Inquest into the death of Felipe Esteban Alvarez (No 2)

Male·toxicity caused by a combination of methylamphetamine and morphine

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.