Coroner again pushes for pill testing after ‘Blue Punisher’ death

A Victorian coroner is again calling for the introduction of pill testing after a man died from an MDMA pill known as the Blue Punisher at a festival last year – the fourth coroner to do so in six years.

Pill testing – a harm reduction service that analyses the contents of the illicit drugs users intend to consume – is being trialled in Queensland and the ACT, but Victoria has not committed to a similar trial.

Pill testing will save lives, the Victorian coroner says.Credit: Christopher Pearce

Mental Health Minister Gabrielle Williams did not rule it out on Wednesday morning but said the state has no plans to introduce pill testing.

The coroner Judge John Cain on Wednesday released his findings on the death of a man at Karnival Music Festival in Flemington in March last year. The 26-year-old was seen taking a pill that resembled a Blue Punisher – a pill with the logo from the comic book Punisher on it and dangerously high concentrations of MDMA.

He was taken to the Royal Melbourne Hospital with multi-organ failure and brain swelling, and he died four days later.

“It is impossible to know whether, had a drug checking service existed, [the man] would have submitted a sample of an MDMA pill for testing before taking it at Karnival,” Cain said in his findings.

“Notwithstanding this, a drug-checking service would have at least created the opportunity for him to do so, and for him to receive tailored harm reduction information from the drug-checking facility.

“It is likewise impossible to know whether, had [the man] been provided information of this type, he would have changed his drug consumption behaviour; but likewise, in the absence of a drug checking service, this was not a possible outcome.”

Over the past six years, three other Victorian coroners have recommended the state introduce a pill-testing service in an effort to prevent people dying from accidental drug overdoses. But the Health Department has so far decided against trialling the service.

In April 2021, coroner Paresa Spanos said lives could be saved if the government urgently introduced a public drug checking service that rapidly analysed samples for content and purity.

Her findings followed the deaths of five young people, aged between 17 and 30, who had consumed a cocktail of synthetic drugs they thought were MDMA or magic mushrooms. One sustained “unsurvivable” brain damage. Others suffered seizures and cardiac arrests after running into windows and walls in 2016 and 2017.

Two years on, Cain said if the Health Department had “any particular concern about the harm reduction potential of drug checking services in Victoria, they could potentially consider the type of staged implementation that has occurred in the ACT”.

“Initial government-approved trials of drug checking occurred in 2018 and 2019 at the Grooving the Moo music festival in Canberra, and these informed the establishment of the CanTEST fixed-site drug checking service for an initial six-month pilot period between July 2022 to January 2023,” he said. “The CanTEST pilot has now been extended twice, with lessons learnt being used to inform future service design.”

The final CanTEST evaluation, published in July 2023, found that in many cases the substances submitted for testing contained different drugs than what the attendee expected.

The Victorian government has not explained why it has rejected the repeated calls from coroners to introduce a drug testing service.

In response to the latest findings, Health Department secretary Euan Wallace said the department acknowledged such a service “can provide information in support of reducing drug related harms”.

“However, there are no current plans to implement a drug checking service of the kind you have recommended in your findings.”

Williams, the mental health minister, said the Health Department already monitored drugs with dangerous impurities circulating in the community. “Should there be evidence to suggest that there’s more that we need to do, of course, as policymakers, we will look at it,” she said.

“Our thoughts go out to the family of that young man. And, of course, any death in these circumstances is one too many.”

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