Deputy State Coroner Grahame NSW State Coroner's Court

lA Main Ave Lidcombe NSW 2140

Dear Deputy State Coroner Grahame

As the NSW Chief Health Officer and Deputy Secretary of Population and Public Health at

the NSW Ministry of Health I am able to assist with providing information regarding the

NSW Health policy and operational response to drug related harms associated with music

festivals.

I am a public health physician who was appointed to the role of Chief Health Officer on 1

February 2009 . Prior to this appointment I was the Director of Health Protection and

Deputy Chief Health Officer. I have extensive public health experience having held senior

positions in NSW Health since 1991. My curriculum vitae is attached (Attachment A}.

1. There has been a recent increase in drug-related harms associated with music

festivals in New South Wales

2. There has been a recent, substantial increase in the drug related harms associated with a

small number of music festivals in New South Wales (NSW) .

3. From September 2018 to January 2019, five deaths were associated with music festivals in

NSW. In add ition to these deaths, a number of people who attended music festivals

developed serious medical illness requiring hospital admission and intensive care

management for drug related toxicity. For the 25 NSW music fest ivals held in 2018-2019

that have been exam ined in detail, the re were 29 pre-hospital intubations, 25 drug­

re lated intensive care admissions, and at least an additional 23 drug-related hospital

admissions.

4. This number of deaths is an unexpectedly marked increase within a short period. Over the

last decade in Australia, around 12 deaths were associated with music festivals, including

four festival related deaths across Australia over the summer of 2015.

5. Australian surveys of festival attendees consistently demonstrate that drug use is more

common among attendees than in the general population (Day et al. , 2018; Lim, Hellard,

Hocking, & Aitken, 2008). A study undertaken at a NSW festival reported that respondents

were three times more likely to have used drugs in the last 12 months than the age­

matched population studied in the National Drug Strategy Household Survey. The most

commonly used drugs were cannabis (64%) and ecstasy (60%) (Day et al. , 2018) .

6. Patterns of drug use at festivals are an additional concern, such as t he practice of "double

dropping," where individuals consume two pills simultaneously, usually two ecstasy pills.

Almost half of Australian respondents who used ecstasy pills reported double dropping at

the last festival they attended (Grigg, Barratt, & Lenton, 2018) .

7. Polysubstance use, i.e. the mixing of different drugs alongside tobacco, alcohol and energy

drinks, is also a higher ris k practice and is more likely to occur in festival and rave settings

(Fernandez-Calderon, Diaz-Batanero, Barratt, & Palamar, 2019) .

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8. Internationally, music festival related deaths and adverse events are typically reported in

the media, but rarely formally documented in the academic literature. Attachment B

provides international examples of festivals with associated drug related deaths.

9. Surveys undertaken at festivals have demonstrated that certain genres of music have

different associations with reported substance use. Internationally, electronic dance music

(EDM) festival attendance has been correlated with the use of psychoactive substances,

including alcohol and amphetamines (Chhabra, Gimbar, Walla, & Thompson, 2018) . An

Australian study of festival attendees found EDM and rap genres were associated with

higher rates of illicit drug use in the month prior to their attendance. EDM was particularly

associated with recent use of ecstasy (Lim et al., 2008).

10. What we have learnt from recent experience in NSW - Experience of drug related

serious illness at recent festivals

11. Between September 2018 and May 2019, the majority of NSW festival patrons with

serious drug related illness presented with features clinically consistent with MDMA

toxicity.

12. There is no evidence to date that people who presented with serious illness at music

festivals in NSW between September 2018 and May 2019 have experienced significant

toxicity from novel or emerging illicit substances, or chemical contaminants. Many of

these cases self-reported ingesting one or more MDMA capsules. Where performed,

laboratory testing has confirmed the presence of MDMA at toxic or potentially fatal levels

in the majority of the cases (26 of 36 cases, 72 per cent) of serious illness in this period .

