Finding into death of B T

IN THE CORONERS COURT Court Reference: COR 2023 004474

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Sarah Gebert, Coroner Deceased: BT Date of birth: 1969 Date of death: 15 August 2023 Cause of death: 1(a) Complications of a hypoxic brain injury 1(b) Mixed drug toxicity (methylamphetamine, benzodiazepines, metonitazene) Place of death: Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria

INTRODUCTION

1. On 15 August 2023, BT was 53 years old when died in hospital following illicit drug use.

2. At the time of his death, BT lived in North Melbourne with a flatmate.

THE CORONIAL INVESTIGATION

3. BT’s death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.

4. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

5. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.

6. Victoria Police assigned Senior Constable Mallory Bubb to be the Coroner’s Investigator for the investigation of BT’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

7. This finding draws on the totality of the coronial investigation into BT’s death, including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1 1 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

Background

8. According to his family, BT struggled to cope with his parents’ divorce when he was 12 years old. He had been a precocious child, keeping his mother on her toes.

9. After leaving high school early he went on to work in various jobs, and appears to have enjoyed some of those roles. At the time of his death, BT was unemployed.

10. In his adult life, BT began using illicit substances and engaging in offending behaviour. His drug use continued throughout his adult life, along with the negative effects often associated with that lifestyle. BT’s mother, CF, tried to support her son. She provided him and his brother with a house to live in Oak Park, but he eventually stopped paying rent.

11. BT later spent some time in Perth. It was there that BT discovered he was HIV positive, which he assumed was due to using dirty needles. At about this time, BT was also involved in a motor vehicle incident, which caused a deterioration in his mental health requiring hospitalisation. It appears he also served a term of imprisonment.

12. When BT returned to Victoria, he again lived in his mother’s Oak Pak house until it was sold.

He subsequently received assistance from Ozanam House, living in North Melbourne and surrounding suburbs for the remainder of his life.

13. According to CF, during the last years of her son’s life, BT had a flatmate who suffered schizophrenia. He and BT used drugs together. CF continued providing her support by bringing him frozen meals and paying his bills.

14. It was clear from CF’s statement that she loved her son very much and tried to help him as best she could. She admitted that BT exasperated her as he was always in trouble, which was understandable. She noted that her son “couldn’t take hard knocks”.

15. At the time of his death, BT had an undetectable HIV viral load. His medical history also included bipolar affective disorder, anxiety, depression, substance use disorder, and reflux.

According to his general practitioner, Dr Dean Membrey at CoHealth, BT commenced heroin use in his mid to late 20s and developed an opioid use disorder, which was managed with opioid agonist therapy (sublingual buprenorphine). Between 2017 and 2021 Dr Membrey was able to rotate BT to long-acting buprenorphine injections and then bring the therapy to completion, after which BT did not appear to relapse to illicit opioid use.

16. BT engaged with local mental health services and a psychologist in regard to his mental health.

However, Dr Membrey noted that BT regularly used methamphetamine throughout the time he was treating him, and that the methamphetamine had a substantial impact on his mental health and behaviour.

17. According to Victoria Police, BT had contact with police several times from early 2020. These incidents were related to deterioration in his mental health, and he was arrested for the purpose of undergoing mental health assessment in hospital. As a result of the most recent incident, occurring on 22 December 2022, BT was charged with assault police officer, assault with weapon, and unlawful assault. He was due to appear at the Melbourne Magistrates’ Court on 12 July 2023 in relation to these charges.

18. In early 2023, BT was referred for a Comprehensive Alcohol and Other Drug Assessment by the Australian Community Support Organisation (ACSO) as part of his Court Integrated Services Program bail requirements. The purpose of the assessment was to determine BT’s pattern of substance use, whether it correlated with his offending, and to refer him to treatment as appropriate. During his initial assessment, BT disclosed trying cannabis when he was 15 years of age and smoking cannabis regularly when he was 15-16 years of age. In recent times, he used cannabis about once a week. BT also disclosed trying speed (amphetamine) in his early 20s and had used it off and on since then. He then tried methamphetamine in his late 30s or early 40s and had used it regularly (about daily) since about 50 years of age. He had also tried heroin in his early 30s and used it regularly then but had not used it recently.

