Sheppard, Mark Andrew

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Mark Andrew Sheppard TITLE OF COURT: Coroners Court

JURISDICTION: BRISBANE FILE NO(s): 2019/1231 DELIVERED ON: 23 May 2022

DELIVERED AT: BRISBANE HEARING DATE(s): 25-26 October 2021 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, death in custody, police shooting, chronic illness, mental health treatment, suicide.

REPRESENTATION: Counsel Assisting: Mr Joseph Crawfoot Commissioner of Police: Ms Anne-Maree Ireland, QPS Legal Unit Snr Constable Dallimore Snr Sergeant Hayden: Mr Peter Lyons, FC Lawyers Snr Constable Jurd: Mr Stephen Hollands instructed by QPUE

Contents

Introduction

1. Mark Andrew Sheppard was aged 50. On 18 March 2019, police attended the Endeavour Caravan Park on Deception Bay Road, Deception Bay after receiving a triple zero call at around 2.05pm from a man who stated a couple of people had been stabbed at “Endeavour”. The caller terminated the call and attempts to call the number back were unanswered. Subscriber checks on the mobile number revealed the number was registered to Mr Sheppard, who lived at the Endeavour Caravan Park.

2. At around 2.15pm, Senior Constable Randall Jurd and Constable Amy Dallimore1 arrived at the caravan park in a marked police vehicle. They parked near site 80, where Mr Sheppard’s caravan was located. They were approached by a park resident, Mr Geelmann, who lived next to Mr Sheppard. He told the officers Mr Sheppard had not been taking his medications. As they approached Mr Sheppard’s site, they saw Mr Sheppard sitting on a chair beside his caravan.

He was armed with a tomahawk. A large knife and a cutlass machete were next to him on the ground. Mr Sheppard and the officers were separated by the length of Mr Sheppard’s caravan.

3. Senior Constable Jurd tried to engage with Mr Sheppard and told him he was there to check on him. Mr Sheppard did not wish to engage in a conversation.

He threw his tomahawk at Senior Constable Jurd and it hit the side of the caravan, narrowly missing the Senior Constable. After throwing the tomahawk, Mr Sheppard armed himself with the machete and the knife. He walked towards Senior Constable Jurd and threw the knife at him, hitting Senior Constable Jurd on the left calf.

4. After throwing the knife, Mr Sheppard started walking towards Constable Dallimore armed with the machete. After he came within six metres of her, he was shot three times. The duration of the police contact was less than 90 seconds. The Queensland Ambulance Serve attended at the scene but resuscitation efforts were unsuccessful.

5. A post-mortem examination found Mr Sheppard had died from gunshot wounds of the chest. The incident was captured on the officers’ body worn cameras.

6. Mr Sheppard had emphysema/chronic obstructive pulmonary disease (COPD).

In 2002 he was diagnosed with alfa-antitrypsin deficiency, which is an inherited disorder causing lung disease. At the time of his death he was using home oxygen. He also had mental and behavioural disorders connected to substance abuse.

7. Three weeks prior to his death, Mr Sheppard was admitted to Caboolture Hospital for end-stage COPD.

1 Now Senior Constable Dallimore Findings of the inquest into the death of Mark Andrew Sheppard Page 3 of 23

The investigation

8. Detective Senior Sergeant Peter Ryan from the QPS Ethical Standards Command (ESC) conducted an investigation into the circumstances leading to the death. The investigation commenced at 3.00pm on the day of Mr Sheppard’s death when scenes of crime officers attended the location. Ballistics officers attended at 7.15pm.

9. Both officers participated in video walk-through re-enactments late on the night of 18 March 2019. Police also obtained audio recorded statements from other residents of the caravan park.

10. DSS Ryan provided a comprehensive coronial report in February 2020 with various annexures, including witness statements, digital recordings, medical and offender records. DSS Ryan’s coronial report discussed Mr Sheppard’s death as a possible victim ‘precipitated homicide’ or ‘suicide by cop’. I thank DSS Ryan for his assistance with the investigation.

The inquest

11. Mr Sheppard’s death was reported as a death in custody under the Coroners Act

12. He died while he was trying to avoid being put into custody. In those circumstances an inquest was mandatory. A pre-inquest hearing was held on 30 September 2021 at Brisbane. Following the pre-inquest hearing, the issues for inquest were settled as:

13. The findings required by s 45(2) of the Coroners Act 2003; namely the identity of the deceased, when, where and how he died and what caused their death.

14. Whether the actions of the police officers who attended at the Endeavour Caravan Park were appropriate in the circumstances.

15. Whether there are ways to prevent a death occurring in similar circumstances in the future.

16. The inquest was held at Brisbane on 25 – 26 October 2021. All statements, records of interview, photographs and materials gathered during the investigation were tendered at the inquest. Over 130 exhibits were tendered in evidence. Oral evidence was heard from the following witnesses:

• DSS Peter Ryan

• Dr Rohan Samarasinghe, Forensic Pathologist

• Dr Naeem Jhetam, Psychiatrist

• Ms Judith Jensen, civilian witness

• Mr Christopher Geelmann, civilian witness

• Senior Constable Randall Jurd

• Constable Amy Dallimore

• Senior Sergeant Damien Hayden

13. I am satisfied that the evidence tendered, in addition to the oral evidence, was sufficient for me to make the necessary findings under s 45 of the Coroners Act 2003.

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14. The primary purpose of an inquest is to inform the family and the public about the matters required by s 45 of the Coroners Act 2003, including how the person died and what caused the person to die.

15. In appropriate cases, a coroner can make recommendations with a view to reducing the likelihood of similar deaths. As a result, a coroner can make preventative recommendations concerning public health or safety or ways to prevent deaths from happening in similar circumstances.

16. A coroner is not able to include in the findings or any comments or recommendations any statement that a person is, or may be, guilty of an offence or civilly liable.

The evidence Background

17. Mr Sheppard was of three sons born to Colleen Hamill and Barry Sheppard in Central Queensland. He was the youngest child until his half-sister was born in

18. The death of his second brother at the age of two was reported to have devastated his parents. Mr Sheppard had an unstable upbringing with the family, moving around as his father worked as a truck driver. Mr Sheppard’s parents separated when he was nine. He spent time between his parents and often lived in different towns. He witnessed his mother in new relationships with abusive partners. His father was also reported to be abusive and controlling and their personalities clashed.

