An inquest into the death of a young First Nations man, who went missing while on release from a central Victorian psychiatric facility six years ago, is expected to result in recommendations about cross-border police communication.
Aboriginal and Torres Strait Islander readers are advised that this article contains images and names of people who have died.
Darren Higgins, 26, was on leave from Bendigo Health's Vahland House treatment facility in February 2017 when he jumped into the Murray River and disappeared.
His body was found in the river seven months later.
New South Wales deputy state coroner Magistrate Erin Kennedy is holding an inquest into Mr Higgins' disappearance.
The court heard Mr Higgins' disappearance could have been avoided if police were quicker to respond and had communicated better.
"We should step forward and we should be at least encouraging the discussion about, 'How do we do this better?'" Coroner Kennedy said.
Closing submissions were heard on Tuesday, after a week-long inquest in Deniliquin in November.
Relatives of Mr Higgins travelled to Sydney to hear the closing submissions.
Coroner: Higgins died from dehydration
The coroner confirmed the death of Mr Higgins and found that he died between February 11 and 12, 2017, in the Moira State Forest at Barmah, in NSW.
She found the cause of death was dehydration, with contributory causes of severe mental health conditions and hyperthermia. The manner of death was misadventure.
The family of Mr Higgins told the inquest they wanted clinicians to have to provide more of an explanation of their reasons for granting leave in their forms.
Lawyers for Bendigo Health are seeking further information to assist the coroner, including any considerations arising from new Victorian mental health legislation.
"You must know that has been brought about by Darren [Higgins] himself," Coroner Kennedy said.
"He has really highlighted the importance of the border towns and communication between them."
Coroner calls out 'troubling' language
Coroner Kennedy raised concerns about references to Mr Higgins trying to "avoid apprehension" or having "absconded before" in submissions to the inquest.
In closing submissions, counsel for Victoria Police told the inquest Mr Higgins had gone missing before on a treatment order and would have known he was liable for apprehension by police, based on his prior experiences.
"I'm troubled by language, here, because I think it's not that helpful to look at him in that way," the coroner said.
"He is, as we've said, one of the most vulnerable people. His liberty's been taken away. But he's also psychotic — we've heard evidence that he would go in and out of that state, that could never be eliminated.
"It's a lens I think that generally comes through a lot of the police statements … but, at the end of the day, we're dealing with a person who cannot look after themselves and his right's been taken away for that very reason."
Cross-border collaboration under scrutiny
Counsel assisting the coroner told the inquest there was a lack of documented communication between police on both sides of the state border, as well as with the urgency of the response by NSW Police.
The coroner told the inquest a police officer, who provided evidence earlier in the inquest, had feared delays in communication and request for extra resources.
"He feared exactly what would happen. He tried to overcome that from Victoria — he was unsuccessful, even though he tried," the coroner said.
Counsel assisting the coroner suggested there should be a person on either side of the border with responsibility for the search, and that they be required to exchange information regularly and consistently.
"And if that's too hard, then it seems to me that there's potentially something wrong with our whole state system that we can't work together across borders," he said.
Police defend response
Lawyers for Victoria Police and NSW Police defended their respective organisations and cautioned against "hindsight bias".
The lawyer for Victoria Police said a thorough investigation was conducted, and that finding Mr Higgins was a priority throughout.
The lawyer for NSW Police said there were some constitutional reasons for the challenges with cross-border communication, which was why a commissioner had been appointed.
"The problem is a lot broader than policing agencies," he told the inquest.
The coroner said she got the impression that tackling the challenges was "too hard" and "too big".
"We had officer after officer sit there and say it's no better," she said.
The lawyer for NSW Police said there had been positive developments, which meant fewer people were missing long-term.
Coroner Kennedy is awaiting further information before handing down her written findings on February 23.