19. BT reported a belief there was a direct relationship between his substance use and his offending. In light of this information, he was referred for standard counselling with a local drug and alcohol service to focus on harm minimisation strategies to assist him in his goal of reducing his illicit substance use and reducing the associated harms.

20. BT attended several counselling sessions. In April 2023, he reported making enquiries with Windana (an alcohol and other drugs service) for a detox admission. His last session was on 27 June 2023 at which time he was still waiting to hear whether his application for detox had been accepted.

21. The ACSO history-taker specifically recorded that BT had been residing with his friend, FP, for the last three or four years, they used methamphetamine together, and they both enabled one another’s substance use. The ACSO history-taker characterised FP as a protective influence on BT’s welfare.

22. BT’s brother, NW, confirmed that FP was an important part of the social context in which BT’s drug use took place. He stated that FP moved in to live with BT in his flat about four years before the fatal incident, and “I know there were hard drugs involved and they both used needles, they used drugs when they had the money”.

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

23. At about 6.35pm on the evening of 30 June 2023, BT’s flatmate used a public phone to contact emergency services to request an ambulance for BT who was having trouble breathing and shaking. When Ambulance Victoria paramedics arrived, they found BT breathing but having a prolonged tonic clonic seizure. Paramedics also noted a possible recent left cubital fossa injection mark. BT’s housemate described the drug cocktail BT had taken as, “brown bromide, white Ottawa, and robot leg lubricant (brown powder)”.

24. BT was transported to the Royal Melbourne Hospital where he was sedated and intubated. A hospital drug screen found no alcohol, but there was detection of amphetamine type substance, benzodiazepines, and cannabinoids. There was no detection of opiates or cocaine metabolites (screen conducted 30 June 2023 on urine).

25. After extensive investigation and consultation from multiple specialty units, it was the collective impression that BT had subcortical myoclonus secondary to a hypoxic brain injury versus a persistent toxidrome from a polysubstance overdose, or a combination of both.

26. On 16 July 2023, BT was extubated; he was able to follow simple commands for movement and able to maintain his own airway. His admission was complicated by a pneumonia and severe dysphagia.

27. On 10 August 2023, clinicians held a family meeting with BT, who communicated his preferences using a communication board. It was explained that BT was unlikely to make a meaningful neurological recovery, his symptoms of myoclonus would likely be persistent, and that he was at risk of recurrent aspiration pneumonia/infections. BT indicated his wish to transition to palliative care.

28. On 11 August 2023, BT was transferred to the Peter MacCallum Cancer Centre Palliative Care Unit. He passed away at 1.00am on the morning of 15 August 2023.

Further Accounts

29. Police were unable to obtain a statement from FP, who was the only eyewitness to the fatal incident. FP did however make a 000 call which was summarised by the Coroner’s Investigator as follows: On the 30th of June 2023 at 6.36pm FP went to a public phone box and called 000 and requested Ambulance Victoria attend [BT’s address]. FP stated that BT wasn’t breathing well, he couldn’t talk, he was shaking and shivering and possibly having a heart attack.

30. The Ambulance Victoria Patient Care Record (ePCR) documented on arrival at the scene, a recent injection site on the inside of BT’s elbow, as well as used needles present at the scene and, “Friend on scene reports patient has been having ? seizure activity for ~60mins so 000 called”.

31. Dr Izanne Roos, a specialist neurologist at the Royal Melbourne Hospital, who treated BT in the emergency department, documented the following: The handover from Ambulance Victoria (AV) indicated that BT had been found at home by a friend displaying abnormal movements described as flexion of the upper limbs, extension of the lower limbs, and a clenched jaw. The movements had been continuing for more than an hour before AV was contacted. There was evidence of drug paraphernalia and used needles around the apartment.

32. FP also spoke to NW after the overdose who stated: FP told me, he thought the stuff they brought that BT overdosed on was a rubbish mix and he felt apprehensive about it, so he only took a little bit. He thought it was a rubbish mix, but BT used a lot.

