Coronial
WAhospital

Inquest into the Death of Salvatore Giovanni OTRANTO

Deceased

Salvatore Giovanni OTRANTO

Demographics

68y, male

Date of death

2020-06-09

Finding date

2022-06-08

Cause of death

Complications following myocardial infarction and its treatment in a man with multiple severe co-morbidities

AI-generated summary

Salvatore Otranto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatment. Admitted to hospital on 30 May 2020 with suspected NSTEMI, he developed acute-on-chronic renal failure requiring dialysis. A VasCath was inserted into the right subclavian artery instead of the vein but was promptly identified and surgically removed without complication on 5 June. Despite appropriate medical management, he deteriorated with cardiogenic shock and died on 9 June. The coroner found no major contributing factors from the VasCath error. The only identified systemic issue was the Department's failure to initiate Royal Prerogative of Mercy procedures when his terminally ill status escalated to Stage 3, though this was unlikely to have resulted in release given the serious nature of his offending.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

cardiologyintensive carenephrologyvascular surgeryemergency medicine

Error types

procedural

Drugs involved

enoxaparinaspirindual antiplatelet medicationsglyceryl trinitratemetaraminolinotrope medications

Clinical conditions

myocardial infarctionnon-st-elevation myocardial infarctionischaemic heart diseasecongestive cardiac failurecardiogenic shockacute-on-chronic renal failurediabetes mellituschronic obstructive pulmonary diseaseperipheral vascular diseasetrifascicular heart blockchronic kidney diseasecoagulopathyencephalopathyacute hepatitisaspiration pneumonia

Procedures

vascath insertion for dialysiscoronary angiogramvascular surgical removal of vascathsubclavian artery stentingintubation and mechanical ventilation

Contributing factors

  • Acute myocardial infarction (NSTEMI)
  • Acute-on-chronic renal failure requiring dialysis
  • Cardiogenic shock
  • Poor left ventricular ejection fraction (35%)
  • Multiple severe pre-existing comorbidities
  • Aspiration and encephalopathy during hospital admission

Coroner's recommendations

  1. Addition of safety mechanisms to assist with confirming correct VasCath insertion into the correct vessel
  2. Continued compliance with Royal Prerogative of Mercy procedures for terminally ill prisoners, which has been addressed by employment of dedicated staff in the Sentence Management Unit
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