Alliance for Coronial Reform

Alliance for Coronial Reform An alliance working towards a restorative coronial system that delivers social justice for bereaved families and loved ones who have died.

We endorse a restorative coronial practice enabling full and effective participation by families.

https://www.bbc.com/news/articles/cvgydn9k4p2oDid someone read my mind? This article resonates so strongly with me regar...
25/08/2026

https://www.bbc.com/news/articles/cvgydn9k4p2o

Did someone read my mind? This article resonates so strongly with me regarding the conduct of many coroners, on an international level it seems.

The lack of model litigant behaviour demonstrated by highly experienced and highly remunerated legal teams representing government departments, police etc appalls me.

I also felt like I was a defendant in a trial when I was in the witness box during Brontë's coronial hearing. It was shattering, however, I was warned by our solicitor this would happen.

So, it appears to be normalised behaviour by the 'suits' who would rather not seek the truth; rather, they work hard to bury it.

Shame, shame, shame.

One man's death highlights the growing strains on the UK's coroner's courts

04/08/2026

ACT News 4th August 2026.

Bystanders deprived Canberra man 'any chance of survival' by waiting hours to call ambulance after overdose

By Zaarkacha Marlan

The coronial inquest found bystanders left Felipe Alvarez to "sleep it off" for several hours despite him showing signs of an overdose. (ABC News: Matt Roberts).

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 he**in 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.

Coroner Ken Archer found the support workers deprived Felipe Alvarez of "any chance of survival" by not contacting emergency services sooner.

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.

ACT Coroner Ken Archer said the inquest had raised broader public safety concerns about CAHMA's peer-worker model and governance.

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.

The support workers were both trained to administer naloxone to reverse the effects of an opioid overdose, but neither had any available when Felipe Alvarez collapsed.

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.

04/08/2026

The Canberra Times 4th August 2026.

I supported Gabrielle at Felipe's coronial hearing. The findings were handed down yesterdays. Disappointing is an understatement.

Sister says Phillip deserved 'fearless investigation' into his overdose death

By Hannah Neale
Updated August 4 2026 - 1:14pm, first published 11:40am

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.

'Conduct deprived any chance of survival'

Shortly after injecting he**in 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 he**in 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.

Issues of public safety

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.

22/07/2026

City News this week.

No one’s saying how little Safa died

As an advocate for coronial reform, I am sharing the unsatisfactory response of ACT police and the ACT Coroner’s office to the death of two-year-old Safa.

Safa arrived from Sudan with her family as refugees in 2017, making Canberra their home.

She died on April 30, 2018, just hours after speaking to her father on the phone. He had moved to regional Victoria for work, after separating from her mother.

A post-mortem revealed Safa had died of internal bleeding caused by blunt-force trauma.

A criminal investigation was commenced, however, eight years later, there have been no charges laid or a coronial hearing conducted. That’s eight years, not eight months. Why is this?

Safa’s father recently asked whether the public conversation would have been different if this tragedy had affected a family with greater resources, stronger networks or a better understanding of the legal system.

When a journalist from The Guardian asked our local authorities for an update, he was advised it was a matter for the coroner. The coroner’s office did not respond to his questions. Why not?

Safa, her father and our justice system have been cheated in this case.

Perhaps the AFP, the coroner and others with the authority within the ACT government will take steps now to put it right. But, will they?

Janine Haskins, Alliance for Coronial Reform

With Adam Shand – I just got recognized as one of their top fans! 🎉
22/07/2026

With Adam Shand – I just got recognized as one of their top fans! 🎉

13/07/2026

What an absolute tragedy, coupled with a what appears to be a very poor police investigation.

Canberra toddler Safa was two when blunt-force trauma ended her life eight years ago. But who was to blame?

Police suspected the daughter of Sudanese refugees was the victim of a ‘horrendous’ murder – but there have been no arrests and no inquest. Her father is impatient for answers

Abubakr Annour remembers the phone call with haunting clarity.
It was mid-morning on Monday, 30 April 2018, and on the other end of the line was his daughter, Safa.

Three weeks shy of her third birthday, Safa was living in Canberra with her mother and older brother. Her father was 500km away, working as a fruit picker in Shepparton in regional Victoria.

