Inquest into the Death of Salvatore Giovanni OTRANTO

[2022] WACOR 26 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 17 MAY 2022 DELIVERED : 8 JUNE 2022 FILE NO/S : CORC 1110 of 2020

DECEASED : OTRANTO, SALVATORE GIOVANNI Catchwords: Nil Legislation: Nil Counsel Appearing: Sgt A Becker assisted the Coroner.

Ms E Tapsell (SSO) appeared for the Department of Justice.

Case(s) referred to in decision(s): Nil

[2022] WACOR 26 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Salvatore Giovanni OTRANTO with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 17 May 2022, find that the identity of the deceased person was Salvatore Giovanni OTRANTO and that death occurred on 9 June 2020 at Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, from complications following myocardial infarction and its treatment in a man with multiple severe comorbidities in the following circumstances:

TABLE OF CONTENTS

[2022] WACOR 26 INTRODUCTION

1. Salvatore Otranto was a sentenced prisoner when he died at Fiona Stanley Hospital on 9 June 2020 after a period of declining health. As he was a prisoner at the time of his death, Mr Otranto came within the definition of a ‘person held in care’ under the terms of the Coroners Act 1996 (WA) and a coronial inquest into his death is, therefore, mandatory.1

2. I held an inquest on 17 May 2022. At the inquest, extensive written material was tendered in relation to the WA Police and Department of Justice’s investigations into Mr Otranto’s death. Of particular relevance in this case, extensive information was provided about the medical care Mr Otranto received for his various health conditions prior to his death. In addition, two witnesses were called to give evidence at the inquest in person: Dr Joy Rowland, the Department’s Director of Medical Services, and Ms Toni Palmer, the Senior Review Officer in the Department’s Death in Custody Team.

BRIEF BACKGROUND

3. Mr Otranto was born in Maddaloni, a small town in Italy in 1951. He was one of nine children. He migrated to Australia with his family in 1968, when he was a young man. He qualified and gained work as a chef and enjoyed playing cards, soccer and Tae Kwon Do in his spare time. He later married Mary Otranto, with whom he had three children.2

4. In 2003, Mr Otranto pleaded guilty to, and was convicted of, child sexual offences.

He received a suspended term of imprisonment on 31 October 2003 in relation to those offences. As a result of those convictions, he became a reportable offender under the Community Protection (Offender Reporting) Act 2004 (WA). He was dealt with in 2008 and 2013 for non-compliance with some of his obligations under that Act, but did not serve any time in custody.

5. In December 2018, Mr Otranto was convicted after trial of a large number of further sexual offences, some historical and some more recent. On 5 April 2019, Mr Otranto was convicted of further historical sexual offences. On that date, Mr Otranto was remanded in custody for the first time, pending sentence.

6. On 7 May 2019, Mr Otranto was sentenced in the District Court of Western Australia to a total effective term of 4 years’ imprisonment, with eligibility for parole, for the offences the subject of the first trial, as well as breaching his original suspended term of imprisonment. The sentence was backdated to commence on 5 April 2019.3

7. On 25 September 2019, Mr Otranto was sentenced in the District Court of Western Australia to a further cumulative term of 7 years and 10 months’ imprisonment.

1 Section 22(1)(a) Coroners Act.

2 Exhibit 1, Tab 2 and Tab 9.

3 Exhibit 1, Tab 11A.

[2022] WACOR 26

8. The offending was diverse, and included offences when he was a young man, all the way through to not long before his arrest. Some of the offences occurred during the course of Mr Otranto’s employment as a chef, when he would prey upon much younger female staff members and subject them to unwanted sexual advances.

However, other offences occurred in homes and against many varied complainants.

Mr Otranto denied all of the offences and continued to maintain his innocence after his convictions.