19. When he was aged 17, Mr Sheppard moved to Katherine in the Northern Territory with his mother, step-sister and his older brother. Mr Sheppard had casual employment working on fishing trawlers. At age 23, Mr Sheppard, along with his siblings, discovered their mother and her partner deceased in a car in an apparent murder suicide. This discovery was said to have haunted Mr Sheppard for the remainder of his life.

20. Mr Sheppard is survived by his siblings and two daughters. His former partners described tumultuous, violent and volatile relationships with Mr Sheppard which caused both women to leave him.

21. Mr Sheppard moved to Brisbane in 2004 to be close to his younger daughter. He had a job as a supervisor in a factory but had to resign in 2010 due to his deteriorating health.

22. In 2012, Mr Sheppard’s elder daughter moved to Brisbane from Melbourne to reconnect with him after learning of his medical condition. He was then living on a disability support pension. While she kept in contact with her father, she moved back to Melbourne in 2017.

23. Mr Sheppard’s brother described him as someone who projected the image of being a ‘hard man’. Mr Sheppard’s siblings said that he was obsessed with knives and weapons. His sister believed Mr Sheppard possessed the knives/weapons to protect himself, and used to hide them in different areas of his house. Scenes of crime officers located a number of knives hidden in different areas of Mr Sheppard’s caravan. Mr Sheppard’s brother believed dysfunctional Findings of the inquest into the death of Mark Andrew Sheppard Page 5 of 23

family relationships had ‘scarred’ Mr Sheppard, and witnessing domestic violence had normalised violence for him.

23. Mr Sheppard’s siblings lived interstate and he lived alone with no one to help him as his condition deteriorated. Follow up treatments were made difficult due to his social isolation and not having transport to take himself to appointments. His neighbour, Christopher Geelmann, was the closest person to Mr Sheppard.

They had known each other for eight years and were good friends. Mr Geelmann thought Mr Sheppard should have been in care as he was ill and struggled with day to day activities. Mr Geelmann often helped him to unpack groceries and other chores around his caravan.

24. Mr Geelmann knew Mr Sheppard was a drinker as he used to buy alcohol for Mr Sheppard until two years before his death. He knew Mr Sheppard started drinking port first thing in the morning and would be drinking as long as he was awake. In the last two years, Mr Sheppard had confided to Mr Geelmann that he would kill himself as he did not want to die slowly from emphysema.

Criminal history

25. Mr Sheppard had a Northern Territory criminal history for offences of violence, drugs and property and driving related offences. In 2001, he was convicted of stabbing a US flight squadron commander in a night club fight. He was sentenced to 28 months imprisonment with a non-parole period of nine months.

26. Mr Sheppard had a Queensland criminal history with convictions for offences of violence (serious assault, going armed so as to cause fear, assault police), property offences and possessing a dangerous drug. Mr Sheppard had served time in custody for breaching separate probation orders. The serious assault offence and going armed involved Mr Sheppard being armed with a metal baseball bat at the caravan park on 5 April 2012. When police arrived, he also threatened them with the metal baseball bat.

27. An entry for one charge of assault/obstruct police in 2014, involved police attending the caravan park on 23 May 2014 at 8.00pm. Police were investigating a disturbance when they were told of Mr Sheppard pacing near his caravan with a machete. Police walked towards Mr Sheppard and asked him to drop the machete and to walk backwards toward police. Mr Sheppard threw the machete towards his caravan and followed the police direction. He then stopped and started walking towards the machete. Police ran towards him and managed to restrain him.

Medical / mental health history

28. In 2002, Mr Sheppard was diagnosed with Alpha-1 antitrypsin deficiency. This is an inherited disorder causing lung disease. This exacerbated Mr Sheppard’s emphysema/COPD, and his condition was terminal.2 His COPD saw him admitted to different hospitals in Queensland on 20 occasions between 2006 and 2019 when his COPD worsened, or he experienced shortness of breath (SOB).

He reported smoking a packet of cigarettes per day and abusing alcohol.

2 Exhibit B2 – Borthwick, Dr Ian, Caboolture Hospital.

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29. His disclosures regarding alcohol indicated he drank a carton of beer and up to three litres of port each day. His disclosures about when he quit smoking and stopped drinking varied during each admission to hospital. One progress note recorded he may have quit smoking and drinking sometime in 2009 and another entry indicated he stopped drinking or minimised alcohol intake in 2016. Other notes indicated he had been smoking cigarettes since the age of 9 and smoked cannabis from age 17.

30. In 2016, Mr Sheppard’s health continued to deteriorate, requiring the full time use of oxygen. His condition became terminal without a lung transplant. His mental health also deteriorated but he was reluctant to follow through with any treatment plans. His sister believed he did not really want help and chose to be in a ‘dark place’. She said Mr Sheppard used drugs and alcohol to self-medicate.

31. During hospital admissions between 2016-2018 Mr Sheppard had signed an Acute Resuscitation Plan which indicated he did not want to be resuscitated in the event of cardiac or respiratory arrest. In September 2016, Mr Sheppard was on home oxygen to assist with his breathing. A review of his medical records indicated that as early as 2017 he accepted that his illness was terminal. He changed his mind about being placed on a waitlist for a lung transplant. He did not want to be on the waitlist for fear of disappointment. There were also times when he cancelled future appointments/treatments and advised the hospital that as he was dying there was no point to treatment.

32. On 10 May 2018, Mr Sheppard was consulted in relation to palliative care. He was referred to a palliative care outpatient clinic for follow up and symptom management. It was noted that he had a complex history and clinical management was made more difficult given his social isolation, no family support and his limited function. There is no record of Mr Sheppard following up on this appointment.

33. Mr Sheppard reported wanting to keep his dignity when it came to dying. He advised of doing research on severe cases of COPD and stated he did not want to be in the same position, stating “If I can’t wipe my bottom then I’m no longer a man”. He was accepting of being placed in palliative care but not to the detriment of his dignity. He did not want to let his family know the extent of his medical condition as he was worried about distressing them.

34. On 24 February 2019, three weeks prior to his death, Mr Sheppard was admitted to Caboolture Hospital for shortness of breath. He was treated and discharged on 26 February 2019.

35. Mr Sheppard’s other medical conditions were alcoholic liver disease, anxiety and depression.3

36. In relation to mental health issues, Mr Sheppard’s GP records from June 2011 indicated he was suffering from depression, stress and anxiety. He was placed on a Mental Health Care Plan on 30 June 2011 and referred to psychologist, Dr Millas. On 5 July 2011, Dr Millas saw Mr Sheppard for an initial psychological assessment. He noted that Mr Sheppard wanted management of his depression/anxiety symptoms as well as continuing to manage his abstinence from alcohol and cannabis. Dr Millas found Mr Sheppard to be ‘strongly 3 Ibid.

