Inquest into the death of Jesse Drabsch

Case Number: 2017/353545 

Date of Findings: 29 October 2021

Magistrate: Deputy State Coroner, Magistrate Harriet Grahame

Catchwords: CORONIAL LAW –accidental death after use of insulin, Performance and Image Enhancing drugs (PIEDs), Insulin, death in 24 hour gym

Responses

Recommendations

To Anytime Australia:

Bathrooms:

1. That Anytime Australia implement the Trial Policy on a permanent basis at all existing and future Anytime Fitness gyms in Australia. 
2. That Anytime Australia direct its franchisees to undertake a documented internal audit of the bathroom log sheets every three months so as to assess compliance with the requirement in the Trial Policy for regular, documented bathroom checks. 
3. That Anytime Australia direct its franchisees to provide training to all new and existing staff and external cleaners at Anytime Fitness centres which includes:
       a. a summary of the requirement for regular, documented bathroom checks as embodied within the Trial Policy;
       b. a description of the procedure to be followed in the event that a bathroom door is locked and the occupant of the bathroom is non-responsive or requires medical attention; and
       c. training in how to unlock a locked bathroom door from the outside, including ensuring that all staff and cleaners are shown the location of any requisite tools for carrying out that task 
4. That Anytime Australia undertake an immediate costing regarding any technological measures that would assist in detecting an incapacitated person inside the bathrooms at existing and future Anytime Fitness centres, and give documented consideration to prompt installation of those measures, including an upgrade to the main door entry system to record the time that members exit the facility and to notify staff if a member is at the facility for an extended period. 
5. That Anytime Australia give immediate, documented consideration to measures for improving the design of the bathroom doors at existing and/or future Anytime Fitness centres to provide visibility of a potential collapse inside the bathroom, whilst preserving the privacy of occupants of the bathrooms, including by:
       a. creating a narrow gap between the bottom of the bathroom doors and the floor; and b. installing a narrow glass or Perspex panel between the bottom of the bathroom doors and the floor, in a manner that complies with any relevant requirement of the Building Code of Australia (BCA). 
6. That Anytime Australia send a written reminder notification to all franchisees detailing the requirement to log a contemporaneous Anytime Safety incident report in respect of any safety or medical incidents (including those involving patrons inside bathrooms), and that Anytime Australia conduct a regular audit of any such incidents. 

Performance and Image Enhancing Drugs (PIEDs):

1. That Anytime Australia consider liaising with the NSW Ministry of Health, Fitness Australia, Dr Beng Eu, Dr Katinka van de Ven, Kay Stanton and any other appropriate stakeholders with a view to considering:
       a. the actual or suspected use of PIEDs by those who attend Anytime Fitness gyms;
       b. what, if any, measures could be introduced at Anytime Fitness centres (including through digital means such as blogs and social media) to improve awareness of the health risks associated with PIEDs; and c. what, if any, harm reduction measures or strategies could be implemented at Anytime Fitness centres (including through digital means such as blogs and social media) for those who use PIEDs 
2. That Anytime Australia give immediate, documented consideration to the delivery of educational campaigns or sessions to Anytime Fitness franchisees regarding PIEDs use, including by way of recorded online webinars and/or presentations at annual conferences of Anytime Australia.

To the NSW Minister for Health:

1. That the NSW Ministry of Health give immediate, documented consideration to:
       a. adopting or endorsing the Sydney North Health Network’s “GP guide to harm minimisation for patients using nonprescribed anabolic-androgenic steroids (AAS) and other performance and image enhancing drugs (PIEDs)”, including on Your Room and/or the NSW Ministry of Health website for alcohol and other drug health professionals; and
       b. any additional steps that can be taken to educate general practitioners regarding the identification, management and treatment of individuals who use or are suspected of using PIEDs. 
2. That the NSW Ministry of Health consider the preparation and distribution of a dedicated online Fact Sheet regarding the health risks of using non-prescribed insulin. 
3. That the NSW Ministry of Health consider liaising with Anytime Australia, Fitness Australia, Dr Beng Eu, Dr Katinka van de Ven, Kay Stanton and any other appropriate stakeholders with a view to considering:
       a. the nature and prevalence of PIEDs use;
       b. what, if any, additional education, information or resources could be disseminated in NSW to improve public awareness of the health risks associated with PIEDs, including at gyms, at fitness centres and online;
       c. what, if any, harm reduction measures or initiatives could be implemented (including at gyms and fitness centres) for those who use PIEDs. 
4. That the NSW Ministry of Health consider what if any search engine optimisation strategies can be utilised to cause Your Room to appear higher in the ranking for search terms such as “PIEDs”, “performance enhancing drugs”, “bodybuilding drugs”, “fitness drugs” and “steroids”.