Inquest into the death of Felipe Esteban Alvarez (No 2)
Deceased
Felipe Esteban Alvarez
Demographics
male
Date of death
2021-03-30
Finding date
2026-08-03
Cause of death
toxicity caused by a combination of methylamphetamine and morphine
AI-generated summary
Felipe Esteban Alvarez died on 30 March 2021 from toxicity caused by methylamphetamine and morphine (heroin) ingestion at his unit in Taylor, ACT. He collapsed after self-injecting heroin in the presence of others, including two CAHMA peer workers trained in overdose response. Those present performed CPR and restored his breathing, but critically delayed calling an ambulance for hours, apparently fearing police involvement due to drug possession. No naloxone was administered despite trained peer workers being present and having access to it. Emergency services were only called after he stopped breathing again and could not be revived. The coroner found this delay deprived him of any potential chance of survival. Significant governance failures were identified in CAHMA's recruitment (no criminal record checks on staff with serious criminal histories) and management's failure to investigate the peer workers' conduct, influenced by reputational concerns. Recommendations include reviewing CAHMA's overdose training to prioritize saving life and clarifying policies on staff drug use.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- critical delay in calling ambulance after initial collapse
- naloxone not administered despite trained peer workers present
- CAHMA peer workers did not carry naloxone despite anticipating opioid use
- biventricular hypertrophy from prior amphetamine use
- combined use of heroin and methylamphetamine (speedball effect)
- deceased left unattended for hours after CPR restored breathing
- bystanders feared police involvement due to possession of trafficable quantities of drugs
- CAHMA governance failures in staff recruitment and investigation
Coroner's recommendations
- CAHMA training on overdose response should be reviewed to ensure saving life is identified as the primary goal
- Clear published guidance including in CAHMA Code of Conduct clarifying that use of illicit drugs when at work is unacceptable and any off-duty drug use with clients must comply with Code of Conduct and Working with Vulnerable People Act
- CAHMA Code of Conduct to be reviewed to provide appropriate guidance to staff, clarify responsibilities under the Working with Vulnerable People Act, and establish mechanism for actioning breaches
- Findings to be forwarded to Commissioner for Fair Trading regarding CAHMA's compliance with the Working with Vulnerable People (Background Checking) Act 2011
- CAHMA to participate in dialogue with Canberra Health Services, ACT Ambulance Service, and AFP regarding coordinated response to drug overdose and publish progress report within 6 months of the review of amendments to the Drugs of Dependence Act 1989
- Government funding should be considered for inter-agency collaboration on drug overdose response initiatives
- The ACT should not follow the Northern Territory model of criminalising failure to provide assistance in drug overdose contexts
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