9. Ultimately, Mr Otranto was required to serve a total effective sentence of imprisonment of 11 years 10 months’ imprisonment, with eligibility for parole, commencing on 5 April 2019. Accordingly, the earliest date upon which Mr Otranto was eligible to be considered for release on parole was 4 February 2029.4

10. At the time of sentencing, the Court was aware that Mr Otranto had complex health conditions, including being confined to a wheelchair due to an amputation of his right leg and requiring four daily injections of insulin for his diabetes. However, it was accepted that his conditions could be managed within the prison system and it was determined by both learned sentencing Judges that a lengthy immediate term of imprisonment was required, given the seriousness of the offending conduct.5

ADMISSION TO PRISON

11. Mr Otranto was first admitted to Hakea Prison as a new remand prisoner on 5 April 2019, and he spent a week at Hakea before being transferred to Casuarina Prison, where he was housed in the Infirmary due to his multiple health conditions.

Mr Otranto remained at Casuarina Prison in the Infirmary for the rest of his life, other than when he was admitted to hospital for treatment.

12. Mr Otranto’s past medical history was noted on admission as including:6

• ischaemic heart disease with coronary artery bypass grafting;

• congestive cardiac failure;

• permanent pacemaker for tri-fascicular heart block;

• diabetes mellitus requiring daily insulin injections;

• peripheral vascular disease;

• chronic obstructive pulmonary disease;

• right above knee amputation with peripheral neuropathy (phantom limb pain);

• acalculous cholecystitis;

• chronic kidney disease; and

• persistent E. Coli bacteraemia requiring lifelong antibiotics.

13. Mr Otranto was on a large number of regular medications for his complex and varied medical conditions. The same medical management was continued once he was in custody, adjusted as necessary by the prison doctors in consultation with his 4 Exhibit 2, Tab 2.

5 Exhibit 1, Tab 11A and 11B.

6 Exhibit 1, Tab 2 and Tab 7; Exhibit 2, Tab 34.

[2022] WACOR 26 specialists. The only change was that after a period of six months, his long-term antibiotic therapy was ceased. It appears that this cessation of medication was due to an oversight when his prescription ran out, rather than due to a decision by a doctor that the therapy should cease. Dr Rowland noted that the particular antibiotic, ciprofloxacin, is not a typical long-term antibiotic, which may have also led to some of the confusion. It is not suggested that this issue played a role in his death.7

14. Due to his multiple and serious co-morbidities, Mr Otranto was placed on the Terminally Ill Register as Stage 1 at an early stage.8

15. Mr Otranto was assessed by the physiotherapist early in his prison term and deemed to be at high risk of falls. He was taught techniques for transferring from chair to bed and how to manage his clothing to prevent falls.9 Mr Otranto did still experience several falls during his period of incarceration, but he did not suffer any major injuries as a result.

16. Mr Otranto’s mental health was also monitored, as he was at times noted to be visibly upset about the outcome of his court proceedings. He was offered prison counselling at these times, and he indicated he preferred to remain in the infirmary rather than be housed in the Crisis Care Unit (CCU), as he was comfortable there and had good peer support. It was noted he had limited contact with his family but had a strong Catholic faith, which was a protective factor at these times. There were no witnessed incidents of Mr Otranto trying to harm himself or others while in custody, although he was kept in the CCU briefly in October 2019 after making a threat to harm himself and suggesting he may have attempted to hang himself. This occurred around the time his brother died and after he was sentenced for the second time, so he was in a heightened emotional state. Mr Otranto gave assurances he would not harm himself and returned to the infirmary.10

17. Mr Otranto generally seemed content in the infirmary environment and made no complaints about his health care. He was more concerned with what he perceived to be the injustice surrounding his convictions and sentence. Mr Otranto was, at times, described as “surly”11 and “rude”12 but his behavioural issues were able to be dealt with fairly easily through direction and placement in his cell when necessary, and it did not escalate to loss of privileges.13

HOSPITAL ADMISSIONS

18. Mr Otranto had a number of hospital admissions due to acute medical episodes while serving his prison term.

7 T 12; Exhibit 2, Tab 34.

8 Exhibit 2, Tab 34.

9 Exhibit 2, Tab 34.

10 Exhibit 2, Tab 34.

11 Exhibit 2, Tab 24.

12 Exhibit 2, Tab 24.

13 Exhibit 2.

[2022] WACOR 26

19. On 2 June 2019, Mr Otranto was taken to Fiona Stanley Hospital (FSH) after suffering chest pains. He was diagnosed with acute cholecystitis. He was discharged from hospital and returned to Casuarina on 13 June 2019, but was transferred back to FSH with congestive cardiac failure and a chest infection on 15 June 2019.14

