A Victorian coroner has called on federal health regulators to overhaul the regulation of unapproved peptides following the death of veteran Australian actor, stuntman, and martial artist Richard Norton. Norton, 75, suffered a fatal cardiac arrest in March 2025 after injecting prescribed but unapproved substances.
In findings handed down on Wednesday, Victorian coroner David Ryan recommended that the Therapeutic Goods Administration review the therapeutic benefits and safety risks associated with peptides such as CJC1295 and ipamorelin. Ryan suggested that regulators consider reclassifying these compounds from schedule 4 prescription-only drugs to schedule 10, which would restrict their availability strictly to clinical trials or approved experimental use.
“I am not satisfied that it is appropriate for them to be available to be prescribed by medical practitioners,” the coroner said in his report, noting the acknowledged uncertainties regarding their therapeutic efficacy and unknown safety risks.
Norton, a respected film industry figure who worked with martial artist Chuck Norris and served as a bodyguard for music icon David Bowie, first approached medical practitioner Dr. Jerzy Muchnicki in March 2025 to inquire about peptide therapy. According to the coroner’s report, the two men discussed the experimental nature of the treatment, potential risks, and the lack of alternative therapies approved by the regulator. Norton had previously received peptide prescriptions from another practitioner to address fatigue, shoulder pain, and muscle mass loss.
Prior to beginning the regimen, Norton underwent baseline blood tests to check for contraindications or underlying conditions. He subsequently signed an informed consent form detailing potential benefits and risks, including anaphylaxis. On March 19, 2025, Norton was prescribed injections of CJC1295 and ipamorelin. A week later, he reported feeling well and noted symptom improvement.
However, on March 28, Norton informed a nurse that he had been administering double the prescribed doses of the peptides. The nurse instructed him to reduce his intake back to the prescribed level starting the following week. Records indicate the treating physician subsequently prescribed two additional peptides intended to further reduce pain and improve function.
Hours after administering the CJC1295 and ipamorelin injections that day, Norton experienced a sudden onset of warmth and flushing before becoming unresponsive. He was hospitalized and died at the Alfred Hospital on March 30, 2025.
The prescribing physician, Dr. Muchnicki, was subsequently investigated by the Medical Board of Australia. An independent expert consulted by the board concluded there was insufficient evidence proving CJC1295 or ipamorelin to be safe, effective, or beneficial for human use, and criticized the physician’s clinical notes as sparse, inadequate, and below acceptable standards.
The board noted that Muchnicki acknowledged the criticisms, accepted accountability, expressed sorrow, and agreed to cease prescribing peptides unless backed by robust clinical evidence. While formal regulatory action was not pursued, the board mandated one-on-one training for the doctor regarding clinical record-keeping and patient management.
The Therapeutic Goods Administration has previously issued warnings to consumers regarding the importation and use of unapproved peptides heavily promoted online for weight loss, anti-aging, muscle growth, recovery, and athletic performance enhancement.
