Coroner's Finding: Shepley, Adam Troy

30y · Male·Unascertained; likely cardiac arrhythmia

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.