The New South Wales deputy state coroner has recommended police in Victoria and New South Wales develop better processes for working on cross-border missing persons cases.
Aboriginal and Torres Strait Islander readers are advised that this article contains images and names of people who have died.
First Nations man Darren Higgins was on leave from a psychiatric facility in Bendigo, where he was an involuntary patient, when he jumped into the Murray River and disappeared in February 2017.
His body was found seven months later in the Moira State Forest in New South Wales.
An inquest into the 25-year-old's death resulted in recommendations for police on both sides of the border to improve communication and coordination on missing persons cases.
Magistrate Erin Kennedy has recommended Victoria's chief psychiatrist consider reviewing policy and procedures for granting extended leave to involuntary patients.
She also recommended that New South Wales Police consider providing its cultural safety and cultural awareness training to officers in the missing persons unit.
Who was Darren Higgins?
Mr Higgins was a proud Wiradjuri man with strong connections to the Yorta Yorta nation, who called Echuca home.
Ms Kennedy said Mr Higgins was talented, respectful, and much loved by his family and friends, but was also "one of the most vulnerable among us".
He was an involuntary inpatient in Bendigo Health's Vahland House treatment facility where he was being treated for schizophrenia and long-term substance abuse disorder.
Mr Higgins had been at the facility for about 12 months before he was granted leave to spend the weekend with his mother and a family friend, a respected elder.
"In the days leading up to his planned leave, staff raised some concerns about Darren and his ability to attend on leave," the coroner said in her findings.
She said the concerns were raised with the psychiatrist treating Mr Higgins, who decided to grant the leave, but was not informed of where he would be spending it.
What happened to him?
The coroner found that Mr Higgins died of dehydration one or two days after he went on leave.
Ms Kennedy said Mr Higgins absconded almost immediately after arriving at Mathoura, a town north of Echuca along the Murray River in New South Wales, on February 10.
The coroner said Mr Higgins jumped in the Murray and swam back to the Victorian side of the river. He was last seen entering Barmah Forest.
"He was immediately reported missing to both Victorian police and New South Wales police," Ms Kennedy wrote.
"Victorian police very quickly resourced a full-scale search for him the next day, on 11 February 2017."
Meanwhile, the coroner said Mr Higgins was spotted returning to New South Wales.
It took 10 days for the matter to be transferred to New South Wales police, which conducted its first search for Mr Higgins 20 days after he missing, on March 3.
A man who was collecting firewood found the remains of Mr Higgins on September 2.
More remains were found about seven months later, in April 2018.
Evidence suggested Mr Higgins might have been trying to make his way to family in Echuca before he died.
What did the coroner find?
Experts differed in their opinions of whether Mr Higgins should have been granted leave.
Ms Kennedy accepted that the decisions that were made were believed to be in the best interests of Mr Higgins, but completing a thorough risk assessment of where he intended to spend his leave was an "essential" part of the process.
The coroner was critical of the way police collaborated on the case.
"There were a number of identifiable areas where communication opportunities were lost," she wrote.
She said it was unhelpful to the more than two million people living in towns on the border to treat improving communication between the police forces like it was too hard, as she had heard in submissions to the inquiry.
"If Victoria Police is in the air or on the water undertaking a border search then New South Wales [police] in that region should know who they are searching for and ensure they should be searching too," Ms Kennedy wrote.
"With 10,000 missing persons a year in New South Wales alone, this communication issue becomes even more important to cure because the issue is bound to arise regularly."
Authorities respond
A spokesperson for New South Wales Police said a comprehensive review of the findings was underway.
"Any recommendations that are directed to New South Wales Police will be considered," the spokesperson said.
Victoria Police said it would take time to review the coroner's findings and recommendations.
Bendigo Health said it would await any recommendations from the chief psychiatrist and action them appropriately.
A comment has been sought from the Victorian health department.
