Salvatore "Toto" Riina, one of Italy's most feared Mafia bosses, has died in a prison hospital while serving multiple life sentences, Italy's justice ministry said.

Riina, also known as "the beast", was held in a medically induced coma after he did not recover from recent surgery.

On Thursday, on his 87th birthday, he was allowed a bedside visit from his family at the hospital in Parma, where he was serving 26 life sentences for dozens of murders committed between 1969 and 1992.

The ruthless figurehead, seen as the "boss of bosses" of the Sicilian Mafia, advocated the killing of women and children of his opponents, in violation of traditional Mafia codes. He was also known for killing innocent bystanders, solely to put law enforcement on the wrong track.

Riina, who grew up in the poverty-stricken countryside of Corleone on the island of Sicily, was first sentenced for murder in 1949 at the age of 19.

Also known as "U Curtu", Sicilian for "Shorty", Riina climbed the ranks of the Sicilian Mafia, or Casa Nostra, by systematically eliminating his opponents, including two of Italy's top prosecutors.

The 1992 killings of Giovanni Falcone and Paolo Borsellino were carried out after Riina said the prosecutors would be "slaughtered like tuna".

Riina was captured in Palermo in 1993 and held under a strict prison regime designed to keep top Mafia leaders in isolation.

The head of the Sicilian Mafia always pursued a clever strategy in jail, Italy's leading daily La Repubblica reported on Friday.

"It was Riina's obsession to reiterate the role he has played in Italy for the last forty years and to downplay the idea that he was a puppet in the hands of forces nestled within the state," La Repubblica wrote after Riina's death.

Riina's two sons, Giovanni and Giuseppe, were also involved in the Mafia. Giovanni was sentenced to life in prison for four murders in 2001, after his capture in 1997.

His younger brother, Giuseppe, was sentenced in 2004 for various crimes, including extortion and money laundering.