Inquest into the Death of Salvatore Giovanni OTRANTO

68y · Male·Complications following myocardial infarction and its treatment in a man with multiple severe co-morbidities

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.