Inquest into the Death of Thoms, Gemma Geraldine

Contributing factors

• Consumption of unknown quantity of illicit MDMA tablets
• First-aider lacked training in recognition of ecstasy toxicity
• Patient misrepresented the drug taken (said 'dexies' instead of ecstasy)
• Patient misrepresented her age
• Temperature not recorded despite availability of thermometers
• Only one set of vital signs recorded during 25-minute stay when guidelines recommend at least two
• No paramedics, nurses or doctors on-site at the event
• Inadequate medical resources for event with young crowd, hot weather, and expected illicit drug use
• No coordination between St John Ambulance Service first-aid staff and event paramedics
• Medical entry classification system used for the event
• Lack of guidelines requiring higher-level medical care at large events

Coroner's recommendations

1. The Director General of Health should revise the current Guidelines for Concerts, Events and Organised Gatherings 2009, so that organisers of future similar large-scale public events are required to provide the standard of medical care achieved at the 2013 Big Day Out, including tertiary qualified medical practitioners (paramedics, nurses, or doctors) at all first aid posts and an ambulance on-site.
2. The Director General of Health should create a definition of 'paramedic' and consider a form of registration to ensure that only appropriately qualified people are entitled to use the title of paramedic and to practise in Western Australia as a paramedic, to provide public confidence in their qualifications and abilities.