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Highly potent MDMA pill prompts call for drug testing services

Wednesday 6 September 2023
In a coronial finding released for the first time today, State Coroner Judge John Cain has recommended the Victorian Government introduce drug testing services. The recommendation follows an investigation into the 2022 death of a 26-year-old man from a type of highly potent MDMA pill called the ‘Blue Punisher’. 

The Blue Punisher — a small blue pill with a skull design imprinted on it — has gained a reputation internationally for its dangerously high concentrations of MDMA. Over the last five years, pills featuring the Blue Punisher design have been seized and tested in Australia and overseas and have been found to contain varying amounts of MDMA, including up to five times the MDMA dose usually consumed in non-clinical settings. In 2023, two deaths and multiple MDMA overdoses in Germany were linked to Blue Punishers, prompting warnings across Europe about the risk of death from using the pill.

On 13 March 2022, friends observed Mr P take a pill resembling a Blue Punisher at Karnival Music Festival in Flemington. Mr P, who had earlier used cocaine and consumed alcohol, soon developed difficulty talking and began having seizures. He was taken to the Intensive Care Unit of Royal Melbourne Hospital with multi-organ failure and brain swelling, and subsequently died on 17 March 2022. 

Judge Cain found that while authorities did not observe or seize any Blue Punisher pills at the festival, there was evidence the pills were circulating in Australia in 2022 and witness descriptions of the pill Mr P consumed were consistent with that of a Blue Punisher. As such, His Honour concluded Mr P’s fatal overdose was likely due to consuming the high-dose MDMA pill.

In the finding, His Honour said Mr P’s death highlighted how drugs sold in unregulated markets pose a heightened overdose risk because consumers cannot be certain of their composition or strength.

His Honour noted that other Victorian coroners have already highlighted this risk in their investigations into similar deaths, and that coroners in three recent findings called for the introduction of drug checking services to reduce further deaths. The Victorian Department of Health responded to the most recent recommendation acknowledging the death prevention potential of such a service, but indicated there are currently no plans to trial drug checking in Victoria.

Drug checking services have been introduced in the Australian Capital Territory (ACT) and are being introduced in Queensland. His Honour commented that the staged implementation of the ACT’s CanTEST fixed-site drug checking service could potentially provide a model for Victoria to follow. 

The final CanTEST evaluation, published in July 2023, found that in many cases the substances submitted for testing contained different drugs to what the attendee expected; that where test results revealed unexpected drugs the attendee reported being less likely to use the substance; and that the majority of attendees took part in harm reduction education or other health interventions while they were at the service.

His Honour determined that while there was no guarantee that a drug checking service may have been utilised by Mr P or acted as a deterrent if he had tested the pill, such a service would have at least provided an opportunity for him to learn more about the pill and make better informed and safer decisions about his drug use.

To reduce preventable deaths and increase public health and safety, Judge Cain has recommended: 

The Secretary of the Victorian Department of Health, as the appropriate arm of the Victorian Government, implement a drug checking service in the State of Victoria to minimise the risks and the number of preventable deaths associated with the use of drugs obtained from unregulated drug markets.

A copy of the finding into the death of Mr P can be accessed here:


Previous findings involving drug checking service recommendations:

Finding delivered by Coroner Spanos on 7 April 2021:

Finding delivered by Coroner Gebert on 29 April 2022:

Finding delivered by Coroner Gebert on 20 May 2022:


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