13. Specimens from 40 seriously unwell patients who had attended festivals from September

2018 to May 2019 were sent for toxicology analysis. Of these, results are available for 36

cases. For these 36 people, MDMA was detected in 89% of people and was detected at

toxic or potentially fatal levels in 72% of people . The true proportion of people who

experienced MDMA toxicity is likely higher, as there was frequently a lag between the

time when the drug was consumed, the likely peak toxicity period and the time of

collection of clinical samples for laboratory analysis, during which time the drug may have

been partially cleared or metabolised . In some people, other illicit substances such as

methamphetamine and cocaine were detected, alone or in combination with MDMA,

which may have resulted in potentiation of drug-related toxicity .

14. For the 36 people where specimens were tested, the most common drug detected other

than MDMA was cannabis (detected in 25% of people); followed by cocaine (detected in

17% of people); and meth/amphetamines (detected in 14% of people) . Alcohol was

detected in 19% of people.

15. Fentanyl was tested for in all cases, and extended testing for fentanyl analogues was

performed from October 2018 onwards for selected cases. Fentanyl was found in one

case, and no fentanyl analogues were found. The one case with fentanyl detected also had

toxic levels of MDMA detected.

16. Information provided by thirteen people who experienced illness related to festival events

in NSW from September 2018 to May 2019 indicates that some festival patrons take more

than two capsules at once or within a short period of time. Among the thirteen people

where the number of capsules or tablets taken was reported and recorded in the medical

notes, a median of four capsules/ tablets were self-reported to have been consumed .

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17. Impacts on on-site medical services

18. When there is a higher probability of simultaneous serious medical presentations, more

medical service capacity support is needed to identify serious illness, regularly monitor

patients who are unwell, and continuously prioritise care according to clinical need . In

these circumstances it is important to have senior doctors with extensive experience in

the pre-hospital setting available to best coordinate the onsite medical capacity while

concurrently managing multiple patients and facilitating rapid transfer if required .

19. Clinical features associated with cases of serious illness at music festivals as described by

NSW Ambulance situation reports, the NSW Public Health Rapid, Emergency, Disease and

Syndrom ic Surveillance (PHREDSS) line lists, and/or LHD reports were frequently

consistent with MOMA toxicity and serotonergic syndrome, including severe

hyperthermia, aggression, agitation and confusion, decreased level of consciousness,

seizures, cardiac arrhythmias and cardiac arrest.

20. These presentations are very complex to manage, and may require a number of senior

clinicians to provide urgent chemical sedation, rapid sequence intubation and ventilation,

active cooling and urgent transfer to a tertiary facility.

21. One serious medical presentation such as this can easily require the dedicated attention

of a team of four senior clinicians including resuscitation doctor(s), registered nurses

and/or intensive care paramedics.

22. Attachment C provides an overview of learnings from the music festival event debriefs

that have been held to date, with a specific focus on medical service provision on-site .

23. Attachment D provides the clinical case review performed by the NSW Poisons

Information Centre and lessons learned from the death associated with the Lost Paradise

festival.

24. Characteristics of festivals associated w ith higher likelihood of harm

25. Based on the experience of NSW Health's engagement and response during the 2018-19

music festival season, and on an understanding of the potentiating environmental and

behavioural factors for MOMA related toxicity including heat stress and dehydration, the

following characteristics associated with a specific festival event are considered to be

associated with a higher likelihood of serious drug related harm and/or factors that may

increase the severity of harms associated with drug use:

• Target demographic: 18-35 years

• Music type : electronic dance music/high energy music

• Event size: 8,000 patrons or more

• Event time and duration: events which continue past midnight, or where the

duration exceeds 8 hours, or where the event occurs over multiple days

• Anticipated weather conditions: high temperatures can impact on the severity of

drug related harms

• Event site : indoor versus outdoor. Heat exposure and inadequate ventilation can

impact the severity of drug related harms

• Location : metropolitan versus regional or rural locations

• Distance to nearest tertiary hospital.

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26. Attitudes of young people who attend music festivals

27. The Ministry has engaged with young people to help understand their experience and

attitudes in relation to drug related harms at music festivals .

Interviews with young people hospita lised after attending a music festival

28. Interviews with four of eight young people who were available for contact while

hospitalised following attendance at a music festival were undertaken. The primary

purpose of the interviews was to link patients to follow up services, including drug and

alcohol services in their local area or counselling and psychologic support, as appropriate.