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depressed’. While he expressed thoughts of self-dislike, he did not express any delusional thoughts.

37. Dr Millas considered Mr Sheppard may benefit from psychotherapy to help him stop drinking alcohol and using cannabis. Dr Millas also suggested strategies relating to behavioural change and ongoing Cognitive Behavioural Therapy over the next 12 months. There were no further records following this assessment.

38. During Mr Sheppard’s hospital admissions in 2012, 2016 and 2017, he reported feeling depressed and expressed suicidal thoughts. As a result, he was seen by staff from the Mental Health Unit in hospital. He reported a difficult upbringing and witnessing violent and traumatic events growing up. He reported living with his terminal illness and wanting to die in a dignified manner otherwise he “will take care of it myself”.

39. At different times during his admissions to hospital he disclosed having suicidal thoughts every few days. He attempted to kill himself in 2004 (cutting his wrist) and in 2012 (plunging a knife to his chest). During a consultation with mental health staff in 2016, Mr Sheppard gave the impression of suffering from a resistant depressive disorder in connection with alcohol use and a cluster B personality structure. This is a disorder that is characterised by dramatic, overly emotional or unpredictable thinking or behaviour. Mr Sheppard was not deemed to be suffering from a major mood disorder. Mr Sheppard was prescribed antibiotics, prednisolone and sertraline. He was also asked to stop drinking alcohol.

40. While Mr Sheppard engaged with mental health staff in hospital, he did not follow up further referrals or mental health plans/treatment despite efforts to contact him.

41. During his hospital admissions he was seen by staff from Alcohol, Tobacco and Other Drug Services (ATODS) in 2015, 2016 and 2017. In October 2016, he was referred to ATODS at Caboolture Hospital where he was prescribed anticraving medication. In 2017, he declined contact with ATODS and was happy to continue with anti-craving medication.

42. Mr Geelmann said Mr Sheppard attended Redcliffe Hospital on 24 February 2019 and was supposedly told that he only ‘2% lung capacity’. Mr Geelmann observed that Mr Sheppard struggled with every breath and every step. He was amazed that Mr Sheppard was able to do what he did when police arrived. Mr Sheppard had trouble getting doctors to visit him on a regular basis to get his prescription renewed. This was a problem as Mr Sheppard would postpone getting his script renewed until he got another infection resulting in a call for an ambulance and an admission to hospital.

43. Mr Sheppard was required to attend Redcliffe Hospital to get his morphine and, according to Mr Geelmann, this became traumatic for Mr Sheppard as he had to get himself to the hospital. He could not call an ambulance and therefore he had to get a taxi. This proved to be difficult as walking from his caravan to a taxi with the ‘oxygen bottle’ was an effort. The stress of having to go to the hospital caused Mr Sheppard to have anxiety attacks on top of his emphysema. Mr Geelmann suggested to Mr Sheppard that he get a carer as Mr Sheppard was “becoming more and more unable to do anything”.

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44. Mr Geelmann said after his last visit to the hospital Mr Sheppard ‘went through’ his morphine ‘like anything’. Upon his return, Mr Geelmann told Mr Sheppard that things were getting really bad and to go to into private care as he himself was reaching a point where he could no longer support Mr Sheppard. Mr Geelmann felt Mr Sheppard could no longer cope either. Mr Geelmann stated morphine, alcohol and anti-depressants made Mr Sheppard worse but also made him feel better as ‘he was out of it’. Mr Sheppard often had anxiety attacks when sober and these attacks aggravated his breathing condition.

Events leading up to the death

45. On 18 March 2018, at around 1.00pm, Mr Sheppard spoke to Mr Geelmann. Mr Sheppard thanked Mr Geelmann for being a ‘really good mate’. Mr Geelmann asked Mr Sheppard what he was going to do, and Mr Sheppard told him not to worry about it. He just wanted Mr Geelmann to know he appreciated everything he had done for him. Mr Geelmann thought Mr Sheppard was perhaps planning to overdose on medication. He did not worry about it as he knew Mr Sheppard had been so sick and had wanted to die for a long time. He felt sorry for Mr Sheppard as he witnessed that breathing alone was a constant battle for him.

46. At 1.34pm, Mr Sheppard sent a text message to his sister advising that there had been a change of plans, and he was going to go soon. He told her not to believe what she hears, he loved her, and she could do better than now.

47. At around 2.00pm, Mr Sheppard telephoned Mrs Jensen, the mother of a former partner and grandmother to his daughter. Mrs Jensen was aware Mr Sheppard had emphysema. Mr Sheppard was very agitated and emotional during the call.

He said he did not have long to live and asked her to tell his daughter that he loved her. He apologised for treating his former partner badly. He said there would be some things for his daughter in the caravan ‘when police have finished with it’.4 Ms Jensen said that later that day when she heard news of the shooting at Deception Bay, her immediate thought was “that will be Mark”.

48. At around 2.05pm, Mr Sheppard contacted triple zero5 asking for police to attend the caravan park. He told the operator there was a guy who stabbed a couple of people. When asked what happened, he replied ‘This guy stabbed a couple of people and I don’t know I can…it could be very soon’. Mr Sheppard disconnected the call when the operator asked for his name.

49. Shortly before police arrived, Mr Geelmann heard Mr Sheppard shouting angrily.

He went over to Mr Sheppard’s caravan where he saw Mr Sheppard outside the caravan door. He could not recall whether Mr Sheppard was standing or sitting.

He saw a sword stuck in the ground with the handle between Mr Sheppard’s legs. He also saw Mr Sheppard holding an axe or a knife in his right hand. Mr Sheppard yelled at Mr Geelmann to return to his caravan.

4 Exhibit B9.

5 Evidence including subscriber checks that the number was registered to Mr Sheppard, the caller being out of breath, caller breathing into or from a machine, voice of the caller, absence of disturbances in the background proved Mr Sheppard was the caller.

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Police attendance

50. Police attendance was captured on body worn camera (BWC). The following information is taken from the footage depicted on the BWC. The information given by the officers who were interviewed after the incident was consistent with the BWC footage.

51. At around 2.15pm, Senior Constable Randall Jurd and Constable Amy Dallimore arrived at the caravan park, which was around a one minute drive from the Deception Bay Station in response to the Code 2 serious assault. Both officers were approached by Mr Geelmann who told them ‘he can’t do anything even though (indistinct) he needs his anti-depressant’.

