Finding into death of Garry John Stephens

46y · Male·Ventricular arrhythmia in a man with epilepsy and documented episodes of bradycardia

Garry John Stephens, aged 46, died in Port Phillip Prison on 7 September 2007 from ventricular arrhythmia in a man with epilepsy and documented bradycardia episodes. The coroner accepted this as consistent with sudden unexpected death in epilepsy (SUDEP). Key clinical lessons: SUDEP is a recognised but unpredictable complication of epilepsy with no proven prevention strategies despite monitoring. The deceased had unstable epilepsy requiring frequent seizure review and dose optimisation. He was transferred between prisons within days of arrest, with incomplete medical information transfer. While reception assessments were reasonable given available information, clinicians should ensure medical files and medication doses accompany prisoners during transfer, and consider higher-level observation for patients with acute medication instability. However, the coroner found monitoring would not have prevented this death—SUDEP can occur suddenly without warning, and resuscitation is rarely successful.