The offer of this support was generally well received, even if patients chose not to take up

the opportunity for follow up.

29. The secondary aim of these interviews was to inform NSW Health's understanding of the

experiences and behaviours of these patients, so as to better address their perspective in

directing health messaging and onsite service provision. Attachment E presents the

information obtained at these qualitative interviews in more detail.

30. Key themes identified from these interviews were :

• Participants all viewed drug taking as a personal choice

• Participants reported certain behaviours were driven by fear of police or parental

detection, including taking drugs prior to arrival at the event and avoiding the medical

centre or open disclosure of substance use

• Cost is a factor in their decision to use substances, although while pills are "affordable,

is it really worth your life?"

• All were aware of the risks of substance use, and had seen health messaging, but did

not think it would happen to them

• All delayed their presentation to a medical provider as they felt their symptoms would

improve

• Peers/ friends are a crucial support or protective factor - they serve as a source of

information and support, including in directing patients to appropriate services

• Pill testing was specifically mentioned by some participants, but accessibility and

uptake at festivals would depend on policing strategies used.

Social marketing research

31. The Ministry of Health commissioned a research organisation to interview young people

at music festivals as part of the evaluation of the social media campaign. The research

provided the following insights into the attitudes of festival goers aged 18-24 years :

• Festivals tend to be seen as far 'bigger' than a night out. They are often highlights of

the social calendar. People may plan well in advance and travel long distances to

attend.

• Pre-loading (consuming drugs and/or alcohol prior to the event) is common, and

consumption of alcohol and other drugs can continue after the festival ends.

• The majority believed drug taking is the norm; most believe that at least 70% of

patrons will take something (often people believe it is closer to 90%) . The benefits of

using drugs at festivals are largely seen as obvious and "a given"

• It appears MOMA capsules are the primary drug of choice, with ketamine and to a

lesser extent cocaine playing a role too

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• The decision to consume drugs at a festival is often made well ahead of the festival.

Once purchased, it is unlikely people will change their minds about taking them.

• Most acknowledge drug taking comes with inherent risks, including death (at the

extreme) but few believe they are personally at risk of death. The vast majority of

young people appear to see the risks of taking drugs as 'worth it'

• Police operations are front and centre in people's minds. The role of police is

universally perceived to be about enforcing drug laws - police are seen to be at

festivals in an effort to 'bust people' . Increased policing is widely seen to drive ever

more creative methods of concealing drugs (rather than deterring use) .

32 . Reported barriers to seeking medical treatment for patrons or their friends include:

• Fear of getting into trouble from authorities and/or being ejected from the festival

• Fear of looking stupid or overly dramatic

• Being too intoxicated to know they need help

• Not knowing where or who to ask for help

• Not wanting to spoil anyone's fun

• Inexperienced "trip-sitters" -friends or bystanders not knowing the danger signs

• Knowing what to say

• Wanting to tough it out.

33 . Further social marketing research is underway, with a report due to be delivered to NSW

Ministry of Health by the end of June 2019.

34. This research includes face to face qualitative interviews of 24 young people and an on line

survey of 400 people who have attended a music festival within the last 12 months.

35. This research will guide the ongoing development of the NSW Ministry of Health response

to music festival safety and support development of further strategies to keep people

healthy at music festivals .

36. The Ministry is also currently conducting a consultation process to better understand

stakeholder perspectives about how peer-based harm reduction services can reduce the

risks of drug related harm at music festivals .

37. What we know about MDMA use in the community and risk of harm

38. MOMA is an illicit stimulant substance often consumed recreationally (as a 'party' drug) .

Population data does not indicate an increase in general community use of MOMA

(National Drug Household 2016, Waste Water Monitoring Program). Among regular users

of ecstasy in NSW use is consistent with previous years however there has been a shift

towards capsules and away from tablet formulations (Illicit Drug Reporting System, 2018).

This may have been driven by perceptions of increased strength of MOMA in capsule form

(Gibbs & Peacock, 2018).

