Finding into death of Brendan Glover

Contributing factors

• untreated drug dependency
• cannabis use
• access to butane lighter refill cans
• inadequate retailer education on inhalant abuse risk
• lack of product modification of butane products

Coroner's recommendations

1. Department of Health review the contents of the Responsible Sale of Solvents - A Retailer's Kit to ensure it contains relevant, up-to-date information supporting retailers to understand their obligations under the Drugs, Poisons and Controlled Substances Act 1981 (Vic) and offers practical advice on how to meet these obligations, to reduce the sale of butane lighter refills to abusers and reduce resultant harm and death
2. Department of Health develop a process for identifying butane lighter fluid retailers and distributing the Responsible Sale of Solvents - A Retailer's Kit to them proactively, to reduce the sale of butane lighter refills to abusers and reduce resultant harm and death
3. Department of Health should consider developing a professional education resource for youth workers, health workers, drug and alcohol workers, child protection workers and others who have contact with inhalant abusers, to ensure they are familiar with current best practice in managing inhalant abuser risks
4. Department of Health should consider meeting with inhalant abuse experts to explore whether there is an evidence base and rationale for banning butane sales to people aged under 18 years in Victoria