20. Mr Otranto was discharged again on 23 June 2019, but returned to hospital on 25 June 2019 after he collapsed. He was seen by cardiology in the Emergency Department and was diagnosed with trifascicular block (a0 type of heart block) and underwent insertion of a pacemaker at a later date in June.15

21. On 9 July 2019 Mr Otranto was returned to FSH by ambulance for hypotension. He was treated for his hypotension and also diagnosed with faecal loading, which was treated with aperients, and aspiration pneumonia, for which he was started on antibiotics. He was treated in hospital for four days before being discharged back to prison on 12 July 2019.16

22. On 20 July 2019, Mr Otranto was admitted to FSH with a diagnosis of acute on chronic renal failure. He received treatment before returning to prison on 23 July 2019.17

23. Mr Otranto had a further hospital admission on 26 September 2019 after he suffered an exacerbation of his congestive cardiac failure, with increasing peripheral oedema and exertional shortness of breath. He was discharged back to prison on 1 October 2019 after undergoing diuresis and intravenous antibiotics on the ward.18 He saw an optometrist on 9 November 2019 and was prescribed reading glasses.19

24. From that time, Mr Otranto had regular medical reviews, both within the prison and at outpatient appointments at FSH, as well as telehealth reviews during the COVID19 pandemic. He was reviewed by a podiatrist and physiotherapist several times in early 2020. It was noted Mr Otranto had requested a prosthetic limb, which was discussed with the Orthopaedics Team at FSH, who suggested a referral be made to the Rehabilitation Service.20

EVENTS OF 30 MAY 2020

25. On the morning of 30 May 2020, Mr Otranto complained to the health centre staff of chest pain and shortness of breath. He had a high pain rating and very high blood sugar level and an ECG reported as abnormal. It was suspected he was suffering from a heart attack, so an ambulance was called to attend and Mr Otranto was given aspirin and Glyceryl Trinitrate in the meantime.21 14 Exhibit 1, Tab 14.

15 Exhibit 1, Tab 14; Exhibit 2, Tab 34.

16 Exhibit 1, Tab 14.

17 Exhibit 1, Tab 14.

18 Exhibit 1, Tab 14.

19 Exhibit 1, Tab 10.

20 Exhibit 1, Tab 10.

21 Exhibit 1, Tab 10; Exhibit 2, Tab 34.

[2022] WACOR 26

26. The St John Ambulance Service received the request at 8.13 am and an ambulance arrived at the scene at 8.26 am. A history was obtained that Mr Otranto had been suffering from chest pains during the night, but had not reported them until 8.00 am that morning. He was transferred by ambulance, under ECG monitoring, to FSH Emergency Department. He was stable en route and arrived at the hospital at 9.18 am.22

FINAL HOSPITAL ADMISSION

27. Mr Otranto was admitted with chest and epigrastic pain, as well as shortness of breath when lying down. He was treated for a suspected NSTEMI (Non-ST Elevation Myocardial Infarction). His chest x-ray showed interstitial fluid in the lungs and a CT scan showed aortic atherosclerosis, bilateral pleural effusions and possible bruising to the left anterior abdominal wall (thought to be a haematoma from insulin injections).23

28. On 31 May 2020, a Medical Emergency Team (MET) call was made due to Mr Otranto’s lowered conscious level. He was found to have a low glucose level and was administered glucose. He slowly improved. Mr Otranto’s troponin level rose significantly, confirming NSTEMI (a ‘heart attack’) and he was managed with Clexane (an anticoagulant) and dual action antiplatelet medications.24

29. On 1 June 2020, another MET call was made following a further episode of chest pain and lowered oxygen saturations. A chest x-ray showed Mr Otranto was fluid overloaded and he was transferred to the Coronary Care Unit. Mr Otranto was also experiencing recurrent nose bleeds, and plans were made for cauterisation by the Ear, Nose and Throat doctors.25