Identity of the deceased

33. On 15 August 2023, BT, born 1969, was visually identified by his brother, NW.

34. Identity is not in dispute and requires no further investigation.

Medical cause of death

35. Forensic Pathologist, Dr Melanie Archer, from the Victorian Institute of Forensic Medicine (VIFM), conducted an external examination on 17 August 2023 and provided a written report of her findings dated 27 November 2023.

36. The post-mortem CT scan detected patchy pneumonia. External examination revealed evidence of a possible track mark scar in the left cubital fossa. There was no evidence of any injuries that could have caused or contributed to death.

37. Toxicological analysis of ante-mortem samples collected on 30 June 2023 identified the presence of methylamphetamine,2 metonitazene, diazepam3 and nordiazepam, midazolam,4 and paroxetine.5

38. In regard to the detected drugs, Dr Archer noted the following:

(a) acute methylamphetamine toxicity can result in agitation, convulsions, cardiac arrhythmia and cardiac arrest. Long term use can result in cardiac disease;

(b) metonitazene is a novel synthetic opioid which is not legally available in Australia and has no legitimate therapeutic use. The pharmacology and toxicology of this drug is not completely understood, but use of the drug has been associated with cases of mixed drug toxicity;

(c) diazepam can contribute to central nervous system and respiratory depression;

(d) midazolam was most likely to have been administered by the hospital; and

(e) paroxetine was in keeping with therapeutic use.

39. Dr Archer provided an opinion that the medical cause of death was “1(a) Complications of a hypoxic brain injury” secondary to “1(b) Mixed drug toxicity (methylamphetamine, benzodiazepines, metonitazene)”.

40. I accept Dr Archer’s opinion.

2 Methylamphetamine is the N-methyl derivative of amphetamine and has no legitimate therapeutic use in Australia.

Methylamphetamine is supplied in powder or pill form (speed), as crystal methylamphetamine (crystal meth or ice), and a sticky paste (base). The desired effects sought by methylamphetamine users include an increased alertness, reduced fatigue, weight loss, and intense euphoria. The onset of effects is rapid after intravenous injection or smoking, and slower after oral ingestion. The effects typically last four to eight hours but residual effects may persist for up to 12 hours.

Adverse effects of methylamphetamine use include dizziness, headache, restlessness and tremor. Overdose may cause anxiety, cardiac arrhythmias, circulatory collapse, coma, confusion, convulsions, hallucinations, hypertension and hyperthermia.

3 Diazepam is a benzodiazepine derivative indicated for anxiety, muscle relaxation and seizures. Nordiazepam, temazepam, and oxazepam are active metabolites but only nordiazepam accumulates in blood. Adverse effects of diazepam include confusion, incoordination, physical dependence, sedation, and seizures in withdrawal. Overdose can cause ataxia, drowsiness, and muscular weakness.

4 Midazolam is used as a preoperative medication, antiepileptic, sedative-hypnotic, and anaesthetic induction agent.

5 Paroxetine is indicated for major depression, obsessive compulsive disorder, panic disorder, social phobia, generalised anxiety disorder and posttraumatic stress disorder.

DRUG CHECKING AND PILL TESTING Further drug analysis

41. Police had no opportunity to seize any relevant samples of substances and test them for the presence of methamphetamine and/or metonitazene, as they were only notified of the death when BT died in hospital, which was six weeks after his admission.

42. Toxicological testing of a blood sample taken from BT upon his admission to Royal Melbourne Hospital identified the following drugs: metonitazene, methylamphetamine, diazepam, midazolam and paroxetine.

43. Paroxetine, olanzapine and diazepam were likely present as medications prescribed by Dr Membrey.6

44. Methamphetamine is an illegal stimulant drug, and metonitazene is an extremely potent illegal opioid drug (1000 times stronger than morphine) and were likely in the substance BT injected on the afternoon of Friday 30 June 2023.

45. FP described the substance as a “rubbish mix” and suspected that the substance contained other drugs mixed with the methamphetamine.

46. The Royal Melbourne Hospital medical records from BT’s initial admission, include a photograph of a piece of paper recording “Description of ‘cocktail’ taken prior to hospital – from housemate” which read: Cocktail:

• Brown Bromide (antihistamine)

• White Ottawa

• Robot leg lubricant (brown powder).