39 . Recent information from the state reference laboratory - the NSW Forensic and Analytical

Science Services (FASS) indicate that this perception may not be correct. Although the

number of MOMA pills and capsules that have been analysed is limited (particularly in

2009-2011 for capsules), the findings indicate that the average purity of MOMA in

capsules increased rapidly between 2011 and 2013, while for tablets it has remained

relatively low and stable . However, the median dose of MOMA per tablet or capsule has

remained similar and consistent over time. This is due to a commensurate decrease in the

average weight of MOMA in capsule contents at the time that capsule purity increased .

40. A summary of the clinical toxicology and laboratory analysis findings from the NSW music

festival season, September 2018 to May 2019, is provided in Attachments F and G. MOMA

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toxicity can rapidly progress to an acute, severe, life threatening condition that requires

urgent intensive care management. Severe hyperthermia, where the body overheats to

the point of multi organ failure and death, is one of the severe consequences of MDMA

toxicity. Hyperthermia may be exacerbated by environmental factors, such as high

ambient temperature and inadequate shade/cooling facilities, and patient factors

including individual genetics, levels of activity and fluid intake . Presentations with this

level of severity require more advanced onsite cl inical capability in a pre-hospital setting

such as a music festival.

41. Substances purchased as MDMA may be contaminated with other risky psychoactive

substances, some of which have a similar toxicity profile to MDMA, but this kind of

contamination has not been a feature of the recent serious presentations at music

festivals in NSW.

42. What we have learnt from other jurisdictions

43. Other jurisd ictions have responded to reduce the risks of drug and other harms at music

festivals through approaches that can broadly be grouped into the following five

categories . These categories are by no means mutually exclusive. Rather, effective

implementation of one strategy may support one or more other strategies.

44. Onsite health and wellbeing services: Provision of onsite peer-based harm reduction

programs and medical services. In Europe and Canada, harm reduction services are

embedded into event planning and medical provision. These services include trained

peers who engage patrons through education, counselling and support services to make

informed decisions about their drug and alcohol use, promote help-seeking behaviours

and provide information about sexual health . This typically also includes provision of "Chill

out zones" where attendees can be safely supported through adverse drug reactions.

(Munn, Lund, Golby, & Turris, 2016) .

45. There is an important role for onsite medical services in harm reduction, particularly

because the potentially rapid onset of serious drug related toxicity means that even

relatively short delays in appropriate treatment may contribute to adverse outcomes. Due

to the predictability of drug related presentations at electronic dance music events,

dedicated onsite medical care is recommended, with an increasing recognition that basic

first aid should be supplemented with multidisciplinary critical care teams capable of

providing a higher level of care (Lund & Turris, 2015) .

46. In Ireland, the national guidelines require approval of appropriate onsite medical services

by the health department as part of licensing processes, to ensure that event organisers

engage private health providers with the capacity to manage their event-specific

anticipated risk profile and patient complexity (Health Service Executive, 2013) . Medical

staff must either be fully qualified critical care specialists or advanced trainees specialising

in emergency medicine who are approved by the President of the Emergency Medicine

College (Interview with Dr Sinead Ni Bhraonain, 2018).

47. Patron education and harm reduction messaging : targeted public health alerts and harm

reduction messaging can be provided to festival attendees. For example, the New York

Health Department required viewing of harm reduction messages before patrons were

able to enter a music festival (Ridpath et al., 2014).

48. Regulatory approaches: codification of t he expectations of service delivery by music

festival organisers and onsite medical providers through best practice guidelines and

regulation of approval processes. State governments in Western Austral ia and Victoria

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produced guidelines in 2009 and 2011, respectively (Department of Health, 2009;

Department of Health & Human Services, 2013). In the Irish context, compliance with their

guidelines has been linked with alcohol licensing approval (Health Service Executive,

2013).

49. Drug checking services : This includes the provision of onsite or community based services

that analyse the composition of substances and provide individual feedback to consumers

alongside appropriate counselling. The underlying rationale of these services is to provide

accurate information about the composition of products to enable consumers to make

more informed decisions about their use, and use them more safely. (Barratt, Kowalski,

Maier, & Ritter, 2017; Measham, 2018).

