Finding into death of Brendan Glover

Rule 60(2)

FINDING INTO DEATH WITHOUT INQUEST

Section 67 of the Coroners Act 2008

Court reference: 5571/08

FORM 38

In the Coroners Court of Victoria at Melbourne

I, HEATHER SPOONER, Coroner

having investigated the death of:

Details of deceased:

Sumame: GLOVER First name: BRENDAN

Address: 12 Lloyd Avenue, Epping, Victoria 3076

without holding an inquest:

find that the identity of the deceased was BRENDAN STEPHEN GLOVER

and death occurred on 13th

at 12 Lloyd Avenue, E

from

December, 2008

pping, Victoria 3076

la, BUTANE TOXICITY

Pursuant to Section 67(2) of the Coroners Act 2008, an inquest into the death was not held and

the deceased was not immediately

before the person died, a person placed in custody or care; but

there is a public interest to be served in making [findings regarding the following circumstances:

1. Mr Glover was aged 30 when he died. He was unemployed and lived at home with his supportive family. He had enjoyed good health but was known to use cannabis.

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2. A police investigation was conducted into the circumstances surrounding the death, It was appatent that Mr Glover said goodnight to his mother and retired to his bedroom at about 11.00pm on 12 December 2008. When his mother went to his room the following morning she found her son slouched back on his bed still in the clothes he wore the previous evening, Mrs Glover called to her husband for help and emergency services were contacted. Paramedics were quick to arrive on the scene but it was apparent that Mr Glover had already died, Police attended and observed drug paraphemalia cluding a can of ‘max’ brand butane gas on the bed. Ona table in his bedroom they located empty deal bags with traces of white powder, nozzle attachments for the can of butane gas, a glass pipe and a lighter with the top removed. Nearby were two bongs.

3. The coroner granted an objection to autopsy lodged by Mr Glover’s parents and an Inspection and Report was prepared by Dr Bedford, General Pathologist at the Victorian Institute of Forensic Medicine. He found the cause of death to be butane toxicity as formulated. He also

commented that toxicology testing revealed the presence of cannabis.

4. The Coroners Prevention Unit (CPU)|, were requested to review previous butane-inhalant related deaths to assist in the consideration of prevention strategies, A number of issues concerning preventative opportunities emerged and CPU contacted many experts in the field, including Ms Ruth Mahon, Dr Sarah MacLean, Ms Angela Rizk and Associate Professor Richard Midford. Their assistance is greatly appreciated.

5. It is apparent that Mr Glover suffered from untreated drug dependency issues and has unfortunately and unintentionally died after inhaling toxic butane fumes,

I The Coroners Prevention Unit is a specialist service for coroners crealed (o strengthen their prevention role and provide them with professional assistance on issues pertaining to public heath and safety,

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COMMENTS: Pursuant to Sections 67(3) of the Coroners Act 2008, I make the following comments connected with the death:

Retailer education

1, Retailer education is a widely used strategy for reducing incidence of inhalant abuse. The general principle underpinning this strategy is that if retailers follow a code of conduct whereby they (a) understand their legislative obligation not to sell inhalants to people who may abuse them, (b) do not display inhalants openly, (c) store inhalants where customers must ask for them, and (d) have strategies in place to refuse sale of inhalants to suspected abusers, then access to inhalants is restricted and the harm associated with abuse is reduced.

2, Experts advised that a number of challenges must be overcome in order to achieve an effective retailer education strategy, including how to identify relevant retailers to target with education materials, and how to monitor retailers to ensure they comply with the code of conduct.

A tnulti-pronged approach was recommended, which might involve elements such as the following: (1) Working with retail traders associations and other relevant peak retail bodies on an ongoing basis to identify relevant businesses selling inhalants and distribute education materials to them; (2) maintaining and continually updating a database of retailers, so letters can be sent out regularly (for example every six months) reminding them of their obligation to sell inhalants safely and informing them of helpful strategies to meet this obligation; (3) engaging with local community groups, particularly in regional and remote areas, and providing them with education material that they can tailor to their needs and distribute to local retailers, (4) making use of community workers practical knowledge and experience, to identify and target retailers where abusers are obtaining inhalants; (5) implementing an annual audit process whereby compliance with the retailer code of conduct can be measured; and (6) working with retail groups to spread education messages through trade publications, newsletters and other media where they might

reach relevant retailers.

3, In Victoria, retailer education strategies were first introduced in 2002, when the Victorian Department of Human Services developed a suite of resources titled Responsible Sale of

Solvents - A Retailer’s Kit. These resources address retailers obligations under the Drugs, Poisons and Controlled Substances Act 1981 (Vic), as well as strategies for how to store solvents in shops, how to refuse a sale to a probable substance abuser, and so on.

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4, Following the restructure of the Department of Human Services, the Responsible Sale of Solvents - A Retailer’s Kit is now administered by the Department of Health s Mental Health, Drags and Regions Division. The Coroners Court of Victoria contacted the Mental Health, Drugs and Regions Division to learn more about its strategies for ensuring that retailer education is effective. ‘The response from the executive director of the Division, Dr Karleen Edwards, indicated that kit was widely distributed when it was first produced in 2002, but in recent years has not been distributed proactively. Additionally, Victoria Police still distribute the kit locally to retailers in areas where they identify a need (such as where there are instances of inhalant abuse).