52. Mr Sheppard was not visible to the officers but started shouting from the other side of the caravan. Both officers told the inquest that they regarded Mr Sheppard as the informant to an alleged stabbing incident at that stage and they needed to speak with him to see if anyone had been injured. While there were usually lots of people present when the QPS attended the caravan park, on this occasion it was like a ghost town.

53. Both officers approached the caravan and Senior Constable Jurd saw Mr Sheppard siting on a chair beside his caravan. Mr Sheppard was armed with a tomahawk. A large knife and a cutlass machete6 were also next to him on the ground. Mr Sheppard and the officers were separated by the length of Mr Sheppard’s caravan. Mr Sheppard had a clear plastic bag covering his face and did not have his oxygen tank/tubes connected to him.

54. Senior Constable Jurd told Mr Sheppard to put the tomahawk down on two occasions and told Mr Sheppard not to throw it. Constable Dallimore was behind Senior Constable Jurd and called for back-up.

55. Senior Constable Jurd told Mr Sheppard they were there to make sure he was alright. He asked Mr Sheppard if it was him who called police advising of someone getting stabbed. Mr Sheppard got angry at this question and asked why Senior Constable would say that and threw the tomahawk in the direction of Senior Constable Jurd, hitting the side of the caravan. After throwing the tomahawk, Mr Sheppard picked up the machete and held it in his right hand.

56. Senior Constable Jurd broadcast that Mr Sheppard had thrown the tomahawk at him and Mr Sheppard mimicked him and raised the machete. Mr Sheppard put the machete down and picked up the large knife and held it in his right hand. He picked up the machete and held it in his left hand.

57. Senior Constable Jurd told Mr Sheppard to ‘drop the stuff’. Mr Sheppard held onto the knife and the machete. Senior Constable Jurd repeated they were there to make sure he was alright. Mr Sheppard replied he was fine and ‘let’s have some fun’. Senior Constable Jurd told Mr Sheppard what he was doing was not fine. Mr Sheppard stood up from the chair and started walking towards Senior Constable Jurd. Senior Constable Jurd told him to stop and to sit down.

6 Also described as a samurai sword by some witnesses.

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58. Senior Constable Jurd started walking backwards and repeatedly told Mr Sheppard to stop and sit down. As Mr Sheppard neared, Senior Constable Jurd drew his gun, pointed it towards Mr Sheppard and told Mr Sheppard to stop, sit down and repeatedly yelled ‘don’t do it’.

59. Mr Sheppard continued to walk towards Senior Constable Jurd. During this time, Constable Dallimore was to the left of Senior Constable Jurd and did not have Mr Sheppard in view. She was positioned to the back of the caravan. Constable Dallimore walked around towards the back of a caravan and crouched down in an attempt to look underneath. She sought to position herself to attempt to affect another use of force option from behind the deceased such as a Taser.

60. Senior Constable Jurd yelled for Mr Sheppard to ‘drop, drop, drop and don’t do it’. Mr Sheppard threw the knife towards Senior Constable Jurd causing him to turn away to avoid being hit. The knife hit Senior Constable Jurd causing a cut on his left calf.

61. At this point both officers had ‘triangulated’ Mr Sheppard. Constable Dallimore walked towards Senior Constable Jurd and Mr Sheppard. She drew her gun and continued to yell for Mr Sheppard to drop his weapon. Mr Sheppard took a couple of steps towards her still armed with the machete which was raised above his head.

62. Both officers, with their guns drawn and pointed at Mr Sheppard, yelled for Mr Sheppard to drop the machete without success. Mr Sheppard turned to look at Senior Constable Jurd and both officers fearing for their lives and/or their partner’s life fired their firearms. Senior Constable Jurd fired two shots and Constable Dallimore fired one shot. Mr Sheppard fell to the ground.

63. Senior Constable Jurd walked over to Mr Sheppard and kicked the machete away with his foot. He found a smaller flick knife near Mr Sheppard’s head which he did not previously see and picked it up and threw it to the side. Senior Constable Jurd yelled to Mr Sheppard “why did you do this to me mate, why did you do it”.

64. The time between police first interacted with Mr Sheppard and the shooting was approximately 90 seconds.

65. Civilian John Baillie resides at the Endeavour Residential Village. Mr Baillie stated that he saw a male police officer backing out from behind a van close to site 79. The male police officer walked about five or six steps back towards the police vehicle. The police officer had his gun drawn and was pointing it back towards the van. Mr Baillie then saw a knife flying out from somewhere. He described the knife as large and about 30cm long. The knife had a silver blade it flew through the air and hit the male police officer,"...who sort of put his arm up or something". He saw the knife land on the road.7

66. Mr Baillie then heard the police officer yelling loudly: "Put down the weapon! Put the weapon down!". He then saw the police officer charging back towards the van. He then heard four loud bangs in succession. He describes the bangs as "bang bang bang bang". He thought it was three or four shots. He did not know who fired the shots because it was happening behind the van.8 7 Ex B5 8 Ex B5 Findings of the inquest into the death of Mark Andrew Sheppard Page 11 of 23

67. Another park resident, Mr Bandera, saw a man come running with a sword in his hand from the vicinity of site 80. He described this man as being Caucasian, late 50s to early 60s, average build with a “bit of a gut, no shirt, tattoos on both arms, he has tubes coming from his nose”. They appeared to be tubes for oxygen. He stated that when he saw the man running, he thought he was going to hit or slice the police officer with the sword. He could see the man's facial expressions, he looked angry and ‘not right’. His face was screwed up a bit. He was looking away momentarily as he was running towards the police officer. He was holding the sword with two hands above his head and the blade was facing towards the police officer. He described the sword as black in colour, approximately 1 metre in length. The man was moving the sword around above his head.9

68. According to Mr Geelmann, Mr Sheppard had spoken about attempting suicide in the past. He was not sure how much of it was true as Mr Sheppard had endless stories. Mr Sheppard spoke of having seen ‘people like that go and no one wants to go that way’ and talked about committing suicide or getting one of his “hard mates to top him’’. Mr Sheppard also spoke of previously having a gun but could not go through with killing himself. Mr Geelmann had thought Mr Sheppard would ask for something from his contacts to take and ‘go that way’.

He also thought Mr Sheppard would ask for his help and he knew he could not.

He often ‘tuned’ out but if Mr Sheppard was given something lethal to take and Mr Sheppard told him about it, he believed it was Mr Sheppard’s choice.

