Victorian coroner backs pill testing after inquest into deaths of four men and a boy
A Victorian coroner investigating the deaths of five young men who consumed a potent psychoactive substance has called on the state government to introduce illicit drug testing and a warning program.
The coroner, Paresa Spanos, said on Wednesday the men – aged between 17 and 32 – died in a six-month period starting in mid-2016.
Four of the men died from mixed drug toxicity following seizures and respiratory distress. In the fifth case, the man leapt from a 10th-floor balcony and died from his injuries combined with mixed drug toxicity.
The men had taken drugs they thought were MDMA or magic mushrooms before they died but the substance was actually a combination of two highly potent novel psychoactive substances: 25C-NBOMe and 4Fluoroamphetamine.
“Risk has always existed when obtaining drugs from unregulated markets: for example the risk that the drug’s contents are not what you believe them to be; the risk that the drug is more potent than expected; and the risk that the drug’s contents are adulterated,” Spanos said.
“If we accept there are unlikely to be any major changes to drug regulation in the foreseeable future, or any changes in individual’s preparedness to use illicit drugs, Victorians will continue to be exposed to the risks of unregulated drug markets.
“The evidence available to me supports a finding that there is broad support for a drug checking service and drug early warning network as evidence-based interventions, at least among those with knowledge and expertise in harm minimisation.”
Spanos recommended the Victorian health department introduce a drug checking service and an early warning system alerting the public to dangerous drugs that may be in circulation. The change should happen as “a matter of urgency to reduce the number of preventable deaths”, she said.
The findings will reignite debate about how governments regulate illicit drugs. In Victoria, the Greens and the Reason party have repeatedly pushed for drug testing, and a parliamentary committee in 2018 recommended a testing trial and a warning system.
The Andrews government has not supported these measures and repeated on Wednesday that there were “no current plans to trial pill testing”.
But it has previously had changes of heart when it comes to coronial recommendations designed to reduce the harm caused by illicit drugs. In 2017, it decided to implement a trial of a safe injecting room only months after dismissing another coroner’s call to do so.
In 2019, a New South Wales coroner recommended the introduction of pill testing after six MDMA-related deaths at music festivals. The Australian Capital Territory government allowed trials at a Canberra music festival in 2017 and 2018.
The first of the Victorian men to die was Anson. He worked at his parent’s restaurant in Melbourne’s north-west, and the local McDonald’s, and had turned 17 only a few weeks earlier. On the morning of 25 July 2016, he twice snorted a brown powder.
“About half an hour later, Anson began to manifest extreme symptoms,” Spanos found.
“[He] appeared to be having a ‘flashback’ or thought he was running away from something. He called out ‘boys, stop’ and then, ‘no, no, no’ and fell backwards on the bed and had a seizure that lasted for about 10 minutes.”
After the seizure finished, Anson coughed and vomited, repeatedly asked for water and “kept banging against the headboard”. After he smashed his arm through a window and sustained a gash to his elbow, which bled profusely, paramedics were called. He died later that afternoon.
Ilker died on 1 December 2016. He was a 32-year-old whose “drug use was known to his friends, to Northern hospital clinical staff and to members of Victoria police”, the coroner found.
He bumped into a friend at a shopping centre in Melbourne’s north, went to their house to consume drugs, and died that afternoon.
Jordan, 22, was pronounced dead on Christmas Day 2016, four days after he lost consciousness as his friends tried to restrain him while he was in an agitated state. Jason, 30, died less than three weeks later, after taking the drug at his girlfriend’s flat.
James, a 23-year-old British citizen on a working holiday, died the next day, 14 January 2017.
“He began to act erratically and kept saying he had ‘never felt a trip like this before’ and kept apologising for being naked when he was fully dressed,” Spanos found.
“[A friend] helped James to bed and gave him several glasses of water, but James would not (or could not) lie still. At about 4am, while four others were talking on the 10th-floor balcony, James came onto the balcony, said ‘fuck this’ before jumping over the railing without hesitation.”
Spanos said the coronial investigation into the five deaths had been delayed because of the prosecution of people involved in the supply of similar drugs, but she was unaware of any direct evidence linking those prosecutions to the cases she had investigated.
In a report provided to the coroner, drug harm researcher Dr Monica Barratt confirmed Victoria police knew the substance was circulating and dangerous in January 2017, when it sent an email to staff, but did not share the information with the public.
Barratt said Victoria police analysed drug seizures and disseminated the information internally, and the Victorian health department issued a public alert in March last year about a drug sold as MDMA that instead contained a novel psychoactive substance named N-ethylpentylone – both initiatives, along with several others, which could support a warning system.
The health department was noncommittal in a submission to the coroner, saying it was “considering opportunities to better monitor and respond to alcohol and drug consumption, harm and risk in a more systematic and timely manner”.
“This includes timely identification of harms through analysis of existing health and justice data and other testing sources.”
The department said there were no plans to trial “pill testing” at public events.
The Victoria police chief commissioner, Shane Patton, said in a submission to Spanos that the force did not support drug testing nor the use of a warning system that relied on police data. It did not express a view on warning systems generally.