Finding into death of Carl Robert Adler

Contributing factors

• Failure to formally re-assess wandering/absconding risk on transition from secure psychiatric facility to open community residential setting
• Risk stratification from secure environment (low absconding risk) was not re-evaluated in the context of open Leopold Street complex
• Inadequate appreciation of information in Clinical Risk Management Plan from secure facility
• Multiple wandering incidents (at least six) not triggering comprehensive risk review or strategy revision
• Inadequate documentation and reporting of incidents by staff
• Limited incident response—only one reported incident led to staff meeting discussion
• Strategies developed were only for planned supervised walks, not for unexpected elopement
• No specific staff training in managing active elopement risk
• Light clothing inappropriate for winter night (temperature 1.6°C)
• Pre-existing cardiomegaly increasing risk of sudden cardiac death under physiological stress such as hypothermia

Coroner's recommendations

1. Governmental entities and NDIS-funded facilities should consider how best to approach discharge of involuntary psychiatric patients to appropriate supported accommodations, with particular attention to formal risk reassessment when transitioning from restrictive to less restrictive environments.