50. Surveillance systems: some models of surveillance or early warning systems are supported

by drug checking services, others are national systems that receive information primarily

from samples of substances collected through law enforcement seizures or poisoning and

death investigations. Through networking between jurisdictions, this information plays a

role in informing public health alerts to festival patrons and clinicians. In the European

model, the collated findings of national early warning systems also support international

risk assessment and policy. (Butterfield, Barratt, Ezard, & Day, 2016; European Monitoring

Centre for Drugs and Drug Addiction, 2019) .

51 . Additional challenges in the NSW context

52. Due to differences in population density, events in NSW do not typically reach the scale of

European or North American festivals in terms of patronage. However, there are specific

issues relating to the NSW environment and health services infrastructure that pose

additional challenges, particularly for onsite risks and service delivery. These include:

The environment and geography

53. Heat: Australian summers experience much higher ambient temperatures than most

European jurisdictions.

54. Geography: Regional and remote music festivals in Australia experience significant

additional challenges due to distance and limited local infrastructure, for example, road

access and telecommunication services.

55. Natural disaster: particularly for reg ional events, plans should specifically address

evacuation in the event of major natural events such as storms, flood or fire.

The health system

56. Music festivals that occur in regional NSW locations are substantially more affected by

prolonged transfer distances and times than similar "regional" events that occur in

European jurisdictions.

57. How NSW Health has responded to date

58. NSW Health has responded rapidly with the introduction of a number of new harm

reduction strategies since September 2018 to reduce drug related harm including

developing guidelines, a new social media campaign and support for event organisers.

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59. Advice and guidance for event organisers on harm reduction at music festivals

60. Guidelines for Music Festival Event Organisers: Music Festival Harm Reduction were

developed (Attachment H).

61. Interim Guidelines were published initially in December 2018, to ensure advice was

available during the peak summer festival period, while also allowing for further

consultation and revision. As a living document, the Interim Guidelines were revised and

updated, and published as Guidelines in March 2019.

62. NSW Health consulted with festival event organisers, onsite medical providers, NSW Users

and AIDS Association (DanceWize) and the Australian Red Cross (save-a-mate), relevant

medical Colleges and professional groups, health services and other government agencies,

and other jurisdictions in the development and revision of the guidelines.

63. These Guidelines describe the three elements of the NSW harm reduction approach to

date, including: social messaging and provision of peer-support to encourage and support

safer behaviours in festival patrons; environmental considerations such as provision of

chilled water, shade, and toilets; and onsite medical service provision to strengthen the

onsite capability for management of severe illness.

64. These Guidelines will undergo regular review. Further consultation and revision of the

Guidelines is underway and the next iteration of the Guidelines will be available by August

2019.

65 . Advice provided on event plans, through pre-event health briefings and debriefs,

and briefing sessions

66. NSW Health has reviewed event plans and has provided advice to event organisers on

how to strengthen harm reduction strategies and risk management approaches.

Recommendations directed to improve implementation of harm reduction strategies in

music festival event plans, particularly event medical plans, will now be submitted as part

of licensing approval processes to Liquor & Gaming NSW.

67 . To support communication and coordination between onsite medical staff, NSW Health

facilities, NSW Ambulance and the Ministry of Health, the Ministry of Health has

coordinated pre-brief meetings to support important discussions about harm reduction

strategies, managing serious illness, clarifying roles and responsibilities, emergency

response protocols and escalation pathways. Formal NSW Health debriefs have been

conducted where appropriate, to identify issues and make improvements to the NSW

Health response.

68. NSW Health has met or consulted with a range of groups to provide information about

and seek advice on lessons from the harm reduction response at music festivals, including

festival event organisers, onsite medical service providers, clinical professional bodies,

harm reduction service providers, other Government agencies such as Liquor & Gaming

NSW and the NSW Police, and other jurisdictions. An example face-to-face presentation

for onsite medical providers is provided in Attachment I.

69. Clinical guidelines for onsite health providers

70. In partnership with the NSW Poisons Information Centre, emergency and intensive care

clinicians, relevant medical Colleges and Ambulance NSW, Interim Clinical Guidelines for

the Management of Drug Associated Hyperthermia (Attachment J) were released to

support pre-hospital service providers during the 2018-2019 festival season.