6 Paroxetine and olanzapine were regular medications, as evidenced by Dr Membrey’s medical records and the Pharmaceutical Benefits Scheme patient summary for BT. Diazepam was not a regular medication but rather prescribed on an as required basis, with the most recent script from Dr Membrey being for 10 tablets on 7 June 2023 (four weeks before the fatal incident).

49. The Coroner’s Prevention Unit (CPU) searched the Bluelight Forums7 for ‘bromide’, “’White Ottawa’ and ‘robot leg lubricant’, and did not return any clearly relevant results.

50. Dr Roos also provided the following account in her statement: BT’s housemate claimed that BT had injected ‘bromite’ on the night of the seizure.

The case was discussed with toxicology/poisons hotline on 2/7/2023. They advised that ‘bromite’ does not exist and perhaps BT’s friend was referring to bromide or bromate.

However, there was no literature about bromide or bromate causing seizures.

51. Given BT’s established history of daily or near-daily methamphetamine use in the period leading up to his death, it is likely that BT thought he was consuming at least some methamphetamine prior to his collapse. Similar to FP, he probably also knew that the substance may have contained methamphetamine mixed in a ‘cocktail’ with other drug(s), however there is no evidence to suggest he knew it contained metonitazene.

Similar drug deaths in Victoria

52. BT’s death, like many other deaths Victorian coroners investigate each year, likely resulted from using a substance obtained in an unregulated (illegal) drug market without knowing for certain what the substance contained.

53. At the time of BT’s death there was no drug checking service in operation in Victoria where he could have taken the substance to be tested, learnt it contained metonitazene, and make an informed decision (having considered any advice from the drug checking service workers) about whether and/or how to use the substance.

54. Following calls from drug and alcohol services, harm reduction experts, people with lived experience of drug use, and coroners (among others), a drug checking service trial has now been established in Victoria under the auspices of the Department of Health. The Drugs, Poisons and Controlled Substances Amendment (Pill Testing) Act 2024 (Vic) provided the legal framework for the trial, and the trial itself is being delivered by a consortium including the Youth Support and Advocacy Service (YSAS), the Loop Australia and Harm Reduction Victoria (HRVic).

7 The Bluelight Forums are an online community where people can participate in discussions about drug use, harm reduction and related topics. The Bluelight Forums currently contain nearly 400,000 discussion topics and an active and engaged readership. The Forums are fully text searchable, making them a unique source of information about topics including drug use terminology. See: https://bluelight.org/.

55. The first stage of the trial was recently completed, which involved a mobile service attending five music festivals and events across Victoria between 1 January 2025 and 25 April 2025 to test patrons’ substances. The next stage, a fixed-site service in inner Melbourne where anybody can bring substances to be tested, is currently in development; a Fitzroy site has been chosen and the service is anticipated to open in August 2025.

56. Whether BT would have attended the fixed-site drug checking service if it was in operation at the time of the fatal incident will remain unknown. In addition, whether BT would have acted on the information that his drug mix contained metonitazene, following testing, will also remain unknown.

57. The public communications about the drug checking service to date predominantly have foregrounded ‘pill testing’ as the title of the service with the official name of the service announced in June 2025 being the ‘Victorian Pill Testing Service’. The Victorian Department of Health’s website however includes as part of its key messages that, “Pill testing, or drug checking, helps people make safer and informed choices by showing them what's really in their drugs.”

58. It also currently describes the fixed-site service as follows: Fixed site pill testing service in Fitzroy The Victorian Pill Testing Service is due to open a fixed site service in Fitzroy by August 2025. The service at 95 Brunswick Street, is close to public transport, nightlife, community health and social services. The free, confidential and anonymous pill testing service will be open to all. This means more Victorians can access year-round testing, health and harm reduction advice.8

59. It further notes that substances in forms other than pills can be tested, that is “pills, capsules, powders, crystals, or liquids and identify substances such as dangerous synthetic opioids, like fentanyl and nitazenes”.