69. Mr Geelmann stated that he knew Mr Sheppard had a hard life and witnessed/experience a lot of violence growing up. Mr Sheppard had put a great deal of emphasis on being a ‘hard man’. He also knew Mr Sheppard kept knives in different areas of the caravan as he was paranoid people were coming to attack him. Mr Geelmann spoke of previous police attendance involving Mr Sheppard where it was resolved after police used a Taser, and he thought this was what was going to happen this time.

70. Mr Geelmann believed there was something threatening about Mr Sheppard having the sword in the ground and the axe in his hand. He was full of rage on the day of his death. He also believed there was something ‘final’ about the way Mr Sheppard had thanked him. While he did not see Mr Sheppard being shot, he was amazed that Mr Sheppard had charged at police with a sword. This was unusual given Mr Sheppard’s medical condition.

71. Mr Geelmann said Mr Sheppard had never discussed challenging police and ‘going that way’. However, he believed that ‘going down in a blaze of glory’ would appeal to someone like Mr Sheppard. He did not think Mr Sheppard would be capable of doing what he did because he was so sick. He said that he was obviously mistaken.

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Medical treatment

72. Constable Dallimore called for QAS and walked over to Mr Sheppard with her weapon drawn. At this point, Sergeant Ben Dallimore arrived at the scene.

Constable Dallimore, still with her gun drawn, responded that she was ‘still covering’. Sergeant Dallimore confirmed there were no other weapons.

73. Constable Dallimore yelled ‘open chest wound’ and asked someone to get the tourniquet. Senior Constable Jurd walked away and sat on the ground nearby as Sergeant Dallimore stood by broadcasting there were no more weapons.

74. Mr Sheppard was on the ground struggling to breathe. Constable Dallimore still standing started yelling ‘he’s gone, he’s going he’s going, I’m covering’ followed by ‘he’s dying’. Sergeant Dallimore was in the process of putting gloves on.

Constable Kristic and Constable Lester arrived at the scene. Constable Kristic went to the police car to get the first aid kit. At this point, Sergeant Dallimore had put gloves on and covered the wound on Mr Sheppard’s chest.

75. Constable Dallimore broadcast that Mr Sheppard was going into cardiac arrest.

Once Mr Sheppard’s wounds were covered, Constable Kristic started cardiopulmonary resuscitation (CPR) and other officers took turns in providing CPR, including Constable Dallimore. Constable Dallimore also assisted by holding Mr Sheppard’s head to keep his airway open. There was discussion about getting a defibrillator from a shopping centre nearby.

76. At 2.28pm, paramedics arrived at the scene and provided treatment to Mr Sheppard. Treatments included administration of adrenaline and sodium chloride via intravenous access, intubation, insertion of oropharyngeal airway and laryngeal mask for ventilation and further application of chest seals. Mr Sheppard had to be moved to the back of the ambulance due to storm activity.

77. At around 2.58pm, QAS Medical Director, Dr Steven Rashford arrived at the scene and after consultations with him, Mr Sheppard was declared deceased at 3.00pm.

Internal Investigations Group (IIG) Investigation of the Shooting

78. The Coronial Report was received from QPS on 15 February 2020.

79. The IIG investigation commenced within hours after the incident. Officers Dallimore and Jurd participated in separate video-walk through re-enactments a few hours after the incident. IIG obtained statements from witnesses in the caravan park. One witness was an eyewitness whose evidence was consistent with what was depicted on the BWC footage. Other witnesses provided evidence of hearing someone yell and police yelling and giving warnings followed by gun shots.

80. Senior Constable Jurd was stationed at the Deception Bay Police Station at the time of the incident. According to his training records, Senior Constable Jurd completed training in Use of Force OLP 2018-19, Operational Skills Requalification 2018-19, Police Operational Skills and Tactics (POST) Requalification 2018-19 in July 2018. He also completed training in Performing CPR on 29 November 2018. He last completed an Active Armed Offender training in September 2016.

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81. Constable Amy Dallimore was also stationed at the Deception Bay Police Station at the time of the incident. According to her training records, Constable Dallimore completed training in Operational Skills Requalification 2018-19, Police Operational Skills and Tactics (POST) Requalification 2018-19, Use of Force OLP 2018-19 in August 2018. She completed training in Apply First Aid in February 2019 and Perform CPR on 26 September 2018. Her last Active Armed Offender training was on 6 April 2017.

Situational Use of Force Model

82. The QPS uses the Situational Use of Force Model, Threat Assessment and Tactical Decision Making Process as operational tools to train officers in order to assist them in a confrontational situation that may require them to use force. The Situational Use of Force Model assists police officer to select the most appropriate option(s) to resolve an incident. Section 14.3 of the QPS OPM is a reminder to officers that they should only use the minimum amount of force necessary to resolve an incident despite having statutory authority to use lethal force against a person in certain situations.

83. Officers are instructed to continually assess threat by considering the level of risk to a person, object or other officers and having an understanding that there are high and assessed risks involved in an incident. High risk involves the obvious risk, for example, responding to a person who is armed. Assessed risk is the consideration given to a response based on an officer’s assessment of a person, the situation, information known at the time and the officer’s past experiences and training.

Assessment of Senior Constable Jurd and Constable Dallimore’s Use of Force

84. Senior Constable Jurd attempted to speak to Mr Sheppard and did not draw his firearm despite seeing Mr Sheppard was armed with a tomahawk which was subsequently thrown at him, and seeing other weapons within reach. Senior Constable Jurd drew his firearm and pointed it at Mr Sheppard when Mr Sheppard stood up and started walking towards him, armed with a knife in one hand and a machete on the other. He gave Mr Sheppard many warnings to drop the knives and still did not discharge his gun when Mr Sheppard threw the knife at him, hitting him on his calf.

85. Senior Constable Jurd discharged his weapon when he saw Mr Sheppard, still armed with the machete, turn his attention to Constable Dallimore and then back to him. He fired his gun in order to stop the threat/serious injury or death to Constable Dallimore or himself. The distance between Senior Constable Jurd and Mr Sheppard was approximately 3.8 metres when Senior Constable Jurd discharged his gun.10 He believed there was no option available to him other than to use lethal force.