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71. Initial consultation on these guidelines included the Emergency Care Institute and

Intensive Care NSW of the Agency for Clinical Innovation, NSW Ambulance, and the NSW

Health Service Functional Area Coordinator (HSFAC) .

72. Broader consultation is currently underway with a plan to publish a final version by August

2019, ahead of the next festival season .

73. Deployment of medical retrieval and health response teams

74. All events present some risk of harm, and in particular any event associated with

substance use has a risk of serious drug related illness, even if the event is small or

otherwise considered lower risk.

75. Since January 2019, NSW Health has pre-deployed multidisciplinary critical ca re teams to

higher risk music festivals to supplement private onsite health providers, in an effort to

mitigate the impact of serious drug related illness. These teams are comprised of retrieval

and emergency medical specialists, emergency nurses and intensive care paramedics.

Their role is to undertake the management of critically ill patients, rather than manage

first aid or general medical presentations, which remain the responsibility of the private

onsite health provider.

76. Based on a NSW Health risk assessment conducted prior to selected higher risk festival

events, planned NSW Health response pre-deployment may include :

• A medical retrieval team comprising a minimum of one senior specialist doctor and

one critical care paramedic. For some festivals, the medical retrieval team

deployment included an additional critical care doctor to allow the senior specialist

doctor to continue as designated Medical Commander onsite if the retrieval team

was required to transport a patient to hospital

• A local health district health response team comprising two senior specialist

doctors and four emergency department nurses

• Pre-deployment of additional NSW Ambulance crews or a designated onsite

Forward Commander

• A Local Health District Liaison Officer.

77 . Ten festivals in 2019 had a NSW Health medical retrieval team pre-deployed onsite for the

duration of the event. One of these festivals required the deployment of an additional

medical retrieval team mid-event in addition to a pre-deployed medical ret rieval and

health response team due to the number of concurrent serious drug related presentations

at that event. Eight of t hese festivals also had a pre-deployed health response team onsite

for the duration of the event.

78. Three other festivals in 2019 required a retrieval team to be sent to the festival mid-event

to retrieve a seriously unwell patient, and for one of these events the retrieval team

remained deployed onsite for the remainder of the event.

79. In the period September to December 2018, three helicopter retrieval teams were

deployed to retrieve patients from two festivals (Defqon .l and Subsonic).

80. Deployment of ambulance crews

81. Of the 27 festivals from September 2018 to May 2019 for which we have data, there were

a total of 55 NSW Ambulance crews, 25 NSW Ambulance forward commanders and 19

NSW Ambulance liaison officers pre-deployed to these events. There is a user pays

arrangement in place for pre-deployment of ambulance resources to events such as music

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festivals. Some events have had up to three ambulance crews pre-deployed under the

user pays arrangement, as well as one to three forward commanders and one to three

I iaison officers.

82. Additional ambulance crews have been deployed during at least 22 of these 27 events in

response to demand . The number of additional ambulance crews deployed mid-event has

ranged from one to twelve, and a total of 120 additional ambulance crews were deployed

from the community to these events. Five additional forward commanders were also

deployed mid-event to four of these events.

83. Enhanced peer support and harm reduction

84. NSW Health has funded additional peer-based harm reduction services, including

DanceWize and/or Australian Red Cross save-a-mate, at higher risk festivals . This has

included additional chill out spaces, fans to help cool down the crowd during extreme

weather events, electronic screens to display harm reduction messages, extra signage

directing patrons to medical tents, and provision of free bottles of chilled water and

electrolyte drinks.

85. Social media campaign

86. A targeted and strategic social media harm reduction campa ign has been developed . This

involved four 15 second advertisements on youth-oriented on line platforms such as

Spotify, lnstagram and Facebook. The campaign was informed by a rapid e-consultation

with 603 young people who had recently attended a festival. A key message was

encouraging early help seeking. Festival organisers have been provided with the NSW

Health assets to use on their social platforms and display during the event. Research was

undertaken to evaluate these campaign messages at music festivals held over the

Australia Day long weekend (Appendices Kand L present key findings from this research).

87 . Of survey respondents, 77% had seen or heard drug related messaging at music festivals .

'Know the signs and get help' was broadly appreciated for being simple and direct.

