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When NSW teenager Bradley Hope died after inhaling from an aerosol, his mother was determined his death would not be in vain.
"We as a society can't afford to lose one more young life in this way… there must be answers or solutions to prevent this," Corinne Mair told an inquest into her 16-year-old son's accidental death.
Hope, described as a kind and loyal young man, died in the early hours of December 8, 2019, after using an inhalant with friends during a sleepover in Tweed Heads, on the NSW North Coast.
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In the first inquest of its kind, NSW State Coroner Teresa O'Sullivan on Friday handed down lengthy and urgent recommendations to address the trend of inhalant use, known as "volatile substance misuse".
O'Sullivan recommended NSW Health hold a roundtable with police, the education department, paramedics, manufacturers, retailers and youth and community services.
The roundtable should consider a public health campaign, education programs for children and parents, potential legislation relating to the sale of inhalants, and greater training for police and paramedics.
"The heartache of Bradley's loss continues to be felt daily by his family," O'Sullivan said in her findings, handed down at Byron Bay Court.
"It is hoped that from this inquest process, some small measure of solace can be taken by the family, given that these proceedings are a step towards reform to prevent the occurrence of another similar tragedy."
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O'Sullivan also recommended the Aerosol Association of Australia look at the effectiveness of warning labels on containers, while manufacturers should continue research into new, safer products.
The inquest heard Bradley stopped breathing and turned pale late on December 7.
His friends and one of their mothers, who was a nurse, repeatedly tried to revive him, an act O'Sullivan described as courageous.
Paramedics also tried to resuscitate him before he was treated at the Tweed Hospital, where he died of heart failure, a complication of inhaling the aerosol.
Experts told the inquest there was no effective data about the prevalence of inhalant use, but one study found there were 164 deaths between 2000 and 2021, most of them male.
Inhaling aerosols can have a "paint stripping" effect on the brain and disturb heart rhythms, with possible chronic effects like nerve and organ damage and dementia, the inquest heard.
O'Sullivan offered sympathies to Bradley's family, saying their grace and dignity was remarkable.
"It is very clear how much they loved him and how much they miss him."
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