60. I note that many organisations treat ‘pill testing’ and ‘drug checking’ as synonyms, though I understand there is concern in the alcohol and other drugs sector about the connotations the two terms carry. That is, pill testing may imply the use of what are colloquially described as ‘pills and powders’ – stimulants such as MDMA and amphetamine and cocaine – in 8 Victorian Department of Health, “Victoria's pill testing trial”, reviewed 16 June 2025, accessed at https://www.health.vic.gov.au/alcohol-and-drugs/pill-testing, accessed 31 July 2025.

recreational settings such as music festivals and music events, whereas drug checking is the umbrella term, encompassing more generally services for the diverse people who use drugs.

61. In this context, it was useful to consider how BT, who regularly injected drugs, would have understood the scope of a ‘Victorian Pill Testing Service’ rather than a ‘drug checking service’, and whether the choice of nomenclature would fully capitalise on the projects harm reduction potential.

62. I wrote to the Victorian Department of Health to find out how drug checking is being promoted outside the context of music festivals and pill testing, including whether there is an engagement strategy to provide information about the service to people who inject drugs, and whether the Department of Health has any concern that promoting a ‘pill testing’ service might mislead people as to the nature of the service. I also wrote to HRVic with the same questions, seeking their view as the Victorian peak body representing people who use drugs as well as a partner in the consortium delivering the drug checking trial.

Harm Reduction Victoria correspondence

63. I received a response to my questions from Sione Crawford, Chief Executive Officer of HRVic.9

64. Mr Crawford explained that HRVic commenced consultation with people who use and inject drugs well before the Victorian drug checking trial was announced, to understand what service model might best meet their needs. As part of this process, HRVic in conjunction with the Victorian Alcohol and Drug Association (VAADA) commissioned the 2024 report Drug Checking: Principles of Practice - A Model For Victoria, which was informed by expert input including from people with lived experience of drug use.10 The guiding principles articulated in the report included: Peer organisations that represent service users must be centred in the governance, planning, design, implementation, promotion and evaluation of services and the early warning system, as well as fully resourced to undertake all aspects of this work.

Centring peers in these ways recognises their unique strengths and expertise, and the vital role they can play in community engagement, as well as their capacity to earn 9 Dated 8 July 2025.

10 See Seear K, Drug Checking: Principles of Practice - A Model For Victoria, Melbourne: Harm Reduction Victoria and Victorian Alcohol and Drug Association, 2024.

the trust of those who will use these services, many of whom have been heavily stigmatised, criminalised or over-policed.11

65. Consistent with this principle, Mr Crawford wrote that: […] we have made best efforts to engage with people who inject drugs as well as other people who use drugs prior to the fixed-site opening announcement, and have carried both general and specific feedback into discussions on service delivery with our consortia partners on issues including but not limited to: opening hours; location; types of ancillary services (if any); lighting and decoration; security; likelihood of dependent users accessing the service, and how they will need access; overdose management and prevention and so on.

66. Specifically regarding the ‘pill testing’ terminology used to describe the service, Mr Crawford stated, following discussion with potential service users and affected community generally: There are mixed views on the issue, but most we spoke to saw drug-checking as a preferable term, and this is why we were able to include the term in the branding for the Victorian Pill Testing Service – Confidential Drug Checking.

Some views on the issue that surfaced during a consultation session in May included the belief that “drug checking” as a term was too much like drug testing and sounded like something that would be done by police or by workplaces. On the other hand there was concern that “pill-testing” would not immediately convey the fact that most types of drugs (and people who use drugs) are welcome to be tested or checked at the service.

67. Mr Crawford emphasised that in HRVic’s engagement and communications with affected community members and service users, they have made clear (and will continue to make clear) that a wide range of drugs can be checked, and the service has the potential to support nearly every person who uses illicit drugs – depending on the audience they might say ‘drug checking – often known as pill testing or visa versa’. He wrote: Having a more recognisable phrase – ‘pill testing’ - in the public comms and the name does mean that as the community partner on this program we will need to make a concerted and stronger effort to make sure that some of our most marginalised 11 See Seear K, Drug Checking: Principles of Practice - A Model For Victoria, Melbourne: Harm Reduction Victoria and Victorian Alcohol and Drug Association, 2024, p.6.

community members feel welcome and included in the service. We are committed to undertaking this and feel supported in this effort by our consortium partners The Loop Australia and YSAS and the funders, the Victorian Department of Health.