“She was asking me, ‘When are you coming to pick us up?’ Annour recalls of the conversation.

The pair never spoke again.

The toddler – whose family arrived as refugees in Australia just eight months earlier – was pronounced dead after she was rushed to Canberra hospital about 1.50pm that afternoon.

An autopsy concluded that she had died of internal bleeding caused by blunt-force trauma.

Australian Capital Territory police, who waited six months to inform the public about the case, suspected Safa was the victim of an “absolutely horrendous” murder.

More than eight years later, police have still made no arrests, laid charges or named suspects, despite CCTV footage showing Safa in public, seemingly happy and healthy, on the morning she died. There has been no coronial inquest or other public inquiry.

No one from the family, Canberra’s small Sudanese diaspora or the wider community ever came forward to appeal for answers and justice, which helps explain why, after an initial burst of interest, the tragedy disappeared from public consciousness.

‘Sometimes I feel she is with us.’

Annour is sitting on a couch in his dimly lit unit in Canberra’s western suburbs, flicking through an album of family photos.

In one picture of the father and daughter, taken a few months before Safa’s death, the toddler’s face is scrunched into a wide and joyful smile.

“Sometimes I feel she is still with us and sometimes I realise she is not and I get really angry,” Annour tells Guardian Australia through a translator.

“I have never forgotten what happened to Safa. I never forget it and it always [is] in my mind.”

The 42-year-old has spent eight years waiting for a breakthrough from police that has never come.

So, after learning of media coverage about his daughter’s death, he has decided to come forward and break the silence that has hung over the case.

Annour wants a coronial inquest and justice to be served to whoever caused her fatal wounds.

He is critical of police, adamant that mistakes were made and more resources could have been deployed in the early weeks of the investigation.

“Justice for me, even after 100 years, it must come,” he says. “At the end of the day I want justice for my daughter and whoever did this should be punished.”

‘She was unlike other kids’

Annour was born in south Darfur, a region of western Sudan known internationally as the scene of devastating conflict and humanitarian crisis.

He moved to the capital, Khartoum, after the first Darfur war erupted in 2003, where he met his future wife, Huda Yagoub, and the couple had their first child.

Fearful of raising children in a strife-torn country, the young family fled north-eastern Africa for Indonesia. Safa Abubakr Annour was born on 19 May 2015 in the port city of Makassar on Sulawesi.
The family were granted refugee visas by the Australian government and shortly after Safa’s second birthday arrived to live in the nation’s capital.

“She was unlike other kids,” Annour says of his daughter.

“She was always very happy, always smiling. She always sought out knowledge, she always asked questions. She loved music and every time we played a song she sat beside me and she heard me singing and repeated after me and danced.”

The family were welcomed by members of Canberra’s small Sudanese community but struggled for money and in accessing services and overcoming language and cultural barriers.

The parents separated after their relationship deteriorated and Annour left town in search of work.

Yagoub, Safa and her brother moved into a home for women, which is where the toddler was living in the days before she died.
At 8.40am on 30 April 2018, the three of them were seen stepping off a bus in Griffith in Canberra’s inner-south, a short drive from Parliament House.

By that afternoon, Safa was dead.

‘This is a crime.'

Details of the suspected murder were revealed six months later in a public appeal for information by ACT police, who believed there were people in Canberra with knowledge of the case who were choosing not to come forward.

The force released a photo of the toddler along with footage that showed her walking off the bus. A fortnight later, a second clip was circulated showing Safa the day before she died, walking with her brother and a different woman, who police stressed was not a suspect.

Police said two people were responsible for the toddler’s care at the time she suffered her fatal injuries but refused to name them or disclose their relationship to the child. They did not refer to them as suspects.

Guardian Australia has established that one of the people was Yagoub.

The other was a Sudanese-born man named Luay Shaor, who had befriended Yagoub in Canberra.

After Annour received news of his daughter’s fatal injuries, friends of the shell-shocked young father rushed him back to Canberra and straight to the hospital.

By the time he arrived, Safa’s body had already been taken for an autopsy. Her death wasn’t treated as a possible murder until the postmortem results prompted police to ramp up their investigation.

