The government IT worker, who hasn't been named, took drugs socially with friends at music festivals and raves.
On March 13, 2022, he went to Melbourne's Karnival music festival at Flemington Racecourse with a group of mates, who later reported he took a blue punisher MDMA pill.
The pills, which are blue and feature a skull design imprint, have been found to contain up to five times the usual MDMA dose.
The 26-year-old, who earlier took cocaine and drank alcohol, eventually couldn't stand on his own, became incoherent and started having seizures.
He was admitted to the Royal Melbourne Hospital's intensive care unit with multi-organ failure and brain swelling and died four days later.
Another two people have died and multiple people have overdosed in Germany this year after they were believed to have taken the blue punisher pills.
The deaths have prompted warnings across Europe about the dangers of blue punishers, which evidence showed were circulating in Australia in 2022.
While none of the pills were seized at the Karnival festival, the 26-year-old likely died because he took a high-dose pill, State Coroner John Cain found.Â
The coroner called on the Victorian Department of Health to introduce drug testing in the wake of his findings to reduce "preventable deaths".
He noted other coroners in three recent findings also pushed for the measure to be introduced.
In response to a recent recommendation, though, the department acknowledged a drug testing service's potential to save lives but indicated there were no plans to trial drug testing in the state.
"It is impossible to know whether, had a drug checking service existed, (the 26-year-old) would have submitted a sample of an MDMA pill for testing before taking it at Karnival," Judge Cain said in his findings.
"Notwithstanding this, a drug checking service would have at least created the opportunity for him to do so."
The coroner suggested a Victorian drug testing service could be modelled off one in the ACT called CanTEST.
A final evaluation of the service, published in July this year, found many of the drugs it tested were different to what people expected.
When festivalgoers were surprised by the contents of their drugs they were less likely to take them, and many took advantage of other information at the service.
RMIT drugs policy researcher Monica Barratt said Victoria was lagging behind other Australian jurisdictions and missing an opportunity to get information about changing drug markets fast.
"In Victoria, we find out about local drug trends after the harms have occurred: through analysis of overdose presentations at hospitals, at the morgue or through police seizures," Dr Barratt said.
"In contrast, drug checking services can identify substitutions and adulterations, or unusually high dose or high purity substances, within hours."
Queensland is also introducing drug testing services.
