Coroner's Finding: Shepley, Adam Troy
Deceased
Adam Troy Shepley
Demographics
30y, male
Date of death
2020-10-24
Finding date
2026-03-26
Cause of death
Unascertained; likely cardiac arrhythmia
AI-generated summary
Adam Troy Shepley, aged 30, died in police custody following restraint after climbing onto roofs while displaying drug-affected and paranoid behaviour. Post-mortem examination revealed an unascertained cause, likely a cardiac arrhythmia triggered by extreme physical and psychological stress, exacerbated by methadone use, methylamphetamine use, and possible underlying cardiac predisposition (prolonged QT interval). The critical clinical failing was the attending paramedic's (Mr Timmins) failure to conduct any proper assessment of the unconscious patient upon arrival at scene. He did not check airway, breathing, circulation or consciousness, did not attach a cardiac monitor despite the patient being unconscious with a Glasgow Coma Score of 3, and demonstrated no sense of urgency. This denied the patient any potential chance of survival, though expert evidence suggested survival was unlikely even with appropriate intervention. Police restraint was lawful, appropriate, and carefully monitored by officers who escalated concerns about deteriorating breathing.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- extreme physical exertion during restraint
- psychological stress and heightened emotional state
- methamphetamine use with associated cardiac fibrosis
- methadone use contributing to prolonged QT interval
- possible underlying cardiac channelopathy or predisposition
- failure of paramedic to perform timely assessment and monitoring
- communication system failure between police and ambulance service regarding escalating concerns
Coroner's recommendations
- A general publication be made to all members of SA Ambulance Service reminding them to consider the possibility of sudden post-agitation restraint cardiac issues and to swiftly examine and monitor such patients upon arrival
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