This story contains the name and image of an Aboriginal man who has died. He has been identified with the permission of his family.
When Felipe (Phillip) Esteban Alvarez overdosed five years ago the people present, including two workers employed by a drug harm minimisation organisation, did not call triple zero for possibly hours.
The group's actions have since been labelled "morally blameworthy" by a coroner who said they "showed a chilling indifference to the possibility of a loss of a life".
In a statement, his sister, Gabrielle Alvarez-Sledge, said the inquest had been "profoundly difficult to watch" because she believed "important evidence was not heard or tested before the court".
"[My brother] deserved a full, fair and fearless investigation into the circumstances surrounding his death," she said.
"Phillip's memory deserves honesty. He deserves dignity. He deserves a process that inspires public confidence, and a legacy that helps improve the system for those who come after him.
"My brother's life mattered. His death mattered. The truth matters."
The family has also called for the non-publication orders on the names of the two workers present during the overdose to be lifted.
The long-awaited ACT Coroner's Court findings into Phillip's death were published on Tuesday, August 4, one year after a multi-day hearing was conducted.
The inquest also examined practices at the Canberra Alliance for Harm Minimisation and Advocacy [CAHMA], which it found raised issues of public safety.
Coroner Ken Archer said that one of the risks of the model was that "public monies can become an indirect support for the drug taking practices of peer workers and their clients".
"The integrity of peer and peer support workers and appropriate governance structures within CAHMA are critical to ensuring this does not occur."
The ACT and federal government-funded service aims to reduce the harms of drug use. It employs former, or active, drug users to provide services and programs to support other users.
The coroner said that through the use and distribution of naloxone, a medication that rapidly reverses the effects of an opioid overdose, CAHMA "can and does play a role in mitigating the consequences of overdose".
Phillip, 48, died in his unit on March 30, 2021, with a group of people present, including the two support workers employed by the organisation at the time.
They were not at the unit in an official capacity, having taken illicit drugs themselves at the time, but the pair were trained by the not-for-profit to deal with overdoses.
This included the administration of naloxone, which the workers did not have on them despite having access to the medication.
Due to non-publication orders issued by the court the people present cannot be named. They were not called to give evidence during the coronial process, a decision Phillip's family disagreed with.
Phillip, a Ngunnawal and Chilean man, battled with drug addiction and, with the help of his family, moved to Canberra in 2020 for a fresh start. He was a client of CAHMA and had recently been released from a long period in a NSW jail for robbery-related crimes.
Ms Alvarez-Sledge described her brother as "not simply another file before the court".
"He was deeply loved, and his life had value. His death has left a permanent void in our family, and the emotional toll of these proceedings has been immeasurable," she said in the statement.
"I hope that the findings in this matter, together with any recommendations made by the coroner, lead to meaningful improvements in the way deaths are investigated and families are included throughout the coronial process.
"No family should have to spend years fighting simply to feel heard."
In handing down the findings, Mr Archer said the case had previously been referred to the ACT Director of Public Prosecutions, who advised no criminal charges would be laid.
Shortly after injecting heroin in 2021, Phillip experienced "jelly legs" and stopped breathing. After the people present conducted chest compressions, they determined he was breathing again and left him on the ground in a recovery position "possibly for some hours" to "sleep it off".
While the court previously heard triple zero was not called for four hours, Mr Archer found he could not determine the exact amount of time.
"It was apparent that his condition was a medical emergency and that an ambulance should have been called," the coroner found.
During the eventual emergency call at 12.33pm, the caller misled the operator about the overdose and gave a fake account, instead saying she was "not quite sure" what the cause could have been and did not mention drugs.
Phillip died later that afternoon despite the efforts of paramedics, with an autopsy finding that his death was caused by taking heroin and methamphetamine with an underlying heart condition.
"The conduct of the group in not calling for medical help immediately upon Mr Alvarez's initial collapse and providing misleading information to [the ambulance service] was morally blameworthy and showed a chilling indifference to the possibility of a loss of a life," Mr Archer said in the published decision.
"Their conduct deprived Mr Alvarez of any chance of survival he may have had after his initial collapse.
"I am not able to say with certainty why an ambulance was not called. Self-interest, including concern as to the possible involvement of the police, is likely to have been one of the motivating factors."
A CAHMA training document tendered to the court in 2025 suggested that staff and clients not mention "drugs or overdose" when calling triple zero.
Giving evidence in August 2025, the organisation's executive director, Chris Gough, said this suggestion was "provided to increase the chance of a caller calling triple zero to provide a better response to the individual's overdose".
"It's common within our community that people are too afraid of the consequences to ring triple zero," he told the court.
"The police are the most feared institution to people who use drugs."
Mr Archer recommended CAHMA overdose response training be reviewed to ensure "that the goal of saving life is identified as the primary goal".
He also recommended the drug harm minimisation group advance a dialogue with emergency services.
The coroner said he could not be satisfied, on the balance of probabilities, that the actions of those present caused or contributed to Phillip's death.
Mr Archer described the death as an accidental drug overdose.
The coroner found CAHMA failed to apply its own safety and integrity processes in not obtaining a Working with Vulnerable People Check or police check for the two unnamed workers.
Both CAHMA employees present at Phillip's overdose had extensive criminal histories. The court found that while it was not possible to determine if they should have been employed, their fitness for the role "should have been determined on the basis of a rigorous application of established screening and eligibility tools".
Mr Archer also determined the organisation's justifications for not conducting an internal investigation into the death "was influenced to some degree by extraneous and irrelevant considerations" including reputational damage.
The court found the failure to conduct such an investigation exposed clients and users of CAHMA's services who interacted with those peer workers to potential risk.
"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.
The inquiry heard evidence that CAHMA's governance structures had been enhanced since the death.
Last year, Mr Gough told the court that while taking illicit substances at work contravened a code of conduct, outside work hours, "we do expect that peer workers will do drugs with service users".
"It wouldn't be appropriate for us to say you cannot use with service users outside of work," he said.
However, a CAHMA code of conduct stated that in their private life employees could not engage in lawful conduct that compromised the position of the organisation in the community.
Mr Archer recommended clear published guidance be developed to make clear that the use of drugs with clients outside work hours must be consistent with the code of conduct, and consistent with the Working with Vulnerable People Act.
The two unnamed employees were terminated shortly after Phillip's death for unrelated reasons including poor performance.