30. On 2 June 2020, a coronary angiogram reported Mr Otranto’s vessels were unchanged since 2017, but his heart function was noted to be poor, with an ejection fraction of 35%. Ongoing medical management was recommended. Mr Otranto was still experiencing nose bleeds, which were thought to be exacerbated by his anticoagulant therapy as part of the management of his NSTEMI.26

31. Mr Otranto developed acute-on chronic renal failure, thought to be possibly related to the contrast medium used during the coronary angiogram. He was reviewed by the renal team and urgent dialysis was recommended.27

32. At the Coronary Care Unit ward round on 3 June 2020, Mr Otranto was noted to be drowsy and delirious. It was suspected that he had aspirated and he was commenced on intravenous antibiotics.28 22 Exhibit 1, Tab 10.

23 Exhibit 1, Tab 7 and Tab 14.

24 Exhibit 1, Tab 7.

25 Exhibit 1, Tab 7.

26 Exhibit 1, Tab 7.

27 Exhibit 1, Tab 7.

28 Exhibit 1, Tab 7.

[2022] WACOR 26

33. On 3 June 2020, Mr Otranto’s Terminally Ill Prisoner status was escalated to Stage 4 due to his rapidly deteriorating health. His wife’s ‘next of kin’ contact details were provided by the Department’s Health Services to Fiona Stanley Hospital.29 An entry was made in the security services records that a FSH doctor telephoned Mr Otranto’s wife on 4 June 2020.30

34. A VasCath (large bore catheter inserted into a major vein for kidney dialysis) was inserted on 3 June 2020 by a renal advanced trainee under the supervision of a consultant. A post procedure chest x-ray suggested the VasCath was in the correct position, in the superior vena cava, and Mr Otranto underwent dialysis that afternoon. About 15 minutes after his dialysis, Mr Otranto’s level of consciousness decreased and his blood pressure dropped, which initiated another MET call. He was administered metaraminol, a medication used to assist with increasing blood pressure. A portable chest x-ray showed the VasCath to be deviated but with no evidence of bleeding. At review by the Intensive Care Unit team, it was suspected the VasCath had been placed in the subclavian artery instead of the vein and this was confirmed on a CT scan.31

35. Mr Otranto was reviewed by the vascular surgical team and removal of the VasCath was performed on 5 June 2020, followed by stenting of the right subclavian artery, without complication. Mr Otranto was returned to the ICU, intubated and ventilated for post-operative care.32 Mr Otranto’s mechanical restraints were removed that day prior to his surgery as it was noted he would be chemically restrained by his anaesthetic. Mr Otranto continued to have no mechanical restraints while in recovery as he was in an induced coma.33 A single restraint was later reapplied late in the evening of 6 June 2020.34

36. On 5 June 2020, a Next of Kin notification was made to Mr Otranto’s wife regarding his sudden deterioration in health while in hospital. Mr Otranto’s wife was informed that his family could attend FSH and visit Mr Otranto if they wished to do so.

Mrs Otranto indicated she would contact other family members and inform them of this advice.35

37. On 7 June 2020, ICU records state that Mr Otranto was suffering from ongoing acute hepatitis, coagulopathy, anuric renal failure, encephalopathy and cardiogenic shock.

He was still intubated at this point and receiving intravenous antibiotics but sedation was being lowered, with the aim to extubate as soon as possible. 36

38. Mr Otranto was extubated on 8 June 2020 and was able to maintain his own airway, but he remained restless and his requirements for inotrope medications increased. On 9 June 2020, ICU records state that Mr Otranto was suffering from worsening cardiogenic shock, considered a grave diagnosis. An echocardiogram confirmed 29 Exhibit 2, Tab 18.

