Coronial
NSWhospital

Inquest into the death of Bradley HOPE

Deceased

Bradley John Hope

Demographics

16y, male

Date of death

2019-12-08

Finding date

2023-03-03

Cause of death

cardiac arrhythmia or hypoxia in the setting of hydrocarbon inhalation

AI-generated summary

Bradley Hope, 16, died from cardiac arrhythmia or hypoxia following inhalation of hydrocarbon propellants from an aerosol deodorant purchased at a supermarket self-checkout. After engaging in volatile substance use with friends, he rapidly deteriorated with unresponsive state, respiratory distress, and colour change. Despite immediate CPR by friends, police and paramedics, and extensive resuscitation efforts at hospital including intubation, medications, and consideration of ECMO, he could not be resuscitated. The inquest found he was engaging in recreational VSU, an accessible practice among young people. Clinical lessons include recognising VSU can cause sudden fatal cardiac arrhythmias even in first-time users or healthy young people; the need for early emergency services activation; education for first responders about VSU risks; understanding that cardiac arrhythmias may follow VSU due to myocardial sensitisation to catecholamines; and broader public health strategies including parent education, retailer awareness, and product reformulation research.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • inhalation of hydrocarbon propellants from aerosol deodorant
  • sensitisation of cardiac muscle to catecholamines
  • ventricular fibrillation
  • rapid deterioration preventing effective intervention
  • lack of specific antidote for hydrocarbon toxicity
  • delay in seeking emergency services
  • accessibility of aerosol products for purchase

Coroner's recommendations

  1. NSW Ministry of Health to convene a VSU Roundtable forum with government, industry, retail, health and community stakeholders to address volatile substance use issues
  2. Roundtable participants to include NSW Police, Department of Education, NSW Ambulance, Department of Communities & Justice, Aerosol Association of Australia, Unilever, retailers, community youth services, First Nations health agencies, and expert academics
  3. Prioritise collection and collation of data across agencies on VSU prevalence, trends and hotspots in NSW including mortality and morbidity
  4. Review NSWPF P79A Form to capture sufficient information indicating need for toxicology testing in suspected VSU cases
  5. Establish arrangements for sharing VSU data between agencies and stakeholders at state and national level
  6. Ensure adequate training of first responders (police, ambulance, social and youth workers) in identifying VSU and associated risks
  7. Formulate public health education program addressing: school-based VSU prevention, teacher education on signs and management, parental education, harm reduction for regular users, links to reputable information sources, first aid and emergency response training for young people, peer education
  8. Consider legislation regulating sale of volatile substances where reasonable grounds to suspect abuse, as exists in Queensland and Western Australia
  9. Include basic life support training in high school curriculum to equip young people with skills for medical emergencies from VSU
  10. Collaborate on potential resurrection of National Inhalants Information Service website (operational until 2014)
  11. Explore non-volatile compressed gas propellants as alternative to hydrocarbon propellants in aerosol deodorants
  12. Aerosol Association of Australia to collaborate with industry participants including Unilever to evaluate efficacy and impact of warning labels on aerosol containers
  13. AAA to update its Aerosol Labelling publication to include guidance on VSU warnings such as SACKI (Solvent Abuse Can Kill Instantly) or IMCKI (Inhalant Misuse Can Kill Instantly)
  14. AAA to liaise with Standards Australia Committee PK-013 regarding inclusion of mandatory VSU warnings in Australian Standard AS 2278.1
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