86. Constable Dallimore drew her gun when Mr Sheppard threw the knife at Senior Constable Jurd. Mr Sheppard turned to her still armed with the machete and turned his attention back to Senior Constable Jurd. As Mr Sheppard turned to Senior Constable Jurd, Constable Dallimore discharged her firearm. The distance between Constable Dallimore and Mr Sheppard was approximately 5.5 metres when she fired her firearm.11 1010 Measurement taken at the end of Senior Constable Jurd’s walk-through interview.

11 Measurement taken during Constable Dallimore’s walk-in interview.

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87. IIG engaged Senior Sergeant Hayden, who at the time of the incident was the Officer in Charge of Operational Skills Section (OSS) at the QPS Academy.

Senior Sergeant Hayden provided an opinion on the officers’ decision to discharge their firearms, and whether these actions in all the circumstances were justified.

88. Senior Sergeant Hayden considered the actions of Senior Constable Jurd and Constable Dallimore in discharging their firearms were reasonable and appropriate in light of the imminent threat of grievous bodily harm and death posed by Mr Sheppard.

89. Senior Sergeant Hayden also commented on the physical attributes of Mr Sheppard who was suffering from a medical condition severely impacting his health. Senior Sergeant Hayden thought this may have been advantageous to both officers if the situation was a conventional arrest type situation where officers were to overpower, restrain and if required ‘man-handle’ resisting persons. However, the dynamic of this situation was considerably different with Mr Sheppard being armed with a number of edged weapons. Mr Sheppard’s use of the machete placed both officers at a tactical disadvantaged as they were unable to close the distance and restrain him to establish control.

90. Senior Sergeant Hayden indicated that Mr Sheppard’s actions in throwing the tomahawk and knife and while still being armed with a machete could reasonably be construed as being offensive and attacking in nature. Senior Sergeant Hayden concluded the actions of both officers to be legally defensible and they were not in breach of policy or legislation. I accept that conclusion.

Victim Precipitated Homicide

91. The IIG investigation considered whether Mr Sheppard’s death was preventable and addressed whether Mr Sheppard’s death was ‘suicide by cop’. IIG provided a paper titled ‘Suicide By Cop’.12 Van Zandt defined ‘suicide by cop’ as ‘a suicide method in which a suicidal individual deliberately acts in a threatening way, with the goal of provoking a lethal response from a law enforcement officer or other legitimately armed individual, such as being shot to death’.

92. Van Zandt indicated the role of the ‘victim’ in ‘suicide by cop’ is to be ‘the first one to use physical force directed against his chosen executioner’. A person wanting to die in the hands of police understands violence and uses the weapon of police to commit the act of suicide by the hand of the officer involved.

93. A profile of a ‘suicide by cop’ victim can include someone who is often a member of a lower socio-economic class, has an aggressive lifestyle, poor self-concept and individual social standards that s/he may not view killing him/herself as a socially acceptable way to die. Therefore, they will provoke a law enforcement officer in a way that will involve a lethal force response from the officer.

94. Van Zandt provided 16 indicators of a potential ‘suicide by cop’, some of which were applicable to Mr Sheppard. Van Zandt stated while the indicators are not all inclusive some of them will assist in identifying a person who is possibly depressed and/or suicidal. He indicated that a combination of these indicators should be considered evidence of a possible ‘suicide by cop’, especially in a 12 Suicide by Cop, Clinton R. Van Zandt, 60 (7) The Police Chief (IACP) 24-30 (July 1993).

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situation where the individual challenges the authorities in a way that could bring about his own death.

95. The indicators applicable to Mr Sheppard included:

• his refusal to negotiate,

• socio-economic background,

• criminal record for previous assaultive behaviour,

• a diagnosis of a life threatening illness,

• experience of a traumatic event that has had an impact on his life, and

• expressed feelings of hopelessness and helplessness.

96. According to Van Zandt, a low key and non-dramatic response is how police should deal with a potential ‘suicide by cop’ and that time will allow for authorities to consider their responses in dealing with this scenario. The IIG investigation concluded that it was highly likely that Mr Sheppard created the scenario to bring about his own death.

Mental Health Treatment

97. The IIG investigation addressed the mental health treatment Mr Sheppard received. DSS Ryan discussed Mr Sheppard’s past suicidal ideation and previous suicide attempts. DSS Ryan submitted that as Mr Sheppard’s physical condition deteriorated so too did his mental health, and the trigger for his final actions was the devastating effects of his terminal illness. DSS Ryan considered that while it is almost impossible to determine whether Mr Sheppard’s death could be prevented, the outcome may have been different if Mr Sheppard had followed through with mental health treatment. However, he was unable to do this due to lack of physical and emotional support and social isolation.

98. DSS Ryan provided information relating to Queensland Health Mobile Intensive Rehabilitation Teams (MIRT). MIRT provides specialist mental health intervention to people with complex needs in the community. MIRT assists people who have been diagnosed with severe and persistent mental illness, comorbid secondary diagnosis of substance abuse and severe personality disorder. MIRT assists by providing a number of services including extended hours of service, on an outreach basis, home visits and other community based interventions, assessment, recovery planning, and intensive psychosocial rehabilitation services for consumers with complex mental health needs. The service is accessible through a referral from a medical practitioner. Mr Sheppard’s medical records do not show any referrals to MIRT.

99. Dr Jhetam, Psychiatrist and Clinical Director at the Caboolture Hospital, gave evidence in relation to Mr Sheppard’s mental health treatment history. Dr Jhetam had not treated Mr Sheppard. He said that in his involvement with the Caboolture Hospital’s mental health service, Mr Sheppard engaged voluntarily in each of his service episodes. There were no grounds to treat him involuntarily under the Mental Health Act 2016. He was thought to have chronic fleeting suicidal ideation, usually low acute risk, although risk increased at times, due to impulsivity, given his history of alcohol use disorder and social isolation.13 13 Ex B4 Findings of the inquest into the death of Mark Andrew Sheppard Page 16 of 23

100. Dr Jhetam said that Mr Sheppard did not have an admission to a mental health unit. His contact with mental health services was always following a presentation to the hospital for physical complaints (usually in the context of his respiratory problems), and only on those occasions when he complained of feeling depressed, hopeless, or suicidal. He had multiple presentations for physical problems without needing mental health input. His last contact with the Consultation-Liaison Psychiatry team was in August 2017. While there were services available to assist, there was no evidence that he accepted the recommendation to engage in counselling for his alcohol use or to engage in psychotherapy for his childhood and other issues.14

101. Dr Jhetam said that if a Mental Health Practitioner forms the view that a mental health service consumer is deemed to be at past or future risk when interacting with Queensland Police Service (QPS) or Queensland Ambulance Service (QAS) this would trigger the Mental Health treating team to commence the process of preparing a Police and Ambulance Plan (PAIP). Dr Jhetam checked whether or not there were any Alerts with respect to challenging behaviours on the part of Mr Sheppard. That search confirmed that there were no Alerts regarding challenging behaviours; and no Alert pointing to a PAIP. While Mr Sheppard did express suicidal thoughts from time to time, there were no intimations of Mr Sheppard wanting to entice the QPS into shooting him as a means of ending his own life.15 Autopsy results

102. On 20 March 2019, an external and full internal post-mortem examination was performed by Dr Rohan Samarasinghe. Toxicology, radiology and histology tests were also conducted.

