Finding into death of Adam Laufer
Deceased
Adam Laufer
Demographics
32y, male
Date of death
2016-11-24
Finding date
2021-07-26
Cause of death
Multiple injuries sustained in a fall from a height
AI-generated summary
Adam Laufer, a 32-year-old man with longstanding bipolar disorder, died by suicide on 24 November 2016 when he jumped from the LaTrobe Street overpass in Melbourne. In the early hours of 24 November, his father called triple zero reporting Adam was psychotic with paranoid delusions. Victoria Police officers assessed Adam using section 351 Mental Health Act and concluded he did not meet the threshold for compulsory detention based on his calm presentation, despite his father's assertion he was experiencing acute psychosis. Ambulance paramedics attended but conducted no formal assessment. Adam left the scene by taxi and died 16 hours later. The coroner found police and ambulance conduct reasonable but highlighted critical system gaps: absence of 24/7 mental health crisis teams, limited assessment orders in early morning hours, PACER teams rostering only to 11pm, and lack of 'safe spaces'. The coroner recommended prioritising Royal Commission into Victoria's Mental Health System recommendations for 24/7 crisis response, safe spaces, and health-led (not police-led) responses to mental health crises.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Bipolar disorder with acute psychotic symptoms on day of death
- Absence of current psychiatric medication for approximately one year
- Lack of assessment order despite acute presentation
- Inadequate mental state assessment by paramedics
- Limited availability of 24-hour crisis assessment and intervention services
- PACER team not available after 11pm (call at 3:35am)
- Disagreement between father and police on threshold for involuntary detention
- Adam's poor insight into psychiatric illness and refusal to engage with mental health services
- Absence of 'safe spaces' or crisis respite facilities
- Approximately 16-hour gap between police intervention and death with minimal monitoring
Coroner's recommendations
- That recommendations 8, 9 and 10 arising from the Royal Commission into Victoria's Mental Health System be prioritised and implemented in their entirety as recommended by the Royal Commission, specifically: ensuring 24-hour-a-day centrally coordinated crisis response services; investing in diverse 'safe spaces' and crisis respite facilities; ensuring emergency services responses are led by health professionals rather than police where possible; diverting mental health 000 calls to Ambulance Victoria; providing 24-hour telehealth consultation systems for crisis responders; and establishing in-person co-responders in high-volume areas
- That the current power provided pursuant to s351 Mental Health Act, however it is to be drafted into the new Mental Health and Wellbeing Act and supporting documentation, provides clear and practical guidance on the role of the family in informing the use of police powers in circumstances requiring a community-based crisis response
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