The report goes on to say…….The 53-year-old Killara resident died on board an Albury-bound V/Line train on October 6 last year.

He boarded the train at Melbourne, collapsed and could not be resuscitated.

A blood test showed he had a synthetic cannabinoid in his system known as Cumyl-PeGACLONE.

A pathologist performed an autopsy, which found the man had heart problems.

The death of the father-of-two, known only as Mr P, was investigated by coroner Audrey Jamieson, who noted the drugs could induce cardiac arrhythmia.

Coroner Audrey Jamieson

She found synthetic cannabis could be more dangerous than regular marijuana, with 12 Victorian deaths from 2017 to 2019 under review.

“There is so little definitive information about the effects of novel synthetic substances and there is no practicable way for a user to know precisely which illicit synthetic drugs are being consumed,” Ms Jamieson said.

“It thus seems unlikely that Mr P and other users of synthetic illicit drugs would or could anticipate any potential increased risk to health and life.

“The combination of limited information and general ignorance about the potential risks of synthetic illicit drugs presents a unique challenge to health and governance policy makers.”


Coroner finds gap in awareness about dangerous synthetic drugs

Friday 24 July 2020

A finding released today by Victorian Coroner Audrey Jamieson has revealed a dangerous lack of awareness about the potentially lethal effects of synthetic cannabinoids.

The finding follows an investigation into the death of Mr P, a 53-year-old Killara man who was found struggling to breathe on an Albury bound V/Line train on 6 October 2019. Despite numerous efforts, Mr P could not be revived and died while being treated by Ambulance Victoria paramedics at Broadmeadows Train Station.

Coroner Jamieson determined that Mr P’s death was the result of using Cumyl-PeGACLONE, a synthetic cannabinoid, in the context of two underlying heart conditions.

Synthetic cannabinoids are designed to imitate the effects of cannabis in the brain, but are generally more potent. Their use has been associated with cardiac arrhythmias, seizures and sudden death, particularly in people with pre-existing cardiac conditions. However, the full range of harms and risks associated with synthetic cannabinoid use is not well understood, in part because of a lack of studies.




To understand the issues associated with Cumyl-PEGACLONE, Coroner Jamieson directed the Coroners Prevention Unit (CPU) to review other relevant Victorian deaths involving the drug. The CPU identified 12 such deaths between 2017 and 2019, including:

  • four deaths where Cumyl-PEGACLONE played a causal or contributory role.
  • four deaths where the role of Cumyl-PEGACLONE was unable to be ascertained.
  • three deaths where the role of Cumyl-PEGACLONE was not explicitly addressed.
  • one death where the role of Cumyl-PEGACLONE was still under investigation.

In her finding, Coroner Jamieson noted that Cumyl-PEGACLONE is only one of hundreds of synthetic cannabinoids circulating in illegal drug markets, and that users can never be sure which synthetic cannabinoid they are using — so harm reduction strategies need to be targeted at synthetic cannabinoids generally rather than a specific drug.

Her Honour stated

“the combination of limited information and general ignorance about the potential risks of synthetic illicit drugs presents a unique challenge to health and governance policymakers.” 


Coroner Jamieson recommends that the Victorian Department of Health and Human Services review how education regarding synthetic cannabinoids is disseminated to health services and, if deemed appropriate and necessary, develop a training package or similar resource for clinicians to equip them to have conversations with patients about synthetic cannabinoid risks and harm reduction.

A copy of the finding can be found at:

2019 5437 Mr P