Victorian Department of Health correspondence

59. I received a response from Michelle Chiko, Acting Executive Director of the Reform Implementation Branch in the Mental Health and Wellbeing Division at the Victorian Department of Health.12

60. Ms Chiko stated that engagement with impacted stakeholders such as people who use drugs has been an important part of establishing the Victorian Pill Testing Service. The engagement plan to date has included: […] a range of strategies to build awareness and understanding of the service, such as leveraging trusted local networks, conducting targeted engagement with specific cohorts, participating in existing community meetings and networks, hosting drop- in information sessions, and remaining responsive to emerging opportunities.

61. Specifically regarding people who inject drugs, Ms Chiko explained: As illicit substance use remains a crime, people who inject drugs may be reluctant to disclose this through consultation or direct engagement with government. For this reason, it is considered more effective for the Consortium, which includes trusted peer-led organisation HRVic, to lead the delivery and engagement activities targeting this cohort.

62. Ms Chiko confirmed more generally that people with lived experience of drug use have been “involved in the design, government, delivery and evaluation” of the service. She wrote: HRVic, which is part of the consortium delivering the trial, is Victoria’s lead health promotion organisation for people who use drugs. HRVic delivers a range of peer-led services and programs with and for communities of people who use drugs. The organisation’s involvement in both the trial and development of the engagement strategy reflects its connections to these communities and longstanding expertise in harm reduction and peer engagement.

12 Dated 8 July 2024.

As noted above, the community engagement plan for the Victorian Pill Testing Service has been informed by the perspectives of people with lived experience of drug use.

This involvement includes working directly with people who use drugs to learn how information about the Victorian Pill Testing Service, and its public health benefits, is most effectively disseminated to diverse communities, including people who inject drugs.

In July 2025 the Consortium will also establish a service user and community reference group, made up of people with lived and living experience of substance abuse, to provide ongoing feedback on how Victoria’s Pill Testing Service can better engage with and serve the needs of this cohort. The department will not be directly represented in this group but will receive advice and insights through its collaboration with the Consortium and will consider this important input to inform decisions on service implementation, data collection and communications processes, and when evaluating the trial.

63. Finally, Ms Chiko explained that a range of communications, branding and engagement strategies have been implemented to ensure that people understand a ‘pill testing’ service covers a broad range of drugs. The strategies include adopting the service tagline ‘confidential drug checking’ to reflect the full scope of substances that can be tested, and messaging via social media campaigns and elsewhere to explain that the service “tests substances in pill, capsule, powder, crystal and liquid form”.

64. Ms Chiko noted that during the mobile testing trial at music festivals, the most commonly tested substances were in powder rather than pill form, indicating an awareness that a range of drugs can be tested beyond “pills”.

Comments

65. I note that both the Victorian Department of Health and HRVic are committed to ensuring that all people who use drugs, including people who inject drugs, understand that the ‘Victorian Pill Testing Service’ tests a broad range of substances and supports all people who use drugs. I also note Ms Chiko’s indication that a service user and community reference group was to be established in July 2025 to provide ongoing feedback on the Victorian Pill Testing Service can meet the needs of the clients and communities it serves.

FINDINGS AND CONCLUSION

66. Pursuant to section 67(1) of the Act I make the following findings:

(a) the identity of the deceased was BT, born 1969;

(b) the death occurred on 15 August 2023 at Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, from complications of a hypoxic brain injury secondary to mixed drug toxicity (methylamphetamine, benzodiazepines, metonitazene); and

(c) the death occurred in the circumstances described above.

67. Having considered all of the circumstances, I am satisfied that his death was the unintended consequence of the drugs he consumed.

I convey my sincere condolences to BT’s family for their loss.

Pursuant to section 73(1A) of the Act, I order that a de-identified version of this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I direct that a copy of this finding be provided to the following: CF, senior next of kin Peter Mac Quality & Safety Unit Senior Constable Mallory Bubb, Victoria Police, Coroner’s Investigator Signature: ___________________________________ Coroner Sarah Gebert Date: 18 August 2025 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.