103. The post-mortem examination revealed three gunshot wound tracks in the body.

Two of which passed through the chest without exit wounds. One of the wounds was located on the front of the left side of the chest showing signs of the bullet passing through the front of the chest causing damage to the front ribs, muscles and sternum. The second gunshot entry wound was found in the back of the upper left arm showing signs of the bullet firstly passing through the soft tissue of the back of the arm and re-entering the left side of the chest before passing through the lungs and the heart, resulting in severe haemorrhage. The two bullets for these wounds were recovered from the right chest wall. The third gunshot wound entered from the back of the right arm and passed through the right forearm and exited from the inner aspect of the elbow and leaving the arm.

104. Dr Samarasinghe was of the view that the range of fire causing the wounds were ‘distant’ due to the lack of gun powder residue around the entry wounds and taking into consideration the distance between Mr Sheppard and police after review of the body worn camera footage.

105. Histology of the lungs showed chronic COPD with changes to the bronchiolar epithelium. The result confirmed gunshot wound damages to the heart and lung.

106. The post-mortem examination revealed left ventricular hypertrophy and alcoholic liver disease which did not contribute to the cause of death.

14 ibid 15 Ex B4.1 Findings of the inquest into the death of Mark Andrew Sheppard Page 17 of 23

107. Toxicology of vitreous humor showed alcohol to be present at 156mg/100ml.

This is equivalent to a blood alcohol reading of 0.156%. Dr Samarasinghe stated that this level was three times than the legal limit for driving and disorientation, decreased balance/gait functioning, slurred speech poor sensory perception and confusion could have been expected. Non-toxic levels of Diazepam, Nordiazepam, Sertraline (anti-depressant) were also detected.

108. Dr Samarasinghe concluded the cause of death was gunshot wounds of the chest.

Investigation findings IIG Findings/recommendations

109. The IIG investigation found that there was no evidence to support a criminal prosecution against any person and the use of force used by the officers involved were authorised, justified, reasonable, legally defensible and tactically effective and sound.

110. DSS Ryan recommended that the Chief Executive of the Metro North Hospital and Health Service give consideration to reviewing the practices and procedures governing the mental health treatment of patients such as Mr Sheppard, who are physically and emotionally isolated.

Critical incident review

111. On 30 April 2019, a review of the incident was conducted in the interests of identifying immediate lessons and to consider if there are any necessary changes that need to be made in relation to policy and practice to improve the QPS response to similar incidents in the future. The review focussed on the preincident, incident and post-incident phases.

112. It was identified in the pre-incident phase that there was very little time between the call being taken and police arriving at the scene. At this point there was little information known to make any detailed plan or assessment. While Mr Sheppard was subsequently identified as the caller he was considered as the informant and not a person of interest. The information from Mr Geelmann was non-specific and Mr Sheppard’s actions in screaming behind his caravan and the requirement to quickly gather further information about the ‘stabbing’ deterred the officers from asking detailed questions of Mr Geelmann.

113. The officers who attended had thought it likely that they were attending a disturbance/domestic violence incident and they had planned for this response until further information could be obtained to make a further assessment.

114. During the incident phase, the officers’ conduct was found to be appropriate and in accordance with procedures, policy and training. The way Senior Constable Jurd communicated with Mr Sheppard was found to be in line with best practice training given the high stress situation he found himself in.

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115. The separation of the officers which involved Constable Dallimore walking to the other side of the caravan away from Senior Constable Jurd was also considered.

It was highlighted that separation of officers in dynamic situations needs effective positional awareness, tactical communication and continuous risk assessment as situations like this evolve rapidly with no apparent triggers. There also needs to be a greater awareness of the environment and situation to make effective decisions.

116. The review of the post-incident phase revealed first aid was commenced when it was deemed safe to do so. The weapons near Mr Sheppard were removed and a call for QAS assistance was made. Shortly after the shooting, a torrential storm hit the Deception Bay area while the caravan park was still a crime scene.

Arrangements were made to locate equipment like tarps and other covers to protect the scene. However, the storm affected the immediate area with only two rounds of bullet being found when three rounds were fired. While this was considered to be an issue, it was accepted that it was something that could not be controlled or prevented from occurring in the future. Scenes of crime vehicles carry covers but there is no option to provide equipment like this to all police vehicles due to spacing issues. Forensics found the footage from BWC assisted immensely in conducting and focusing the required examinations.

117. The review found contributing factors into the incident included Mr Sheppard’s medical condition keeping him socially isolated, previous history for violence, issues with mental health, making the call to triple 000 for police to attend and his obsession with knives. The review indicated it was highly likely that Mr Sheppard created the scenario of people being stabbed to police and then arming and threatening police to bring about his own death or ‘suicide by cop’.

118. There were two recommendations made at the end of the review. The first recommendation involved “the effectiveness of current scenario-based training be acknowledged to develop future training programs and scenarios”16. The actions of officers in this incident be drawn on to support this development’.

119. The second recommendation was that the Operational Skills Training Unit “draws on elements of this incident to reinforce the potentially dynamic and unpredictable nature of these situations, requiring officers at all times to have positional awareness, maintain effective tactical communication and to continually re-assess action plan to ensure office and public safety”.17 16 Exhibit C37 – Critical Incident Review Report Deception Bay at p. 12.

17 Ibid.

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Conclusions Findings required by s. 45 Identity of the deceased – Mark Andrew Sheppard How he died – Mr Sheppard had end stage emphysema/chronic obstructive pulmonary disease (COPD). In 2002, he had been diagnosed with alfa-antitrypsin deficiency which caused lung disease. At the time of his death he was using home oxygen. He also had behavioural disorders connected to substance abuse.

On the day of his death at 2.05pm, Mr Sheppard called 000 to inform police that people had been stabbed at the caravan park he lived at. He terminated the call, which was traced to his mobile telephone. Police officers attended the caravan park. The first police crew arrived at around 2.15pm.

