The family of Perth teenager Gemma Thoms says she should be remembered for the safety changes her fatal ecstasy overdose at the 2009 Big Day Out sparked rather than the mistake she made, after a WA coroner handed down his findings into her death today.
Coroner Dominic Mulligan said medical precautions at the 2009 festival were "inadequate", but he had been impressed that resources, guidelines and plans had been significantly improved in subsequent years.
Gemma, a 17-year-old apprentice hairdresser, died after taking three ecstasy tablets before entering the Claremont Showground for her first ever music festival. She had quickly taken two tablets outside the venue, fearing she would be caught by police, after taking one pill earlier at home.
Mr Mulligan said Gemma did not appreciate the difference between one and three tablets was the "difference between life and death."
She had been taken to a first aid post and examined by volunteer Tony Holding, but the teenager told him she was 18 and had only taken "a dexi". Mr Holding did not think her vital signs were abnormal and allowed her to leave when she appeared better.
Gemma soon collapsed and was rushed to hospital. By the time she arrived at Sir Charles Gairdner Hospital she had a temperature of 43C. Mr Mulligan said Gemma's organs had effectively been "cooked" and there was no reasonable chance of survival by the time she arrived at hospital.
Mr Holding told the inquest he had received no drug training and did not know anything about dexamphetamines.
Mr Mulligan did not criticise Mr Holding, but said he did not have sufficient training and knowledge and in hindsight having qualified medical staff on site could have helped identify Gemma's true condition.
He said had Mr Holding received specific drug training or information he could have looked at Gemma and her symptoms differently and sought higher level intervention.
Although meeting guidelines at the time, Mr Mulligan said medical services at the 2009 festival were "inadequate" to deal with major medical emergencies such as Gemma's overdose and it would be prudent to have professionals like paramedics, nurses and doctors on hand at events of this kind to provide patient care and guidance to first aid volunteers.
Mr Mulligan recommended the Health Department revise guidelines to ensure future similar events have the same level of medical resources that was achieved at this year's Big Day Out, which he inspected as it coincided with the inquest in January.
He said qualified St John paramedics worked this year's events with medical services provided well beyond the mandated standard.
He said the Big Day Out should be ranked as a high-risk event, which makes the presence of qualified medical staff mandatory, rather than its current Health Department classification of a medium-risk event.
The coroner offered his sincere condolences to Gemma's family and friends after saying the teenager was just an ordinary young West Australian excited about attending the festival, but who did not appreciate the dangers of taking ecstasy.
He said Gemma had started taking drugs about two years before her death, but only used them in social settings, while her parents did their best to protect her.
Outside court, Gemma's mother Peta Davies was pleased with the Coroner's findings, which she hoped helped ensure future festivals and events were safe, and said that her and her family's campaigning for changes had been worth it.
Despite medical resources in 2009 being inadequate, Mrs Davies was happy to hear of the massive improvements at the 2013 Big Day Out.
"I just hope all future festivals, not just the Big Day Out, follow suit," she said.
"I'm really proud of her (Gemma), I love her, she made a terrible mistake but I couldn't ask for anything better to come out of this situation."
Gemma's stepfather Paul Davies, who is qualified St John paramedic, also said outside court the findings were the best outcome in the circumstances and called on other similar events to match the Big Day Out in safety precautions.
Outside court, Gemma's friend Cassandra Southern, who was with Gemma at the Big Day Out and took two ecstasy tablets herself that day, welcomed the findings.
"I've learnt a very hard lesson and yes, I've learnt from my mistake," she said.
"(We were) just teenagers having fun and look what happens."
Ms Southern, who has not been back to another Big Day Out since 2009, urged others to think twice about their actions "because you never know what's going to happen."
"I just hope people remember her (Gemma) for who she was, not the mistakes she made," she said.Outside court, WA Big Day Out promoter Ken Knight, from Altered State Events, offered his sympathy to Gemma's family and welcomed the Coroner's finding that the event had followed all of the guidelines in 2009.
'The West Australian' is a trademark of West Australian Newspapers Limited 2013.
All rights reserved.
Select your state to see news for your area.