The NSW Deputy State Coroner has handed down her findings and recommendations with regard to the deaths of six young people at music festivals between December 2017 and January 2019.  Her comments have been widely reported in particular her recommendations to introduce pill testing and to decriminalise personal possession and use of currently prohibited drugs.  You can read her full report via the website of the NSW Coroners Court – Inquest into the death of six patrons of NSW music festivals,

Readers of this blog, in particular those involved in first aid or paramedicine will be interested in the entire report but given its length I won’t attempt to summarise it.  It is better to read it in its entirety.

Of interest to the whole readership might be the issue of the coroner’s response.  The coroner is often used as the ultimate threat – “if you do the wrong thing the coroner will get you!”  I have previously argued that this fear of the coroner is misplaced – see the variety of posts that appear here –

Event medical services

In the deaths the subject of this investigation, event health services were, simply by coincidence, provided by Event Medical Services (EMS).   An expert, Associate Professor Dr Holdgate, was called to assist the coroner and she, and the coroner, were ‘extremely critical of aspects of the care of [two of the young people who died at the Defqon.1 festival] by medical staff who had been contracted by EMS…’ [209].

Being critical, even extremely critical, did not lead to recommendations of professional discipline nor presumably career-ending findings.   The coroner was looking for ways to prevent deaths, not to single out individuals.  The two doctors involved were out of their depth.  Of the more junior doctor the coroner said (at [242]):

In the circumstances of this case, I have considerable sympathy for Dr …. He candidly admitted that he was out of his depth and overwhelmed. He believed, reasonably, that there would be a more senior doctor to handle a patient in these circumstances, and there should have been more support available to him. The frank acknowledgements that he made when he gave evidence showed a level of maturity and insight that is admirable. As Dr Holdgate fairly stated, Dr … lacked leadership skills because of his relative lack of experience in emergency or critical care, meaning “he hadn’t been trained in doing that”.

The care this doctor provided may not have been optimal, but the role of the coroner was to identify that, not to crucify the doctor and the doctor’s own frank admissions and willingness to cooperate with the inquiry held him in good stead.

With respect to the more senior doctor it was not his failings that were the subject of the most severe criticism, but consistent with the role of the coroner being to find ways to prevent future deaths rather than lay blame for the past the coroner was most critical of his failure to learn.  The coroner said (at [231]-[232]):

I accept Associate Professor Holdgate’s view that Dr … was faced with a very challenging situation in a somewhat unfamiliar environment with staff of mixed skills and experience. I am nevertheless troubled by how little he appeared to have learnt from the situation. As Associate Professor Holdgate told the court “…he [Dr …], when asked, said he couldn’t identify anything he would’ve done differently. I can’t think of a single patient I’ve ever seen where I couldn’t think of something I could’ve done a bit better. I find that a worrying lack reflection…”

Having listened carefully to the evidence, particularly the response of Dr …, I remain confident in the expert testimony of Associate Professor Holdgate. I have no doubt that Dr … did his best in a very stressful situation, but he did not appreciate his own limitations when trying to treat [the two patients]. Associate Professor Holdgate identifies a number of troubling gaps in his knowledge. I was not persuaded by the explanations Dr … gave.

The Coroner’s recommendations

The coroner’s recommendations are no doubt controversial and the NSW Government is unlikely to accept them.  The government should, however, be prepared to move away from the traditional punitive law and order debate that is such a common feature of state politics and consider recommendations that are made after consideration of evidence.  With respect to pill testing the coroner said (at [14]):

During the investigation it became clear that there is a wealth of available information that can assist in understanding the context and circumstances surrounding these deaths. Doctors, scientists, criminologists, health policy professionals and peer workers came forward to share their expertise with the court. Many had been working in their respective fields for decades and can properly be regarded as national and international experts. Many had practical suggestions to save lives based on sound research and on experience both here and overseas. A range of views was sought. The court then had the opportunity to sift through divergent opinions and positions, away from the heated political environment where these debates sometimes take place.

That process informed the whole inquest and one might think is likely to lead to more considered responses than one might expect from politicians with a constant eye to the electorate.

With that in mind the coroner made 28 recommendations to the NSW Department of Premier and Cabinet, NSW Health, NSW Police, NSW Department of Communities and Justice, the Australian Festivals Association, NSW Education Standards Authority and EMS Event Medical.  I think of most immediate importance to those engaged in event first aid services are:

To the NSW Department of Premier and Cabinet

1.That the Department of Premier and Cabinet permits and facilitates Pill Testing Australia, The Loop Australia, or another similarly qualified organisation to run front of house medically supervised pill testing/drug checking at music festivals in NSW with a pilot date starting the summer of 2019–20…

6. That the Department of Premier and Cabinet facilitate a regulatory roundtable with the involvement of relevant State and Local government and key industry stakeholders, including the Department of Health, private health providers such as EMS Event Medical, NSW Ambulance and NSW Police, the Australian Festivals Association, harm minimisation experts and promoters, to ensure appropriate minimum standards for policing, medical services and harm reduction are mandated at music festivals.

To the NSW Department of Health

7. That the NSW Health Guidelines for Music festival Event Organisers: Music Festival Harm Reduction be amended to advise of an appropriate time frame and protocol for a private medical service provider to conduct a full evaluation, preferably with an independent consultant, in the event of a fatality involving a patient who they have treated.

To EMS Event Medical

(Noting that this is directed to EMS Event Medical as they were the contracted health service provider at each of the events investigated, but this should be considered by any event health service provider).

1. That EMS Event Medical develop a review protocol so that in the event of another fatality, an independent consultant is engaged to assist with a full evaluation of the circumstances of the death and the adequacy of medical care, and that there be a clear time frame to initiate and complete the report.