Coroner's Finding: Trotta, Giovanni

Contributing factors

• failure to fully transcribe hospital discharge summary into prison medical records
• COPD not recorded in prison medical assessment despite being in discharge summary
• untreated diabetes—high glucose on 28 February flagged for urgent review but no follow-up
• low oxygen saturation readings in February-April 2018 not escalated
• missed opportunity for assessment when prisoner requested Ventolin inhaler at midnight on 2 July 2018
• no temperature or oxygen saturation measured despite respiratory symptoms
• no medical assessment during 3-5 July despite obvious illness: not eating, excessive sleeping, persistent cough
• no proactive intervention by correctional officers despite prisoner remaining in cell and not participating in routine
• incomplete prison medical records
• inadequate observation and assessment of vulnerable prisoner
• delay in calling South Australian Ambulance Service by approximately 11 minutes due to confusion about who should make the call

Coroner's recommendations

1. The Standard Operating Procedure for DCS regarding Code Black calls in correctional institutions should be reviewed to consider including terms of reference for direction of orders and requests by SAPHS medical staff to correctional officers during a Code Black emergency.
2. This review should involve submissions and consultation with SAPHS and authorised representatives of Correctional Services Officers.
3. DCS should complete the substantial upgrade to its electronic data storage system (iSAFE) to replace systems that produce 'buried screens of medical history' and to ensure DCS staff have authorised access to relevant medical records within proper confidentiality boundaries.