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Inquest Into the Death of Six Patrons of NSW Music Festivals, Hoang Nathan Tran Diana Nguyen Joseph Pham Callum Brosnan Joshua Tam Alexandra Ross-King

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Inquest Into the Death of Six Patrons of NSW Music Festivals, Hoang Nathan Tran Diana Nguyen Joseph Pham Callum Brosnan Joshua Tam Alexandra Ross-King STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of six patrons of NSW music festivals, Hoang Nathan Tran Diana Nguyen Joseph Pham Callum Brosnan Joshua Tam Alexandra Ross-King Hearing dates: 8 – 19 July 2019, 10 – 13 September 2019, 19 – 20 September 2019 Date of findings: 8 November 2019 Place of findings: NSW State Coroner’s Court, Lidcombe Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: CORONIAL LAW – Manner of death, death at music festival, MDMA toxicity, harm minimisation strategies, policing of music festivals, drug checking, drug monitoring schemes, drug education, File numbers: 2018/283593; 2017/381497; 2018/400324; 2019/12787; 2018/283652; 2018/378893; 2018/378893. Representation: Counsel Assisting Dr Peggy Dwyer instructed by Peita Ava-Jones of NSW Department of Communities and Justice Legal Gail Furness SC instructed by Jacinta Smith of McCabe Curwood for NSW Ministry of Health, Ambulance NSW and Western Sydney Local Health District Adam Casselden SC and James Emmett instructed by Nicholas Regener and Louise Jackson of Makinson D’Apice for the Commissioner of Police and four involved Police Officers Simon Glascott of Counsel instructed by Fiona McGinley of Mills Oakley for Medical Response Australia Pty Ltd and Dr Sean Wing Patrick Barry of Counsel instructed in part by Erica Elliot of K & L Gates for the Australian Festivals Association (AFA) Jake Harris of Counsel instructed by Tony Mineo of Avant Law for Dr Christopher Cheeseman and Dr Andrew Beshara Ben Fogarty of Counsel for Simon Beckingham Peter Aitken of Counsel instructed by Summer Dow of DLA Piper for EMS Event Medical and Michael Hammond Laura Thomas of Counsel instructed by Melissa McGrath of Mills Oakley for HSU Events Pty Ltd and Peter Finley Michael Sullivan of Norton Rose Fullbright for FOMO Festival Pty Ltd Andrew Stewart of Stewart & Associates for Q-Dance Australia Pty Ltd Non-publication orders: This document can be published in its current redacted form. Any other publication in relation to this matter must be in accordance with detailed Non Publication Orders which are available from the Court Registry. 2 Table of Contents Introduction .......................................................................................................................... 1 The evidence ....................................................................................................................... 3 The scope of the inquest ...................................................................................................... 4 Background .......................................................................................................................... 8 Some common themes ...................................................................................................... 10 The type of music festival ............................................................................................... 10 Personal characteristics of the young people who died.................................................. 11 Lack of knowledge about drugs and the signs of toxicity................................................ 13 Substantial police presence ........................................................................................... 15 MDMA toxicity was a causal factor in each death .......................................................... 17 Polydrug use .................................................................................................................. 19 Heat ................................................................................................................................ 20 Availability of onsite medical services ............................................................................ 21 The young people who died ............................................................................................... 22 Hoang Nathan Tran ........................................................................................................ 22 Diana Nguyen ................................................................................................................ 30 Joseph Pham ................................................................................................................. 32 Callum Brosnan .............................................................................................................. 34 Joshua Tam ................................................................................................................... 36 Alexandra Ross-King ...................................................................................................... 38 The provision of medical care ............................................................................................ 43 Was the care provided adequate? ................................................................................. 44 Onsite care provided to Diana and Joseph at Defqon.1 ................................................. 45 Findings with respect to Dr Wing ................................................................................ 47 Findings with respect to Dr Beshara ........................................................................... 51 Changes made by EMS following these deaths ......................................................... 53 Medical care of Nathan Tran .......................................................................................... 55 NSW Ambulance service at Knockout Circuz ............................................................. 55 Why do young people take drugs? .................................................................................... 58 Estimates of illicit drug use at music festivals .................................................................... 61 The types of drugs consumed at music festivals ............................................................... 64 3,4-methylenedioxy-N-methylamphetamine (MDMA) or ‘ecstasy’ .................................. 64 History of MDMA......................................................................................................... 64 What are the effects of MDMA? .................................................................................. 66 Diagnosis of MDMA toxicity ........................................................................................ 67 What factors can contribute to having an adverse reaction to MDMA? ...................... 68 Is there a toxic level of MDMA that will lead to overdose and/or fatal overdose? ....... 71 Treatment of MDMA toxicity ....................................................................................... 73 Other drugs taken at music festivals .............................................................................. 74 Cocaine and established stimulants ........................................................................... 75 LSD, ketamine and established hallucinogens ........................................................... 75 Amyl nitrate and the inhalants .................................................................................... 76 New psychoactive substances (NPS) ......................................................................... 77 What has been already been done in relation to the identified risk of drug death at music festivals? ............................................................................................................................ 82 The response of NSW Health ......................................................................................... 82 Emergency medical response at festivals ................................................................... 82 3 Guidelines for music festival organisers ..................................................................... 83 Other guidelines.......................................................................................................... 84 Social media campaign ............................................................................................... 85 Support for event organisers: advice, predeployment of medical teams and peer- based harm reduction services ................................................................................... 85 Responses from Australian Festivals Association and promoters .................................. 87 Responses from peer support organisations .................................................................. 90 Responses from the families .......................................................................................... 92 What further interventions to save lives can be identified ? ............................................... 94 Changes to policing at music festivals ............................................................................... 95 The use of drug detection dogs at music festivals .......................................................... 99 Practice of strip searching ............................................................................................ 102 Drug checking .............................................................................................................. 105 Methods of testing ........................................................................................................ 105 Types of services ......................................................................................................... 107 Fixed site testing .........................................................................................................
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