When medics arrived at the home of Sarah and Ryan Shanks shortly after 2:40 a.m. on Jan. 20, 2023, the otherwise healthy mother of two was lying alone, unconscious in the driveway as she struggled to breathe.
The situation worsened. Sarah never regained consciousness and, nine days later, she took her last breath.
What happened that night in Knoxville, Tennessee, is rife with speculation. Everyone agrees Sarah should still be alive, but that's where the agreement ends.
Nearly a year after her death, Ryan Shanks, an emergency room doctor, filed a lawsuit against the first responders and the hospital that cared for her, saying their actions, or inactions, killed Sarah. In January, Sarah's parents filed their own lawsuit, saying Ryan was intent on stopping Sarah from filing for divorce and is responsible for her death.
The lawsuits, both filed in Knox County Circuit Court, shed light on what happened.
Ryan's lawsuit is short and to the point: Everyone involved in Sarah's care is to blame for her death. Had first responders from American Medical Response and the Knoxville Fire Department handled Sarah's care more effectively, she would be alive. Same goes for the staff at Fort Sanders Regional Medical Center, he says in the suit.
He says the staff didn't properly intubate Sarah's airways, failed to perform CPR and failed to take her to the hospital with urgency. Overall, he says, they didn't follow acceptable care practices.
Ryan's lawsuit provides scant details about what happened the night he called 911. It doesn't say how Sarah became short of breath or how her condition deteriorated. It makes no mention of marital troubles or that he and Sarah were separated.
Fort Sanders, Covenant Health (which owns Fort Sanders), American Medical Response and the city of Knoxville all denied wrongdoing in legal filings in response to Shanks' lawsuit.
Sarah had separated from Ryan and borrowed money to retain a divorce attorney in the months before her death, her family says in their lawsuit. They say in the suit he told friends a divorce would be "inconvenient" and "unaffordable."
The two argued over care for their two elementary-age children, and Sarah's family called Ryan controlling. He cloned Sarah's phone - essentially made a copy he could see on a separate phone - so he could get a "better picture of their marriage," a family friend later told police.
Ryan Shanks' attorney, Gavin Shepherd, shared a statement with Knox News, part of the USA TODAY Network, that called the family's lawsuit against "false, defamatory and malicious." Ryan Shanks has filed a motion to dismiss the family's lawsuit.
"Dr. Shanks has never been charged with any crime associated with the death of his wife and he is confident that the true facts associated with her death will continue to be revealed in the pending lawsuit that he filed," Shepherd said.
The night medical care was summoned
The night Sarah Shanks was rushed to the hospital, Ryan called her parents, separately, and told each he was considering purchasing a gun and that he had "suicidal ideations," according to Sarah's family's lawsuit.
Later that night, Sarah and Ryan got into an argument about the calls. Ryan told police Sarah drank multiple glasses of wine and took sleeping pills, according to the family's lawsuit. (Sarah's blood alcohol level was later reported to be 0.1, according to the family's lawsuit, which is considered legally drunk.)
Around 1:30 a.m., Sarah woke up Ryan to tell him she fell in the bathroom and hurt her neck, according to the family's lawsuit, which refers to comments Ryan made to a friend of Sarah's about the events that night. She returned to bed but got up again because she was having a panic attack. He told police Sarah told him she thought she was going to die, the family's lawsuit says.
Eventually, Sarah made her way outside to avoid waking their children. When paramedics arrived she was alone on the driveway and unconscious, according to the family's lawsuit. Ryan Shanks told police he had stepped inside briefly when they arrived.
Twelve minutes after paramedics arrived, Sarah went into cardiac arrest, and the medics began chest compressions and took her to Fort Sanders.
Sarah Shanks' family points out other details about her condition
The family's lawsuit includes reference to a note from Knox County District Attorney Charme Allen to the Knoxville Police Department detective who was reviewing the case, a copy of which Knox News obtained through a public records request.
Allen laid out that she planned to file no charges because Sarah's autopsy was "inconclusive." She called the case "untenable." Her hands were tied.
Allen called Sarah's death "highly suspicious" and said Ryan was the only other adult with her in the hours before she was hurt. Allen pointed to "evidence of instability in their marriage" and concerns about Ryan Shanks' mental health leading up to his wife's death.
Also included is a statement from Knox County's Chief Medical Examiner Darinka Mileusnic-Polchan, who reviewed the Shanks case in December.
Sarah's extended hospital stay and the donation of her organs after her death made it a challenge to figure out what happened, the medical examiner said. Sarah's cause of death is categorized as "could not be determined" on her death certificate.
"We could neither prove nor excluded foul play based on the lack of solid physical evidence of trauma," Mileusnic-Polchan wrote.
When reached by phone, Sarah's mother declined to comment. The family's attorney, Don Bosch, did not respond to a note seeking comment.
Tyler Whetstone is an investigative reporter focused on accountability journalism. Connect with Tyler by emailing him at tyler.whetstone@knoxnews.com. Follow him on X, formerly known as Twitter, @tyler_whetstone.