88. How NSW Health is consolidating its response for the 2019-20 festival season

89. NSW will continue to build on activities to date to consolidate its response to reducing

drug related harm at festivals . This includes updating and providing more clinical and

harm reduction advice and guidance to event organisers and onsite medical providers,

strengthening the social messaging strategies and peer-based support arrangements,

enhancing surveillance and strengthening stakeholder engagement.

90. Additional clinical guidance for management of acute illness

91. The NSW Ministry of Health engaged a clinical toxicologist from the NSW Poisons

Information Centre (NSW PIC) to perform a clinical case review of the death associated

with the Lost Paradise festival, to inform clinical management and health service delivery

(Attachment D) .

92. NSW Ministry of Health has engaged NSW Poisons Information Centre (NSW PIC) to lead

development of Clinical Guidelines in the Management of Illicit Substance Toxicity. Clinical

gu idance will focus on illicit substance-related agitation/behavioural disturbance; severe

hyperthermia; decreased level of consciousness; and dehydration.

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93. An expert working group with representation from the NSW Aeromedical Retrieval Unit,

the Emergency Care Institute (ECI) and Intensive Care NSW (ICNSW) is supporting this

process. Guidelines will include four quick reference resources outlining the management

of these complications in the pre-hospital setting, and a more comprehensive resource

which will include detailed management within the hospital setting. The four quick

reference resources will be formally published by August 2019, to support best practice

management of illicit substance related toxicity ahead of the next festival season.

94. Strengthening support for event organisers

95. Apart from the updated Guidelines for Music Festival Event Organisers, additional

resources are planned for development and will be made available on the NSW Health

website . These include patron information on rights and responsibilities which will be

available by December 2019. A training module for event staff on recognising and

responding to alcohol and other drug related harms is also in development.

96. Strengthening social messaging strategies and peer-support

97. Research has been undertaken to evaluate the impact and outcomes of the 2018-19 social

media campaign, and further research is currently being undertaken to inform the

development of an updated campaign for the 2019-20 festival season.

98. The Ministry is also undertaking audience segmentation research to increase

understanding of: attitudes, motivations and values of young people that attend music

festivals; influencers best placed to deliver messages; and the best channels for delivery of

messaging and information before, during and post event.

99. The Ministry of Health is also updating advice on best practice peer support models for

harm reduction at music festivals .

100. Strengthening stakeholder engagement

101. NSW Health is conducting a process of formally engaging clinicians through peak

professional organisations such as the Australasian College of Emergency Medicine

(ACEM), and emergency medicine, intensive care and toxicology clinical networks across

local health districts and the Agency for Clinical Innovation, as well as private event

medical providers and festival event organisers to support an evidence-based best

practice approach to the management of festival-associated drug-related harms.

102. Developing enhanced surveillance for severe drug related toxicity

103. Key learnings from NSW Health's response to the drug-related deaths of the 2018-2019

festival season have identified the opportunity to enhance a state wide public health

surveillance system for acute, severe toxicological presentations to acute health services,

focused on the emergency department and intensive care setting.

104. NSW Ministry of Health and NSW Poisons Information Centre are establishing a formal

partnership to develop the surveillance framework. This system would facilitate standard

FASS toxicology testing (including a screen for over 300 substances) among seriously

unwell patients admitted to emergency departments or intensive care units where severe

drug associated toxicity is suspected.

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105. Providing advice to the Independent Liquor and Gaming Authority (ILGA)

106. NSW Health can be requested to provide advice to ILGA on the health risks associated

with a music festival event, and whether a music festival licence would be more

appropriate to manage the health risks than another type of licence, as described under

Clause 35A of the Liquor Regulation 2018.

107. This advice has been provided as requested for specific events, and is based on the

characteristics, environmental factors and the health incidents previously associated with

the event, and an assessment of the future likelihood of multiple, concurrent serious

medical presentations at the event.

108. NSW Health will continue to provide formal advice to the Independent Liquor and Gaming

Authority as requested, to inform future music festival licensing determinations.

Please advise if I can be of further assistance.

Yours sincerely

Dr Kerry Chant PSM Chief Health Officer and Deputy Secretary Population and Public Health

31/s/,ci

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