substances. Based on the information provided, the emergency services operator arranged for a nurse to contact MR SD and conduct a further assessment at a later. Concerned over the noise levels from the commotion, Ms KH again left the residence.

26. After the call with emergency services, MR SD contacted Mr AH, a mutual friend of his and Mr Salemme, and asked him to come and help. Mr AH arrived a short time later and found Mr Salemme lying on his right side near the front door of Ms KH’s unit. His face was blue, and he was not breathing.

27. MR SD again contacted emergency services at 6.36am and reported that Mr Salemme was now not breathing. On the instructions from the emergency services operator, Mr AH began

CPR.

28. Ambulance Victoria paramedics responded a short time later. They did not detect any signs of life and formally verified that Mr Salemme was deceased at the scene at 6.55am on 29 May 2022.

29. Victoria Police members also attended the scene a short time later. As Ms KH was not present and her residence was locked, police obtained a search warrant and forced entry to the property. Police did not locate anything to suggest Mr Salemme died in suspicious circumstances.

6 Statement of Simon Doyle dated 29 May 2022

FINDINGS AND CONCLUSION

30. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was John Salemme, born 18 March 1974; b) the death occurred on 29 May 2022 at 5/318 Haughton Road, Clayton, Victoria, 3168; c) the cause of Mr Salemme’s death was cardiac hypertrophy, combined with effects of gamma hydroxybutyrate and amphetamines; and d) the death occurred in the circumstances described above.

31. The available evidence supports a finding that Mr Salemme’s death was the result of significant underlying and previously unknown cardiac disease, in combination with the deliberate ingestion of illicit drugs.

32. The evidence in this matter does not enable a finding that the outcome for Mr Salemme would have been different if accurate information about his use of substances had been communicated to the emergency services operator in the first instance. However, it is likely that the emergency services response and medical response would have been escalated, and Mr Salemme would have had a better chance of survival.

COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.

1. This case highlights the importance of relaying accurate information to emergency services operators, and care providers in general, about any substances a person has consumed prior to a medical emergency.

2. When MR SD contacted emergency services for the first time at 5.39am on 29 May 2022, he reported to the emergency services operator that Mr Salemme “maybe had a bit too much to drink or something.”7 The emergency services operator appropriately asked on two separate occasions if Mr Salemme had used anything other than alcohol. MR SD reported that he had not. In reality, the pair had smoked ‘ice’ together earlier in the evening and MR SD strongly 7 Transcript of 000 call, pg 43 Coronial Brief.

suspected his friend had used GHB due to his behaviour. This was later confirmed by postmortem toxicological testing.

3. Based on the information provided, the emergency services operator arranged a nonemergency response for a nurse to later call back. In the circumstances, I consider the actions of the emergency services operator reasonable and appropriate.

4. The role of emergency services operators is to arrange the emergency care required by a patient. Accurate information is vital for this role to be effectively performed. Questions regarding substance use, such as in this matter, are asked to assist in forming a medical response, not to inform police of potential illicit substance use.

Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I convey my sincere condolences to Mr Salemme’s family for their loss.

I direct that a copy of this finding be provided to the following: Franco & Liliana Salemme, senior next of kin Ambulance Victoria Emergency Services Telecommunications Authority Detective Senior Constable Amelia Kelly, Victoria Police Coroner’s Investigator Signature: ___________________________________ Coroner Paresa Antoniadis Spanos Date : 30 June 2023 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.