Inquest into the death of six patrons of NSW music festivals

Contributing factors

• MDMA at toxic levels, way above recreational dose
• High purity, high-dose MDMA products on illicit market
• Polydrug use (alcohol, cocaine, amyl nitrate, ketamine)
• Lack of knowledge among friends about MDMA toxicity signs
• High environmental heat and vigorous physical activity (dancing)
• Dehydration and inadequate water intake
• Police presence and drug dogs precipitating panic ingestion and pre-loading
• Inadequate onsite medical resources and staffing at some festivals
• Delays in hospital transfer
• Lack of credible drug education for young people
• Genetic factors (possible poor metabolisers of MDMA in Southeast Asian populations)
• Young people's cognitive development affecting risk assessment

Coroner's recommendations

1. Permit and facilitate front-of-house medically supervised pill testing/drug checking at music festivals in NSW starting summer 2019-20
2. Establish permanent drug checking facility similar to Dutch DIMS model
3. Research and support sophisticated drug analysis technology on-site at festivals
4. Develop early warning systems at music festivals
5. Develop protocols for open sharing of drug trends and monitoring information between NSW State Coroner, NSW Police, FASS and NSW Health
6. Facilitate regulatory roundtable involving government, industry stakeholders, health providers, police and harm reduction experts
7. Consider Joshua Tam family submission in developing new music festival regulations
8. Facilitate NSW Drug Summit to develop evidence-based drug policy focused on harm minimisation
9. Research evidence-based strategies to reduce harm in drug-related illness at festivals (ice baths, rectal thermometers, ice vests)
10. Improve NSW Health pre-hospital guidelines for hyperthermia management
11. Research genetic risk factors for MDMA toxicity (poor metabolisers)
12. Continue funding and expand peer-delivered harm reduction services like DanceWize
13. Contribute to Emerging Drugs Network of Australia (EDNA)
14. Establish stakeholder group for annual review of NSW Health Guidelines for Music Festival Organisers
15. Amend NSW Health Guidelines to require independent evaluation in event of fatality
16. Develop resources for parents about talking to children about stimulant drugs
17. Promote festival guidelines for free cold water, ventilated chill-out spaces, additional activities to encourage chill-out, and artist involvement in harm reduction messages
18. Remove police drug detection dogs from music festivals due to evidence of harmful effects
19. Limit police strip searches at music festivals to circumstances involving suspected drug supply with specific safeguards including recording on body-worn video
20. Develop operational guideline for police at festivals with pill testing services
21. Develop and implement training for police at music festivals focused on harm minimisation and positive community engagement
22. Establish drug amnesty bins at music festivals with consultation on placement
23. Develop strategies to limit strip searches to suspected suppliers rather than possession cases
24. Australian Festivals Association to promote harm reduction strategies and guidelines
25. NESA to develop high school curriculum module on MDMA deaths at music festivals
26. NESA to commission expert review of drug education in school curriculum
27. EMS Event Medical to develop review protocol with independent consultant in event of future fatality