Coroner's Court of Western Australia

Inquest into the Death of Salvatore Giovanni OTRANTO

Inquest into the Death of Salvatore Giovanni OTRANTO

Delivered on : 8 June 2022

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Salvatore Otranto (Mr Otranto) died at Fiona Stanley Hospital on 9 June 2020 .  At the time of his death Mr Otranto was a sentenced prisoner.

Mr Otranto was first admitted to Hakea Prison as a new remand prisoner on 5 April 2019.  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 was receiving 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 specialists.  Due to his multiple and serious co-morbidities, Mr Otranto was placed on the Terminally Ill Register as Stage 1 at an early stage.  On 3 June 2020 his status was escalated to Stage 4 due to his rapidly deteriorating health.

On the morning of 30 May 2020 Mr Otranto complained to the health staff of chest pain and shortness of breath.  He had a high pain rating and a 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.  He was transferred by ambulance under ECG monitoring to Fiona Stanley Emergency Department and admitted for treatment.  On 31 May 2020 Mr Otranto suffered a heart attack and was managed by his medical team.  On 1 June 2020 following a further episode of chest pain and lowered oxygen saturations, he was transferred to the Coronary Care Unit.  On 3 June 2020 while still at the Coronary Care Unit it was noted that he was drowsy and delirious.  It was suspected that he had aspirated, and he was commenced on intravenous antibiotics.

On 5 June 2020 following a stent to Mr Otranto’s right subclavian artery, he was returned to the ICU, intubated and ventilated.  Mr Otranto’s wife was advised of his sudden deterioration in health while in hospital and family were advised that they could attend the hospital to visit him if they wished.  On 7 June 2020, ICU records state that Mr Otranto was suffering from ongoing acute hepatitis, coagulopathy, anuric renal failure, encephalopathy and cariogenic shock.  On 8 June 2020 Mr Otranto was extubated and was able to maintain his own airway, but he remained restless and requirements for inotrope medications were increased.  On 9 June 2020, ICU records state that Mr Otranto was suffering from worsening cardiogenic shock, which is considered a grave diagnosis.  Mr Otranto was considered too unwell to undergo further investigations or further coronary intervention.  His prognosis was deemed to be poor.  In consultation with his family, it was confirmed that he was to be “not for cardiopulmonary resuscitation or reintubation”.  Mr Otranto died that evening at 10.25 pm.

The Coroner found Mr Otranto died from complications following myocardial infarction and its treatment in a man with multiple severe co-morbidities and that death occurred by way of natural causes.  The Coroner was satisfied that Mr Otranto received an appropriate standard of supervision, treatment and care while in custody.

Catch Words : Death in Custody : Supervision, Treatment and Care : Natural Causes

Last updated: 18-Jul-2022

[ back to top ]