Carl Adler: Coroner hands down ruling on Alfredton residential care death

The summary inquest into the 2018 death of Carl Adler was held at the Melbourne Coroners' Court on Wednesday, looking at the circumstances surrounding the man's death.

Adler was 46-years-old at his time of death and lived in supported residential accommodation at the McCallum Community Centre on Leopold Street, Alfredton.

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Adler had been diagnosed with autism at the age of 19, and had previously lived in Sovereign Lives Victoria accommodation until his move to the McCallum facility in 2017 - which allowed an increased freedom of movement for residents.

While living at the facility, Adler was given the opportunity to participate in outdoor activities in a supported and flexible manner. He lived in a two bedroom unit with another resident.

The court heard on June 2, 2018, Adler was in the unit watching football with his housemate and a support worker, who said Alder appeared "pretty calm".

The support worker left the living room, where both residents were sitting, to make a coffee.

Upon return the worker noticed Adler had left the living room, and began to search the unit and nearby areas.

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Adler was seen by a witness at 7.30pm running on a footpath in a nearby street.

The facility contacted the police soon after Adler's disappearance was reported, who began to search the surrounding neighbourhood and areas he was known to wander to.

At 11.05am on June 3, 2018, Adler was found laying face down, dead, in a concrete drain near the corner of Learmonth Street and Napier Avenue.

An autopsy of Adler's body was conducted on June 5 by a forensic pathologist, who said the cause of death was from cold environment exposure.

Temperatures recorded on the night of June 2 had reached a low of 1.6 degrees.

The pathologist commented hypothermia as a result of the cold exposure could have triggered a sudden cardiac arrest.

Several superficial abrasions were found on Adler's body, with a suggestion Alder may had suffered from a head injury upon falling into the drain.

Coroner Audrey Jamieson said there was a "clear and cogent evidence" Adler's death was preventable - with McCallum only assessing Adler's propensity to wander after he had became a residence at their centre.

During his stay at the McCallum facility, Ms Jamieson said Adler had made six attempts to wander, and on two occasions did not comply with staff when asked not to leave.

The court was told the McCallum facility had a stop sign on the exit door to the facility, which would often give Adler a visual cue to stop, alerting staff to his attempt to leave.

Ms Jamieson said McCallum staff had also failed to properly respond to Adler's attempts to leave - only meeting once to discuss strategies of mitigating his risk of wandering.

The court heard since the beginning of his stay at the facility, Adler's sister had reported a "blossoming" of his confidence and mental health.

Adler's treating clinicians and support coordinators were also of the view that the Leopold Street facility was an ideal fit for him, despite being a "challenging resident" to manage.

In the wake of Adler's death, the Disability Services Commissioner had conducted an independent investigation into the incident.

The investigation focused on any issues found in the services provided to people with disabilities at the site, and considers the actions McCallum staff should have to take in response.

The final report documented several shortcomings and recommendations around quality of care and staff training for the facility, which Ms Jamieson was satisfied McCallum had since implemented into its provision of care.

Ms Jamieson did not make an adverse finding against McCallum Disability Services.

She also found the police response to the incident to be appropriate and on-time, and Adler to have died from natural causes related to cold exposure.

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