A coroner has found the death of Australian actor Richard Norton was “triggered by” his injection of unapproved peptides, and has recommended the medicines regulator consider tougher restrictions.

Norton, 75, was an experienced martial artist who worked in the film and television industry as an actor, stuntman, and instructor. His death is believed to be the first confirmed fatality in Australia from unapproved peptide use.

Coroner David Ryan found Norton’s death in March last year was a result of complications that arose from his use of unapproved peptide products CJC1295 and Ipamorelin. Norton collapsed and suffered a cardiac arrest after injecting the products, which a doctor had prescribed to him. He died at Melbourne’s Alfred Hospital on March 30, 2025.

In findings delivered on Wednesday, Mr Ryan said Norton “had been taking amounts of the medication in excess of the dose prescribed by his medical practitioner”.

The coroner recommended the Therapeutic Goods Administration (TGA) review the therapeutic benefits and safety risks of peptides such as CJC1295 and Ipamorelin and “consider whether further restrictions ought to be imposed on their use”.

Norton was “interested in peptide therapy” and he approached medical practitioner Jerzy Muchnicki, according to the coroner’s report. Norton, who had asthma, osteoarthritis and previous bilateral shoulder reconstructions, told Dr Muchnicki he had been previously prescribed peptides by another practitioner to treat symptoms relating to fatigue, reduced physical recovery, shoulder pain and the loss of lean muscle mass.

The coronial findings noted Dr Muchnicki reviewed Norton’s medical history and “discussed in detail what was involved with peptide therapy, including the experimental nature of the treatment”. “They also discussed the potential risks and the lack of other alternative treatment options currently approved by the Therapeutic Goods Administration (TGA),” the coroner wrote. Norton also signed an “Informed Consent Form for Peptide Therapy” outlining the treatment, benefits and risks. “Dr Muchnicki also arranged a series of blood tests ‘to confirm baseline health parameters and assess for any contraindications or underlying conditions that may influence treatment decisions’,” the report stated.

Norton was prescribed unapproved peptide products CJC1295 and Ipamorelin in injection form which were compounded for him by a licensed compounding pharmacy in Queensland. The ABC has contacted Dr Muchnicki for comment.

In the days before his death Norton reported to Dr Muchnicki that he was “feeling good and the peptide therapy was improving his symptoms”. The coroner noted Norton disclosed to a nurse at Dr Muchnicki’s clinic that he had been administering double the prescribed dose of CJC1295 & Ipamorelin. “The nurse advised Richard that from the following week he ought to only administer the prescribed dose.” Hours after that conversation, Norton became unresponsive after injecting a dose of CJC-1295 and Ipamorelin.

The coroner’s report said the Australian Health Practitioner Regulation Agency received a notification “raising concerns” about Dr Muchnicki’s treatment of Norton. The Medical Board of Australia (MBA) then conducted an investigation which included a report from clinical professor Alistair Vickery.

Professor Vickery stated: “There is insufficient evidence that CJC1295/Ipamorelin is safe, effective or beneficial for human use.” He said taking into account Dr Muchnicki’s training and experience and the history of written consent obtained from Norton, including his prior use of peptides without adverse effects, “the clinical care provided by Dr Muchnicki was at a standard reasonably expected”.

However, he considered that the notes taken by Dr Muchnicki were “sparse, inadequate and perfunctory” and that his “performance as a medical practitioner was below the standard expected in regards to this issue”. The board’s investigation noted that Dr Muchnicki acknowledged these criticisms, accepted accountability for his actions and apologised for his errors in judgement and lapses in record keeping. “And [he] expressed sorrow for the impact on Richard and his family,” the report stated. He said he had reflected on the circumstances and was committed to improving his practice and professional standards and had engaged an educator to provide one-on-one education in clinical record keeping and management.

In its decision in July this year the MBA found Dr Muchnicki’s practice, “is or may be unsatisfactory” however regulatory action was not warranted. He received a caution and conditions were imposed.

The coroner’s report noted the TGA said various pathways existed which enabled medical practitioners to access unapproved peptides. In a statement after the coronial finding was handed down, the TGA said it “continues to warn consumers about the risks of unapproved peptides which have not been assessed by the TGA for safety, quality or effectiveness”. The medicines regulator said it had also communicated those risks to health practitioners. “We are continuing to assess the risks associated with these products and considering whether further regulatory or other measures may be appropriate,” the statement said.