30 Exhibit 2, Tab 20, PIC Record of Events 264677.

31 Exhibit 1, Tab 7.

32 Exhibit 1, Tab 7.

33 Exhibit 2, Tab 20, PIC Record of Events 264685 - 7.

34 Exhibit 2, Tab 20, PIC Record of Events 264696.

35 Exhibit 2, Tab 9 and Tab 19.

36 Exhibit 1, Tab 7.

[2022] WACOR 26 these suspicions. This was thought to be related to further myocardial ischaemia on a background of his existing ischaemic heart disease. 37

39. Mr Otranto was considered too unwell to undergo further investigations or further coronary intervention. His prognosis was deemed to be poor. After discussions with his family and prison staff, Mr Otranto was confirmed to be ‘not for cardiopulmonary resuscitation or reintubation’ in the case of deterioration. At this time, Mr Otranto’s wife, and some other family members were in attendance at the hospital. Requests for them to be able to go into the room and visit Mr Otranto were forwarded up the chain, noting there were COVID protocols that needed to be met.

Approval was quickly granted and some family members, including Mr Otranto’s wife, were able to visit him at his bedside. Not long after the visitors left, Mr Otranto’s condition worsened and he died at 10.25 pm on 9 June 2020.38

40. The WA Police were notified of the death. Police officers attended and spoke to Mr Otranto’s son and wife, Broad Spectrum officers and medical staff and reviewed Mr Otranto’s body. There was no evidence to suggest criminality or suspicious circumstances in relation to his death.39

CAUSE AND MANNER OF DEATH

41. An external post mortem examination only was performed on 11 June 2020 by Forensic Pathologist Dr Vicky Kueppers. The examination showed evidence of medical intervention, in keeping with the clinical history that had been ascertained by Dr Kueppers from the FSH medical records.40

42. Results of the limited toxicology analysis showed the presence of multiple medications, in keeping with Mr Otranto’s known recent hospital treatment. Alcohol and common illicit drugs were not detected.41

43. Dr Kueppers concluded that a cause of death could be given without further investigations. Dr Kueppers expressed the opinion the cause of death was complications following myocardial infarction and its treatment in a man with multiple severe co-morbidities. I accept and adopt the opinion of Dr Kueppers as to the cause of death.42

44. An internal clinical incident investigation was undertaken at FSH into the circumstances surrounding the erroneous insertion of the VasCath. It was noted that the site of insertion was marked via ultrasound and the procedure was supervised by a consultant. The initial chest x-ray had appeared to confirm the correct position of the catheter, although it was acknowledged that the film was of poor quality, making interpretation more difficult. There were no signs of incorrect line placement evident during the dialysis session. However, after Mr Otranto’s sudden drop in 37 Exhibit 1, Tab 7.

38 Exhibit 1, Tab 4 and Tab 7; Exhibit 2, Tab 20, PIC Record of Events 263856 - 263860.

39 Exhibit 1, Tab 3.

40 Exhibit 1, Tab 6 to Tab 8.

41 Exhibit 1, Tab 6 to Tab 8.

42 Exhibit 1, Tab 6 to Tab 8.

[2022] WACOR 26 consciousness and blood pressure, post dialysis, blood tests were immediately undertaken that raised suspicion that the catheter had been inserted into the wrong vessel, which was confirmed via a CT scan. Urgent removal of the VasCath was then arranged.43

45. I note that the internal medical review concluded that the errors in the procedure were not felt to have resulted in Mr Otranto’s medical emergency. In any event, the VasCath was surgically removed without complication and Mr Otranto’s medical condition continued to deteriorate thereafter. The review panel concluded that Mr Otranto was likely to have had a poor prognosis irrespective of this incident.44 Some suggestions were made at the end of the review to improve the practice of placement of VasCath by the addition of safety mechanisms to assist with confirming the catheter’s insertion into the correct vessel.45

46. Accordingly, based upon the cause of death and noting that there is nothing to suggest that the VasCath error contributed to the death, I find that death occurred by way of natural causes.

COMMENTS ON SUPERVISION, TREATMENT AND CARE

47. Mr Otranto already had a number of significant medical conditions when he first came into prison in 2019. He was housed in the Casuarina Infirmary and received close supervision due to these conditions. His chronic health conditions appeared to have been managed in an appropriate manner in the prison, and when he experienced acute health events, he was appropriately transferred to hospital for medical treatment.

