Skip to main content Skip to home page

Coroner calls for urgent drug testing services in Victoria

Wednesday 7 April 2021

Victorian Coroner Paresa Spanos is calling for the urgent implementation of public services that check the content and purity of illicit drugs, following an investigation into the harrowing deaths of five young men.

The findings, released for the first time today, state that the men, aged 17 to 32, died in five separate incidents from July 2016 to January 2017, after ingesting what they believed to be MDMA and/or magic mushrooms. 

Each of the men exhibited erratic and distressed behaviour after taking the substance, including headbutting walls and furniture, hallucinating and paranoia. 

In four cases the men died of mixed drug toxicity following seizures and respiratory distress. In the fifth case, the deceased leapt from a 10th floor balcony and died from his injuries combined with mixed drug toxicity.   

Post-mortem analysis found that the drug the men used was in fact a combination of two highly potent ‘novel psychoactive substances’ (NPS) — 25C-NBOMe and 4-Fluoroamphetamine (4-FA).

Drugs obtained from unregulated markets always carry high risks, with consumers not knowing the contents, potency or authenticity of the product. 

These risks are heightened with NPS which are poorly understood in terms of their potency, effects on individuals and interactions with other drugs – in part, because these substances tend to be transient within the drug market and replaced by new forms regularly. 

Noting this, Coroner Spanos stated that mitigating the harms of these drugs requires interventions targeted at NPS overall, rather than just 25C-NBOMe and 4-FA. 

During the investigation, Coroner Spanos consulted Dr Monica Barratt, a Senior Research Fellow at RMIT University with expertise in drug harm reduction and NPS. 

Dr Barratt identified two interventions that could reduce drug harms in Victoria:

  • a public drug checking service where samples are rapidly analysed for content and purity 
  • an early warning network to alert the public to dangerous drugs in the community.  

Submissions were also made by government departments, academic experts, and organisations working to reduce drug harms, who gave varying responses regarding the appropriateness and practicalities of implementing both initiatives.

Coroner Spanos concluded that for as long as illicit drug use exists in the community, Victorians will continue to be exposed to the risks of unregulated drug markets. Furthermore, the successful operation of drug early warning systems internationally, coupled with submissions from those working in harm minimisation, demonstrated that these evidence-based interventions could save lives. 

As such, Coroner Spanos recommends that the Victorian Department of Health urgently implements a drug checking service and a drug early warning network. 

Copies of the findings can be found at:

Finding into the death of Anson –

Finding into the death of Ilker –

Finding into the death of Jordan –

Finding into the death of Jason –

Finding into the death of James –

Media contact: 
Claudia Hodgens 
Strategic Communications Manager 
T: 0407 403 371