“This was a crime,” Annour tells Guardian Australia. “No sane person would have done something like that to a kid.”

The father and mother remained in Canberra amid the fallout from their daughter’s death.

Shaor returned to Sudan in the months after the death and Guardian Australia understands that he remains overseas.

A lawyer for Yagoub declined to comment when contacted by Guardian Australia. Shaor could not be reached for comment.
‘Police did not do their jobs.'

Reflecting on the weeks and months after his daughter’s death, Annour believes police did not dedicate enough resources to the case and questions why Shaor was allowed to leave the country with the investigation ongoing.

“The police output of resources don’t match what had happened,” he says. “Police did not do their jobs.”

In a statement to Guardian Australia, ACT police said Safa’s death was still being treated as an open homicide investigation and the force remained determined to identify the person or people responsible.

“A thorough, dedicated and comprehensive investigation was conducted into the death of Safa Annour,” police said. “This work has continued in the eight years since, including enquiries being made this year in support of the investigation.”

The force said it was working with the ACT coroner but the timing of a formal or public inquest was up to the coroner.

Guardian Australia asked the ACT attorney general, Tara Cheyne, and the ACT police minister, Marisa Paterson, if the territory government would support an inquest but was told it was a matter for the independent ACT coroner.

The coroner did not respond to questions from Guardian Australia, including whether a possible inquest was on hold due to the active police investigation. Under the territory’s coronial process, the coroner must refer a case to the director of public prosecutions if it believes a criminal offence has been committed. The coroner must pause its investigation until the matter is finalised.

‘Safa deserves to be treated like any other child.'

A member of Canberra’s Sudanese community, who asked not to be named, says a coronial inquest would be an important step to answer unresolved questions and reassure the public.

“No parent should have to endure not knowing what happened to their child,” they said. “While nothing can bring Safa back, justice matters because it can provide the truth, accountability, and a measure of closure for a father who continues to carry this pain every day.

“Safa deserves to be treated like any other Australian child. Her life had the same value as every other child’s life.

“I often ask myself whether the public conversation would have been different if this tragedy had affected a family with greater resources, stronger networks, or a better understanding of the legal system.”

For roughly a year after she was buried at Gungahlin cemetery in Canberra’s northern suburbs, Safa’s plot was identifiable only by a white tag that misspelt her name “Safia”.

It was eventually replaced with a purple plaque, paid for by her father, showing a butterfly bursting into the sky.

Asked if he ever visits the grave, Annour shakes his head.
“I will never go to the grave until whoever committed the crime [is found],” he says.

Do you know more? Contact [email protected] or [email protected]

11/07/2026

3rd update:

Somehow (I'm not sure how, it must have been a FB thing), I managed to contact Adam Shand, an investigative journalist who has become a podcaster and presenter with a focus on crime.

Following contact with Adam, I sent him information regarding Brontë - a snapshot of the chronology. prior to and following her unwarranted death.

Adam said he would like to interview me, so on Wednesday, 9th July (two days after what would have been Poppy's 30th birthday), I popped on my earphones and mic and joined Adam on line for the podcast.

It was quite the experience. Adam Shand has the knack of making an interviewee feel relaxed and his interviewing technique/s are to be applauded.

After an hour of speaking, I only realised how much time had gone due to the darkness of my dining room due to the sun going down and me not putting on any lights. Everything seemed to flow.

Whilst I am unsure what the podcast will present about Brontë's tragic death, at this stage, I have complete faith in Adam Shand for his compassion, empathy and understanding of the pain and suffering families endure following the death of someone too special to not ask the important questions, and the expectation to receive answers.

Thank you Adam - you have renewed my capacity to believe in truth and justice.

By the way, you can follow Adam Shand and/or subscribe to his podcasts - just google Adam Shand. I think the cost is $3:99 per month - good bang for your buck!

Adam has advised me that his 'Brontë' podcast (I suggest it be call it something like 'was it really su***de, or something else?') will be ready to watch within the next couple of weeks.

I hope you can watch it.

In unity for justice and coronial restorative reform.

Janine.

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