Finding into death of Anson

Contributing factors

• ingestion of novel psychoactive substances mislabelled as MDMA
• dangerous combination of 25C-NBOMe and 4-fluoroamphetamine
• high potency of novel psychoactive substances
• lack of drug checking services to identify substance composition
• absence of early warning network to alert public
• unregulated drug markets
• cerebral oedema and global ischaemic cerebral injury
• profound metabolic acidosis
• critical hyperkalaemia
• cardiac failure

Coroner's recommendations

1. That the Department of Health, as the appropriate arm of the Victorian Government, implements a drug checking service in the State of Victoria as a matter of urgency, to reduce the number of preventable deaths (and other lesser harms) associated with the use of drugs obtained from unregulated drug markets.
2. That the Department of Health, as the appropriate arm of the Victorian Government, implements a drug early warning network in the State of Victoria as a matter of urgency, to reduce the number of preventable deaths (and other lesser harms) associated with the use of drugs obtained from unregulated drug markets.