Finally, the kit has not been formally evaluated or reviewed, though in the past retailer response has been very positive.

5. Dr Edwards acknowledged that the Department of Health probably needs to review and update the contents of the kit, as it has not been touched since 2002. The kit will be considered for review as part of a current broader review of printed materials produced by the Department.

To this end, I make the recommendations at the conclusion of my comments.

Product modification and replacement

6. Modifying products so that concentration and inhalation of butane is made more difficult or more unpleasant, is often discussed as a strategy for reducing incidence of inhalant abuse.

7, There was general agreement among the experts that while product modification could be an effective approach to preventing butane inhalation, there are currently no modifications to butane lighter refifl cans that both are realistically able to be implemented and are supported by the current evidence. For example, trials were conducted both in Australia and overseas into adding bittering agents and unpleasant odourants for some aerosols, but these do not appear to be effective at deterring abusers and in any event cannot be used in the case of butane lighter refills (which are not technically aerosols), In the UK there have been suggestions that the size of

butane lighter refills could be reduced, so that abusers would need to buy multiple cans at a time, which would in tum make detecting abusers easicr. However there were issues with preventing parallel imports of larger cans, and there were also concerns that butane abusers would merely switch to another butane source such as stove gas cans that cannot be made smaller without compromising their function, There are presently no feasible packaging modifications for butane

ighter fluid cans that would make inhalation more difficult. Finally, there is a general concern

hat with so many different products that can be abused through inhalation, when any particular

product is targeted for modification, abusers can simply substitute another product.

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8. Product replacement, whereby butane is substituted with another product that is harmless or less harmful when concentrated and inhaled, is another strategy often mentioned in the inhalant abuse literature. However, none of the experts identified any feasible options for products that could replace butane in lighter refills.

9. Given that at present there do not appear to be any feasible, empirically validated product modifications for butane lighter fluid cans that could reduce abuse, or any substances that could feasibly replace butane in lighter fluid formulations these findings, I make the following

comment: The Department of Health has in the past proactively commissioned research to explore product modification and substitution, and should be encouraged to continue

commissioning research in this area as appropriate.

Health worker education and harm reduction

10. Several experts advised that harm reduction strategies such as providing instruction to users on how to inhale butane in the safest manner, how to recognise if somebody has overdosed, and what to do in case of overdose, are very important for preventing deaths. In particular, a harm reduction strategy predicated on professional education of youth workers, health workers, drug and alcohol workers, child protection workers and others who have contact with inhalant abusers is very important, to ensure they are familiar with current best practice in managing inhalant abuser risks.

11. However some experts warned that care must be taken to target the education at people already using inhalants, and to target the general populations only in areas where there is an epidemic of usage, to reduce the risk that current non-users thereby learn that certain substances can be inhaled for their psychoactive effects and decide to experiment.

12. Given the expert support for user education and harm reduction strategies, I make the following comment:

The 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.

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Restriction by legislation

13, In the UK, the sale of butane lighter refills is restricted to those aged 18 years and over, in

an attempt lo reduce inhalant abuse deaths among the younger population that are believed to be

particularly vulnerable, A similar law was recently proposed and debated in Western Australia.

Additionally, some Australian states have introduced age-based bans for other products (such as

spray cans) the contents of which can be concentrated and inhaled.

14. Available evidence and expert opinion is divided

on whether using legislative changes to

further regulate the sale of butane and propane to those aged under 18 years should be canvassed

in Victoria. Research findings particularly from the UK cause a lasting reduction in deaths, Additionally, inhalan

suggest that restricting access might not users can simply shift to other products

that are not regulated or are less well regulated. However a thorough review of the evidence

including newly published UK data could further elucida age-based regulation in Victoria. To this end, I make the

te whether there is a case to be made for ollowing comment:

‘The Department of Health should consider meeting with inhalant abuse experts to explore

whether there is an evidence base and rationale

for barming butane sales to people aged

under 18 years in Victoria, as has been done already with some other products (such as

spray cans) interstate.

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RECOMMENDATIONS: Pursuant to Sections 72(2) of the Coroners Act 2008, I make the following recommendations

connected with the death: .

1. That the Department of Health review the contents of the Responsible Sale of Solvents - A Retailer's Kit to ensure that it contains relevant, up-to-date information that supports 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. That the 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.

Signature:

a YO AN cam oun naw Heather Spooner

Coroner 20th April, 2011

Distribution list:

Ms Ruth Mahon, National Inhalants Information Service coordinator, Alcohol and other Drugs Council of Australia,

Dr Sarah Maclean, Post-Doctoral Research Fellow,

Turning Point Alcohol and Dug Centre.

Ms Angela Rizk, Coordinator, Volatile Substances Program,

Drug and Alcohol Office, Western Australian Department of Health.

Associate Professor Richard Midford, Deputy Director,

Australian Indigenous Health InfoNet, Edith Cowan University

Dr Karleen Edwards, Executive Director, Mental Health,

Drugs and Regions Division, Department of Health

Mrs Fran Thorn, Secretary, Department of Health

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