After police attempted to engage with Mr Sheppard, he threw a tomahawk at a police officer. He then threw a knife, injuring the officer.

Mr Sheppard then walked towards the officers with a machete. He ignored calls from police to drop the weapon. He was then shot by police officers acting in the course of their duties.

Place of death – Endeavour Caravan Park, 198-202 Deception Bay Road, Deception Bay, Queensland Date of death– 18 March 2019 Cause of death – Gunshot wounds to the chest.

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Whether the actions of the police officers who attended at the Endeavour Caravan Park were appropriate in the circumstances.

120. Senior Constable Jurd and Constable Dallimore were tasked to attend urgently at the Endeavour Caravan Park. At the time they arrived Mr Sheppard was regarded as an informant, and they had limited information about him. After reviewing the evidence and taking into consideration the finding of the IIG investigation, I am of the view that Senior Constable Jurd and Constable Dallimore acted appropriately in assessing the situation, attempting to engage with Mr Sheppard then trying to de-escalate the situation.

121. The confrontation was captured on BWC and it is evident that Mr Sheppard was given numerous warnings, even after he had thrown the tomahawk and a knife at police officers.

122. Efforts to engage with Mr Sheppard proved unsuccessful. Instead of retreating or complying with police directions, he chose to throw a tomahawk and then a knife. He then moved forward to confront the police with a cutlass machete.

123. After Mr Sheppard was shot, Tactical First Aid was applied by a number of the police officers present, including Constable Dallimore. The injuries sustained by Mr Sheppard required advanced medical skills outside the capability of the police officers. The QAS were at the incident scene soon after the shooting but Mr Sheppard could not be saved.

124. Senior Constable Jurd’s evidence was that he did not consider that he could have responded any differently to Mr Sheppard. Constable Dallimore’s evidence when questioned by the ESC about her reasons for discharging her firearm was that: "he's already thrown a Tomahawk, he has then thrown a knife at my partner, he now walking towards me armed with a Samurai sword. I didn't feel like I had enough distance. I had a fence behind me I could 't retreat backwards. He was moving towards me um, and I needed to stop the threat because he had made it very clear that he was going to hurt Police or kill one of us"

125. Mr Sheppard was advancing with the cutlass machete in his possession when he was shot. He had the capacity to kill or do grievous bodily harm to Senior Constable Jurd or Constable Dallimore. Constable Dallimore was backed against a fence and had nowhere to retreat.

126. In the circumstances, it was reasonable for Senior Constable Jurd and Constable Dallimore to form the belief that either one of them would have suffered serious injury or death if Mr Sheppard was not shot. I accept that the officers acted in accordance with their training in responding to the threat posed by the machete with lethal force. Other use of force options such as Taser or oleoresin capsicum spray would not have met the threat posed in the circumstances.

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Suicide

127. Mr Sheppard had a history of suicidal ideation. He was facing a terminal illness and he had expressed his intent to end his life rather than seek palliative treatment in a supported facility. His conversations with his former partner’s mother and Mr Geelmann on the day of his death suggested he was expecting that his death was imminent, and that police would be involved.

128. There was evidence to support the submission that Mr Sheppard planned the incident to bring about his death. The evidence includes: a. His statements during his admissions to hospital about “taking care of things himself” as opposed to being taken by the illness; b. Calling his ex-partner’s mother shortly before the incident to pass on apologies for past wrongdoing and a message to his daughter that he loved her, he did not have long to live, and that there would be things for her in the caravan “when police have finished with it”; c. Making a hoax call to triple 000 about multiple stabbings in order for police to attend the scene, while he waited for police with weapons by his side; and d. His action in throwing a tomahawk and then a knife at police, and continuing to be armed with a machete while advancing on police until he was shot, despite his significant physical illness.

129. In order to make a finding of suicide I am required to be satisfied that Mr Sheppard acted intentionally, knowing the probable consequences.18

130. There was previously considered to be a presumption against suicide. It is now accepted that a finding of suicide can be made having regard to all the evidence on the balance of probabilities. However, a finding of suicide should not be made lightly.

131. Mr Sheppard was affected by alcohol at the time of his death, and was assessed as having a personality structure that made him prone to unpredictable thinking and behaviour. However, it is my view that it is more likely that at the time of his death Mr Sheppard was acting intentionally with sufficient awareness that the probable consequence of his actions would be that he would be fatally shot by police.

Whether there are ways to prevent a death occurring in similar circumstances in the future.

132. Mr Sheppard was terminally ill as a result of COPD in the lead up to his death.

He had many hospital admissions from 2006 as a result of this illness. In May 2018, he was referred to the palliative care outpatient clinic for follow up and symptom management, which was made difficult due to his social isolation and limited functioning. Medical records showed that he concealed the extent of his illness from his family as he worried about the difficulty it would bring them.

18 Clark v NZI Life Ltd [1991] 2 Qd R 11 Findings of the inquest into the death of Mark Andrew Sheppard Page 22 of 23

133. The medical records indicated that at times Mr Sheppard was willing to receive treatment for his condition while at other times he refused treatment. While his refusal of treatment may be due to his isolation and limited functioning, it may also have been due to his expressed fear of ‘getting his hopes up’, his acceptance of the fact that he was dying and the futility of treatment.

134. In relation to his mental health, Mr Sheppard engaged with mental health professionals while in hospital however did not proceed with follow up once he was back in the community. Mr Sheppard was seen by mental health staff during his hospital admissions after expressing thoughts of suicide or attempting suicide in the past. I accept there was no basis for him to be treated on an involuntary basis.

135. While I appreciate DSS Ryan’s recommendation that the outcome may have been different if Mr Sheppard was receiving mental health assistance when in the community, Mr Sheppard did not engage with the mental health system when he was referred for support. This played a role in him not receiving the assistance he may have needed.

136. The last contact mental health staff had with Mr Sheppard was in August 2017 while he was admitted in hospital - nearly 18 months prior to his death. His last contact with the hospital was three weeks prior to his death. However, on that occasion there was no indication that he had any suicidal ideation.

137. Consequently, I do not see a sufficient basis to recommend the revision of the practices and procedures governing mental health treatment for patients such as Mr Sheppard as recommended by DSS Ryan. Nor have I identified any further issues in relation to mental health treatment received by Mr Sheppard.

138. I close the inquest. I extend my condolences to Mr Sheppard’s family and friends.

Terry Ryan State Coroner

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