Bystanders deprived Canberra man of 'any chance of survival' after overdose

Bystanders deprived Canberra man 'any chance of survival' by waiting hours to call ambulance after overdose Tue 4 Aug 2026 at 3:49pm In short: An ACT coroner has found bystanders acted in a "morally blameworthy" way after waiting hours to call an ambulance for a Canberra man who fatally overdosed in 2021. Felipe Alvarez was left for hours without medical help at his home after a group of people, including two trained peer workers from a drug harm minimisation organisation, failed to respond appropriately to his overdose. What's next? Coroner Ken Archer recommended stronger collaboration between the Canberra Alliance for Harm Minimisation and Advocacy, health, and emergency services to improve overdose responses. An ACT coroner found a Canberra man was deprived of "any chance of survival" after bystanders from a drug harm minimisation organisation waited hours to call an ambulance following an overdose. Coroner Ken Archer handed down his findings into the 2021 death of Felipe Esteban Alvarez, identifying broader public safety issues with the Canberra Alliance for Harm Minimisation and Advocacy's (CAHMA) peer-worker model and governance. The inquest examined the organisation because two of its trained peer workers were present when Mr Alvarez overdosed. Hours before help was called Felipe Alvarez, 48, died after injecting heroin and methylamphetamine at his Taylor home in March 2021. A group of people, including two off-duty CAHMA employees, were present when he collapsed. The two support workers were not at the unit in an official capacity, but had been trained by the organisation to respond to opioid overdoses — including administering naloxone, which can rapidly reverse the effects of an overdose. Despite showing signs of an overdose, losing consciousness and stopping breathing, an ambulance was not called for what the coroner found was "probably several hours". Instead, those present left Mr Alvarez to "sleep it off" before Triple Zero (000) was finally called. An autopsy revealed Mr Alvarez died from toxicity caused by a combination of methamphetamine and morphine, with an underlying heart condition contributing to his death. Due to a non-publication order by the court, the two support workers and the other people present at the unit cannot be identified, and were not called to give evidence during the coronial process. Mr Alvarez had moved to Canberra in 2020 hoping for a fresh start, after spending a significant time in a New South Wales jail for robbery-related offences. The Ngunnawal and Chilean man had battled drug addiction and was a client of CAHMA at the time of his death. In statements to the court, his sisters described him as a "beautiful complex soul" and a "gentle giant" who was trying to rebuild his life after years of trauma and incarceration. 'Morally blameworthy' conduct In his report, the coroner found it was apparent Mr Alvarez was experiencing a medical emergency and should have received immediate medical assistance, with the group's actions depriving him of "any chance of survival" he may have had after his initial collapse. "The conduct of the group in not calling for medical help immediately upon Mr Alvarez's initial collapse, and providing misleading information to the ACT Ambulance Service, was morally blameworthy," Mr Archer said. "[The group's conduct] showed a chilling indifference to the possibility of a loss of a life." He found self-interest, including concern about possible police involvement, was likely one of the reasons an ambulance was not called sooner. Despite those findings, Mr Archer said he would not again refer the matter to the director of public prosecutions. The circumstances had previously been referred to prosecutors, who decided not to lay charges, and the coroner found no fresh evidence during the inquest that warranted reconsidering that decision. Public safety concerns In delivering his findings, the coroner said the inquest raised broader public safety concerns about CAHMA's peer-worker model and governance. The ACT and federal government-funded service aims to reduce the harms of drug use. It employs both former and active drug users to provide services and programs to support other users. Mr Archer said CAHMA played an important role in reducing the harms associated with illicit drug use, but warned the model relied on "the integrity of peer and peer support workers and appropriate governance structures". He said one of the risks was that "public monies can become an indirect support for the drug taking practices of peer workers and their clients". Despite being trained by the organisation to respond to overdoses, and it being anticipated drug use would be taking place, neither had naloxone available when Mr Alvarez collapsed. Mr Archer found CAHMA had also failed to properly apply its own integrity processes by not obtaining Working with Vulnerable People registrations or criminal history checks for the two workers. Both peer workers had extensive criminal histories. While the coroner said it was not possible to determine whether they should have been employed, he found their suitability "should have been determined on the basis of a rigorous application of established screening and eligibility tools". The two employees were terminated shortly after Mr Alvrez's death for unrelated reasons, including poor performance. The coroner also determined that the organisation's justifications for not conducting an internal investigation into Mr Alvrez's death was influenced "to some degree" by concerns about reputational damage. Mr Archer found the failure to investigate exposed future clients and users of the service who interacted with those peer workers to potential risk. He recommended the ACT and federally funded service review its overdose response training to ensure "the goal of saving life is identified as the primary goal", and strengthen collaboration with health agencies, ambulance services and police. "Mr Alvarez's death highlights how a lack of integrity amongst peer workers and poor governance in respect of the recruitment of appropriate staff can expose others to the potential for health-related harm,"Mr Archer said. [Image text:] 144 Ambulance NC CE