48. It was identified in the Department of Justice’s medical review that there could have been some better coordination and planning around his specialist referrals, particularly in terms of seeing a renal specialist regularly, but it was also noted that he went out to hospital quite early after being imprisoned, so there was specialist oversight of his medical care at an early stage, in any event.46 The Department’s internal medical review, which I find is generally very thorough and transparent, identified no obvious gaps in his medical care, other than the issue of the cessation of the antibiotics.47

49. On 30 May 2020, Mr Otranto was transferred to FSH with a suspected heart attack, which was confirmed on admission and treated. Whilst in hospital, Mr Otranto developed further chest pain, worsening heart failure and acute on chronic renal failure that required urgent kidney dialysis. A VasCath insertion was required for the dialysis, which I have noted above had complications, which were identified the following day and rectified. Although the VasCath was inserted into the wrong 43 Exhibit 1, Tab 15.

44 Exhibit 1, Tab 15.

45 Exhibit 1, Tab 15.

46 T 11.

47 T 14.

[2022] WACOR 26 vessel before being rectified, this incident does not appear to have been a major contributing factor to Mr Otranto’s death.

50. I was informed by Sergeant Becker that Mr Otranto’s family did not raise any concerns about the care provided to Mr Otranto while in custody. They understood that there had been an issue in relation to the VasCath insertion, but accepted that it did not cause or contribute to his death.

51. One issue that was raised in relation to Mr Otranto’s supervision was a failure on the part of the Department to initiate procedures for the consideration of the potential for Mr Otranto to be released on the Royal Prerogative of Mercy when his status on the Terminally Ill Prisoner register escalated to Stage 3. This was frankly acknowledged by the Director General of the Department in a letter to the State Coroner dated 7 February 2021, noting that notwithstanding the likelihood that the Department would recommend Mr Otranto’s early release was low considering the nature of his offending and sentence, it still should have been initiated and the Minister for Corrective Services notified.48

52. This issue has arisen in a number of mandatory inquests involving the deaths of prisoners from natural causes. I am aware that the issue arose due to a change in staff positions within the Sentence Management Unit that meant that there was no staff member specifically allocated to monitor and perform that task when required. I also understand that last year the Department did a blanket review of every prisoner that was terminally ill, from stages 1 to 4 (which is beyond the usual scope of the policy) to ensure that all prisoners’ circumstances were reviewed. No prisoner was released on the Royal Prerogative of Mercy as a result of that review process. Since that time, a new staff member has commenced in the Sentence Management Unit and that person is charged with ensuring there is compliance with the early release policy. I am, therefore, reassured that this issue is unlikely to arise in future matters.49

53. I am satisfied that Mr Otranto received an appropriate standard of supervision, treatment and care while in custody.

CONCLUSION

54. Mr Otranto had a large number of complex medical issues when he was sentenced to serve his first term of imprisonment in 2019. The aggregate term of imprisonment was imposed for a large number of sexual offences that were the subject of two different trials, and the learned sentencing Judges involved in sentencing Mr Otranto were aware of his health issues when the sentences were imposed and understood that his health needs could be met within the prison environment. This proved to be the case, and I am satisfied Mr Otranto received comprehensive medical care of a high standard while in custody.

48 Exhibit 2, Tab 32.

49 T 18.

[2022] WACOR 26

55. Unfortunately, Mr Otranto’s health deteriorated quite quickly due to a natural progression of his various medical conditions, and he died as a result of natural causes while receiving intensive medical care at Fiona Stanley Hospital.

56. While there was a failure on the part of the Department to initiate the processes in relation to consideration of the Royal Prerogative of Mercy, I am satisfied that given the nature of Mr Otranto’s offending and the early stage of his sentence, as well as the evidence that it is exceptionally rare for anyone to be released on the Royal Prerogative in this State, it is very unlikely he would have been released into the community in any event. I am also advised that the issue with the Royal Prerogative of Mercy processes has been resolved by the employment of a new staff member in the Sentence Management Unit, as of around the time of Mr Otranto’s death, so the issue should not continue to occur in future matters.

S H Linton Deputy State Coroner 8 June 2022