Richard Norton, 75, an experienced film industry fight choreographer and martial artist, went into cardiac arrest in March 2025 after injecting a prescribed but unapproved peptide.
Tributes poured in for the beloved actor who worked alongside stars such as Chuck Norris and served as a bodyguard for music legends, including David Bowie.
Victorian Coroner David Ryan found Mr Norton suffered a cardiac arrest after injecting the unapproved products CJC1295 and Ipamorelin, which had been prescribed to him by a doctor.
In findings handed down on Wednesday, Mr Ryan recommended the Therapeutic Goods Administration review the therapeutic benefits and safety risks of the peptides.
That review should consider shifting peptides from schedule 4 prescription-only drugs to schedule 10, allowing them only for clinical trials or other experimental use.
"I am not satisfied that it is appropriate for them to be available to be prescribed by medical practitioners," the coroner said.
"It is not clear to me how their safe use can be clinically indicated given the acknowledged uncertainties as to their therapeutic benefit and their risks (as yet not fully known) to the safety of patients."
In March 2025, Mr Norton approached medical practitioner Dr Jerzy Muchnicki, expressing interest in peptide therapy.
The pair discussed in detail what peptide therapy involved, 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," the report said.
He had previously been prescribed peptides by another practitioner for fatigue, shoulder pain and loss of muscle mass, the coroner's report said.
A series of blood tests were conducted to confirm baseline health parameters and assess for any contraindications or underlying conditions that may influence treatment decisions.
Following the tests, Mr Norton signed an informed consent form that outlined the treatment, benefits and risks, including anaphylaxis.
Mr Norton was then prescribed CJC1295 and Ipamorelin injections on March 19.
A week later, the actor reported he was "feeling good and the peptide therapy was improving his symptoms".
Two days later, on March 28, Mr Norton disclosed to a nurse that he had been administering double the prescribed doses of CJC1295 and Ipamorelin.
"The nurse advised Richard that from the following week he ought to only administer the prescribed dose," the report said.
The doctor prescribed two additional peptides to further improve function and reduce pain.
Just hours later, after injecting CJC1295 and Ipamorelin, Mr Norton felt hot and flushed before becoming unresponsive.
He died at the Alfred Hospital on March 30, 2025.
Dr Muchnicki was investigated by the Medical Board of Australia, whose independent expert found there was "insufficient evidence that CJC1295 or Ipamorelin is safe, effective or beneficial for human use".
The expert deemed Dr Muchnicki's notes "sparse, inadequate and perfunctory and were substantially below the standard reasonably expected".
The doctor acknowledged the criticisms of his practice, accepted accountability for his actions and expressed sorrow for the impact on Richard and his family, the board said
He also swore off prescribing peptides unless supported by robust clinical evidence.
The board deemed regulatory action was not warranted but it forced Dr Muchnicki to undergo one-on-one training for clinical record keeping and management.
The TGA has warned consumers about the risks of importing and using unapproved peptides that are promoted online.
Peptides are often promoted for weight loss, muscle growth, anti-ageing, recovery and performance enhancement.
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